Hastings Center Report, November-December 1996

ot long ago, Philippe Lazar, Director General of the French biomedical agency INSERM-the equivalent of our National Institutes of Health- N complained about the impact of bio.

ethics in his country. Not only, he said, has it led to restrictive legislation, smothering a diversity of ethi- cal opinion because of the fears of a minority, it has also overemphasized the potential abuses of scien- tific knowledge rather than the new possibilities it offers.

I read that news with a sigh of nostalgia. They used to say that about us. Not any more.

In this country those who would legitimate morally controverted scientific research long ago learned how to put together commissions and pan- els to include sympathetic and progress-affirming ethicists. In the early days of bioethics there was an interesting debate between the views of Joseph Fletchex-who never said no-and those of Paul Ramsey-who usually said no and who argued that the capacity to do so was a test of moral seriousness. It appears that Fletcher won the day. While bioethics creates problems now and then for mainstream, right-thinking trends, it mainly serves to legitimate them, adding the imprimatur of ethical expertise to what somebody or other wants to do. It is hardly likely that the National Institutes of Health (NIH) Human Genome Project would have set aside 5 per- cent of its annual budget for the Ethical, Legal, and Social Implications program if there had been even the faintest likelihood it would turn into a source of trouble and opposition; and it indeed hasn’t.

Now my generalizations are not wholly reason- able or fair. It is by no means the case that all forms of biomedical research deserve a “no”; most in fact merit a moral defense. Nor is it the case that everyone in bioethics is a patsy, easy to co-opt into the service of biomedical aspiration. Though she was a cochair of the NIH embryo research panel, Patricia King boldly opposed its recommendation that embryos be created for research purposes. I have no doubt, moreover, that many of those ethicists who give out what Richard John Neuhaus has called “permission slips” are as serious, as full of gravitas, as those who say no. Only the morally smug could think all virtue is on one side or the other in most bioethical debates.

Yet even as I concede these points I remain un- easy. While they thankfully have little of the nastiness that marks the larger moral struggles of our society, the bioethical debates are beginning to reflect those culture wars. Isn’t it increasingly easy to predict the “expert” views of bioethicists knowing only their age, religious convictions (or nonconvictions) , edu- cational background, and social class? This iirst b e came evident in the abortion debate but has now spread to physician-assisted suicide, fetal tissue and embryo research, surrogate reproduction, and m sorted other issues. It is not, it seems, ethical theory of the kind bioethicists like to include in the text-

Bioethics, Our Crowd, and Ideology

books that makes much difference, but plain old- fashioned ideologywhether one is, to paraphrase Gilbert and Sullivan, “acculturated as a little liberal or a little conservative.”

Perhaps th is was inevitable once bioethics en- tered the mainstream, becoming a respectable part of the biomedical establishment. Bioethics ceased being a cultural curiosity, or a neighborhood crank, and became an accommodating handmaiden. Its practitioners came in with the trappings of the cul- ture around them. In any case, few can say no all or most of the time over many years without a loss of credibility; and it gets wearisome in any case.

I do not by any means exclude myself or The Hastings Center fiom this observation. We courted legitimacy, sought money from the big foundations, tried to make it in the higher reaches of academia, and endlessly worked to persuade physicians and biomedical researchers that we should be seen as allies and not opponents. That was not a pose. We felt that way and worked to convey that feeling. We succeeded. It has been left to the likes of Jeremy Rifkin, a real outsider, to cause trouble. We are r e lieved to say that he is not one of us. I’m not sure we should be proud of that. We became insiders by default, without ever resolving in any full way the question of whether those who pursue bioethics should be insiders or outsiders.

What would I like to see in the future? First, I would hope that bioethicists will be wary of serving on any national or public commission where there is a reasonable certainty that its political aim is to legitimate a controverted research or policy pre posal. This does not mean that those in ethics can never say yes. If one happens to agree with the pro. posal, then one should write independently in its favor, making the best case one can. It is the formal and official legitimation of ethical expertise that should be avoided; and that is usually just what some commissions and panels are after.

