In search of a wide-angle lens.

What issues should bioethics be looking at in the next forty years? Rather than take on new issues, I believe bioethicists should rethink our approach to bioethical topics more generally. Doing so will require refashioning the field itself, but such a reinvention is the only way we can help bioethics live up to its initial ideals and be relevant to our society. Is Bioethics Necessary? Thinking about the future of bioethics should begin with a fundamental question: Is bioethics even necessary? Most bioethicists would certainly think so, and they might find confirmation in histories of the field like David Rothman's Strangers at the Bedside, in which bioethics was a response to the collapse of doctor-patient relations in the mid-twentieth century United States. (1) Here, the field emerged to protect vulnerable populations from exploitative doctors and scientists. As such, it was allied with the civil rights and feminist movements. What could be more necessary than that? But this rosy view of the field's development has been highly questioned. Roger Cooter has argued that bioethics appeared to allow doctors to maintain control over the provision of health care; rather than a progressive movement aligned with civil rights and feminism, it was a reaction to the anxiety these movements generated in physicians. (2) His reading would seem to be substantiated by Susan Lederer's account of the generation of the Helsinki Declaration, in which the opposition of U.S. doctors to the declaration's prohibitions on experimentation on children and prisoners was connected to the pharmaceutical industry's desire to maximize profit. (3) More recently, various authors have illustrated how foundational bioethical concepts like "autonomy" and "informed consent" are used in ways that exploit vulnerable populations, such as the poor and disabled. (4) These sources show that we bioethicists, rather than looking for new issues, would do better to look at ourselves. The problem is the way we have framed our approaches to the field's key topics. We have been obsessed with questions of abortion, euthanasia, stem cell research, and the like. But the very framing of these issues in bioethical discourse can obscure the underlying forces that create the problems to begin with, whether these forces be the economic organization of society, internalized discrimination against the disabled, the epistemology of medicine, or (and most likely) some combination of all three. We need to find ways to understand the larger problems that create the "old" issues--problems in which we can productively intervene. A New Model for Bioethics Education Here we encounter a significant institutional problem: U.S. bioethics education remains tethered to a narrowly defined training regimen that is inadequate to explore the underlying causes of the field's problems. As such, it frequently does not prepare students to understand the issues they are supposed to resolve. Consequently, our primary concern should be reformulating bioethics education in a way that gives students the tools to understand and investigate the field's concerns. Bioethics institutes, rather than being oriented around the transmission of rule-based knowledge, should provide a robust, interdisciplinary curriculum that produces thinkers capable of exploring the complex context of bioethical issues and proposing mechanisms to resolve present conflicts. The goal of this curriculum would not be to prepare thinkers to "take sides" on current bioethical debates, but instead to explore how the framing of these debates can mystify the real issues at play. Exploring the dynamics of problem constitution would be the first step toward problem solving. (5) This would make it possible to productively intervene in debates whose terms have become stagnant. Students emerging from such programs would be prepared to comment on how the dichotomy between the secular "pro-choice" and the religious "pro-life" perspectives that frames our discussions of abortion and euthanasia obscures how the economic ideologies of both sides in the debate might encourage people to abort and engage in euthanasia, even as they negate whatever "freedom" might exist in that choice. …