Bioethics: Private choice and common good

Almost from its start bioethics has been a child of its time, and a child of good fortune at that. In his 1954 book Medicine and Morals, Joseph Fletcher ventured the idea of personal choice as the highest moral value and the struggle against nature as medicine's most liberating mission. That was a bold combination at the time, but it turned out to have been prophetically popular, and by the late 1960s its force was becoming apparent not only in medicine but in the fledgling field of bioethics. Fletcher's grand themes needed only to be complemented by another great theme of the times, justice and equality, to catch fully that era in midflight. History moved rapidly thereafter. In the Belmont Report of the mid-1970s, in the findings of the President's Commission in the early 1980s, and in the push for health care reform that became the mark of the late 1980s the focus on justice brought a powerful counterforce against a dominance of medicine by the market. By its focus on conciliatory, moderate regulation as the antidote to extremism of the right or left, and in its embrace of the regnant individualism of our day, mainline bioethics found a cultural niche for itself that has been remarkably productive. Its analysis and pronouncements are sought by the media, paid at least a nodding tribute by government and professional bodies, and fostered in hundreds of university courses and workshops. What more could be asked? A good deal more, I want to suggest. As a field bioethics has displayed two serious deficiencies, exactly the kind that usually afflict golden children: it has failed to pursue with sufficient imagination the idea of the common good, or public interest, on the one hand, and that of personal responsibility, or the moral uses of individual choice, on the other. By its tendency to reduce the problem of the common good to justice, and the individual moral life to the gaining of autonomy, it has left a moral void. Much more is needed and can be done. If for no other reason than the economic crisis of our health care system, reflection is needed on the common good and individual responsibility. Health care now captures one-seventh of the American economy, with expenditures expected to reach $1 trillion in 1995. Quite apart from the question of its fair distribution, does it serve our common life to spend that much money in the name of health in the first place? And quite apart from the important question of the government's role in providing health care, what is our individual responsibility to attempt to stay healthy so as not to unnecessarily burden our fellow taxpayers? Above all, bioethics needs to develop the capacity to help individuals make good moral decisions in their own lives and to do so in the context of that most basic of all moral questions: how ought I to live my life? The health of the soul (as they might have put it in an earlier day) is even more important than the health of the body. The need for bioethics to develop a richer understanding of its societal dimentsion seems no less evident: modern medicine changes and shapes the way we live our collective lives and that gestalt needs analysis and judgment. A communitarian bioethics, which we now lack--and probably not by accident--would begin its work by looking both at individual responsibility and at the social dimension of the moral life. I want to sketch here an agenda for that kind of investigation, in great part simply by posing some questions that seem too little asked. Culture and Biomedical Changes It is hardly an accident that bioethics gravitated almost from the start toward an ethics of autonomy. That proclivity fit well with the dominant ideology of American society. Moreover, the field itself received much of its early, more specific impetus from egregious violations of individual integrity. Recall that it was the revelations of the abuse of human subjects in the 1960s through the work of Henry Beecher and others that first brought ethics to the attention of the medical community and the government. …