Sally Satel: The limits of bioethics

...Me first? Cunningham was not snatching a kidney away from someone else. Except for the story about her, there would have been no offer in the first place. Moreover, every so-called Good Samaritan donor who gives to someone like Cunningham or Tomas removes them from the queue, and so others move up a slot. No one is harmed while someone is saved.

Caplan is a bioethicist; his titles imply an expertise in ethics. Hanto served as the chair of the Ethics Committee at the American Society of Transplant Surgeons. Yet what are we to make of their willingness to issue life-and-death pronouncements involving other people? Well, we know a few things about them. First, that they share an absolutist approach to egalitarianism: If all cannot benefit, then none should benefit. Second, as ethicists they presume to know how despairing patients should conduct their private affairs. And third, they appear to have few qualms about conveying to desperately ill people a message of hopelessness: Be passive, dying patients — wait your turn and take no initiative to save your own life.

Does being a bioethicist entitle one to any such moral authority, edifying the rest of us about right and wrong? Is this what society should expect of its “ethics experts”?

The proper relationship between experts and citizens is a question of longstanding interest to sociologists and social critics. In the case of bioethicists, the nature of the subject about which they claim authority is up for debate. Traditionally, they have focused on the controversies surrounding biomedical technology, such as cloning, sex selection, in vitro fertilization, nanotechnology, research ethics, organ allocation, and so on. Now experts are calling for involvement in policy. Renee Fox and Judith P. Swazey, senior scholars who have studied the sociology and history of bioethics, urge a focus on “inequalities in health and in access to health care in America.” The field is too “narrowly American-ocentric,” they write in their 2008 book Observing Bioethics; it should become “more centrally and deeply involved with [global] suffering and issues of social justice.” In his new book The Future of Bioethics, Howard Brody, a physician and philosopher at the University of Texas Medical Branch, instructs bioethicists to gauge success by asking themselves if they are “speaking truth to power.” These prescriptions presume a moral authority that bioethicists cannot properly claim.

Origins

Where did bioethicists come from? Ethical conundrums in medicine long predated the creation of the field now known as bioethics. In his respected book The Birth of Bioethics, Albert R. Jonsen, a moral theologian and bioethicist, dates the origin of bioethics as a distinct discipline to 1947, the year that 23 physicians were convicted of war crimes during the Nuremberg tribunal. Others believe the field grew out of postwar technological capabilities that intensified the already vexing dilemmas about human control over life and death. Medical controversies over care for the terminally ill, reproductive technology, genetic manipulation, and organ transplantation drew the attention of Catholic theologians and other religious scholars in the 1950s and 1960s. In concert with philosophically inclined physicians and scientists, they began to apply moral theory to modern medical controversies. The exploration of these issues soon became more secularized as historians, philosophers, anthropologists, legal scholars, and others joined in.

At the same time it became clear that as technology enhanced physicians' therapeutic powers, it increased the range of interventions that patients could undergo and the vulnerability that came from not understanding the risks of those interventions. This recognition brought questions about doctors' duty to inform patients about the treatments prescribed, the alternatives available, the patient's prognosis, and the right to refuse care. A backlash against medical paternalism that was already underway in the 1960s began to attract academics who were engaged in the civil rights and antiwar movements and harbored a keen distrust of institutions; they trained their sights on resetting the balance of power between physicians and patients.

As ethical quandaries multiplied and demanded attention, it was perhaps inevitable that a specialized group of professionals — the bioethicists — would emerge to meet the task. In an impressive burst of institution-building that was funded by both the federal government and private philanthropies, three bioethics think tanks sprang up between 1969 and 1971: the Hastings Center, in upstate New York; the now defunct Society for Health and Human Values, in Philadelphia; and the Kennedy Institute of Ethics at Georgetown University, a Jesuit institute, in Washington. Populated by physicians, legal scholars, philosophers, historians, and humanists, their agendas coalesced around cutting-edge issues such as genetic testing, organ transplants, in vitro fertilization, neonatal intensive care units, euthanasia, and other conundrums surrounding death and dying. And when, in the 1970s, research scandals at Willowbrook and Tuskegee erupted, research ethics and regulatory oversight were added to the bioethics portfolio.

Inhabitants of the ivory tower were eager to make themselves relevant by applying theory to real-world problems. According to Daniel Callahan, one of the founders of the Hastings Center, he and his colleagues wanted to give philosophy “some social bite, some 'relevance.'” In 1982, in an article called “How Medicine Saved the Life of Ethics,” the philosopher and historian Stephen Toulmin argued that the imperatives of medicine enabled moral philosophy to avoid the academic sidelines. And there is no question that, in some cases, physicians themselves turned to theologians and moral philosophers for help...

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