Big Tent Bioethics: Toward an Inclusive and Reasonable Bioethics

The installments of this new column organized by the American Society for Bioethics and Humanities, as well as the thoughtful essays in the recent Cambridge Quarterly of Healthcare Ethics, demonstrate that the field of bioethics is reflecting on its current status and future prospects. And yet these essays also illustrate two troubling tendencies. First, some from within and outside bioethics have tended to treat certain aspects of the field as less worthy or important than others because of their academic nature or their limited relevance for the most urgent "real world" issues. Second, some have tended to obscure the complexity, richness, diversity, and ambivalence within the field by presenting it as increasingly polarized. Any clinician will attest to the fact that thirty-odd years of bioethical discussion have not resolved the difficulties facing professionals, patients, and families. Furthermore, the moral questions raised by high-tech medicine and futuristic speculations about where it may lead are deservedly central to bioethics, including the moral status of different life forms and of human beings at different stages of development, the goals of medicine, the definition and moral significance of the family, and what it means to call for justice in health care. Leigh Turner laments that the field of bioethics has had little to say about gun violence in U.S. cities or about how persistent economic disparities affect health and health care. (1) Surely bioethicists can make manifold and unique contributions to thinking about the health care crisis in the United States and in the world. Further, it is not just a matter of noting that there are health disparities. If more of us educate ourselves as Renee Fox and Judith Swazey recommend, (2) and as Norman Daniels has done, (3) we can engage with economists, political scientists, and health administrators to better deliberate about how to increase access to high-quality health care. I concur with those who want social scientists to help us try to understand the deep personal, social, and cultural sources of "suboptimal" health practices. Insights from ethnography, medical humanities, and philosophy are invaluable as we grapple with questions of justice in health and health care. Fiction, memoir, and qualitative data describe how people experience their encounters with illness and the treatments that heal or ameliorate. Both philosophy and social science contribute to our understanding of what people think they need in order to have a life of meaning and quality; of where health and health care fit into their scheme of values; and of when, if ever, treating people fairly requires treating people differently. We can agree that the current situation is full of injustice without yet having any bioethical (much less societal or global) consensus on what "justice" would look like, or on what methods of deliberation and decision-making would get us closer to justice. Once we acknowledge that life history and experience may influence a person's evaluation of the significance of health, illness, disability, health care, or even normality, we must still do the philosophical and empirical work of determining what role majority or minority opinion should play in remaking health policy. The reports of the current President's Council on Bioethics have been attacked by many in our field as irrelevant or as helping to create an increasingly polarized bioethics. I would urge people to reconsider the Council's work and to use it as a way to deepen our collective conversation. The work should not be dismissed as either marginal or as simple-minded traditionalism. Consider Beyond Therapy, the 2003 Council report that occupied a plenary session at the ASBH conference in 2004. The Council anticipated the criticism of irrelevance by pointing out that the report was addressing questions already facing medicine and society: Some may take us to task for worrying about the excesses and abuses of biotechnology . …