Second, while it would be naive to expect that bioethics could or should be ethically neutral, it should aim to respect the different positions in the debates that break out. This point seems to be stat- ing a banality but of late there has been an increas

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Hastings Center Report, November-December 1996

ing embrace of strong advocacy as a proper role for those in bie ethics. To be sure, one’s moral convictions should be pursued and advocated; no problem there. But this needs always to be done in a way that takes the en- terprise of bioethics seriously: fairly and carefully stating oppos

ing positions, looking always for their best exempli- fications; avoiding the kind of courtroom, daytime TV-show polemic and bombast that have come to pass for civil discourse in our society; and to be acutely aware of one’s own ideological bias, lying like a snake in the grass below one’s arguments and supposedly rational convictions-step on that snake sometimes.

Third, cause trouble now and then with one’s own crowd. Say something nice (and liberal) about bioethics in the journals Commeniary and First Things. Submit an attack on abortion and euthanasia to the Australian journal Biuethk Send the Hasrings Center Rqb& a paper in favor of physician paternalism. In- vite Jeremy Rifkin to be part of a study group on biotechnology at the Institute of Medicine. If we are lucky and do our work well, the director of NIH may someday emulate his French counterpart and think us a potential menace. Jerry Fahvell and Pat Robertson probably already have such thoughts. But that’s too easy.

Albert R. Jonsen

Bioethics, Whose Crowd, und Wbut Ideology?

an Callahan has, in his usual hhion, written a provocative statement: “In

mate morally controverted scientific research long ago learned how to put together commissions and panels to include sympathetic and progress af€irm- ing ethicists.” As one who long ago sat on the first two big commissions, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (National Commission) and the President’s Commission on the Study of Ethical Issues in Medicine and Biomedical and Be- havioral Research (President’s Commission), I deny that my colleagues and I “legitimated” anyhng, much less any “morally controverted research.” I think the same can be said of those who served on the short-lived Ethics Advisory Board, on the TW

D this co~ntry those Who Would legiti-

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kegee Panel, and on the NIH Fetal Tissue Panel. “Our crowd” provided real “ethicists” for all these groups. They were hardly of the same “ideology“- Father McCormick and Sissela Bok? Jim Childress and Father Burtchaell? These ethicists and all the panelists argued vigorously point by point. When the results were in, someone could say that the Na- tional Commission “legitimized” research involving children, which Paul Ramsey repudiated and Rich- ard McCormick justified, and that the Fetal Tissue Panel “legitimized” abortion, which Father Burt- chaell considered an impassable barrier and Jim

Childress viewed as a manageable public policy mat- ter. Pat King is certainly not the only ethicist who has “boldly opposed a recommendation.

I don’t intend to pick out, panel by panel, the “sympathetic and progress-affirming ethicists” and set them against their opposites, who might be called “the critical and conservative ethicists.” I have something more theoretical to say. The “morally controverted issues do attract partisans around each pole of the controversy. Those partisans preach what we loosely call “ideologies” (although usually their repetitious sermons are much shallower than real “ideologies,” looking more like prejudices than philosophies). The morally controverted issue then takes on its public shape as a World War I battlefield, two deeply entrenched armies facing each other across a desolate neperson’s land, shooting at each other what they hope are lethal arguments. As this happens, more and more of the noncombatants get caught up in the fight and add their voices, if not their ideas.

I think the world of ethics, as it has evolved over the last three decades, is a much more peaceful place and its ethicists a much more irenic crowd. Not that they don’t argue; not that they don’t have strong affections and disaffections. And, of course, we must confess, under the baleM eye of the “criti- cal theorists,” that every superficially objective analy- sis hides an ugly ideology. But the characteristic in- tellectual attitude of the modern practical ethicist is pdement-genuine puzzlement before ambiguity. The ethics of science and medicine differs from the m o d arguments over warfare, slavery, subjection of women, tyranny, and torture. These are evils em- bedded in a culture and the moral controversy con- cerns how to expel them. Ethicists in such contre versies must be bold and brave. In science and medi- cine, the enterprises are themselves valuable. Experi- mentation yields new knowledge, which is a human value. Molecular genetics reveals the deep roots of disease, which is a human good. Life-sustaining tech- nology saves imperiled lives, which is a human bene fiL Yet, as these became part of modern medicine, many perceived that they had dark sides: exploita- tion, discrimination, deprivation of quality of life. The ethically problematic feature of the new medi- cine was its radical ambiguity. The ethical task in the new medicine was to sort out the goods and the bads in each of its pieces. Thirty years ago, theole

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