The recent celebration of the 40th anniversary of The Hastings Center afforded an occasion both for looking back and for looking ahead. Much of the programming that surrounded this event, quite rightly, mused about the early days of the field. I was still in grammar school, however, when The Hastings Center was founded. As someone now in mid-career, I would like to take this opportunity to muse about the field, providing a look back but largely challenging us about the future.
I suggest that bioethics has evolved through three phases: a religious phase in the 1950s and ’60s, a philosophical phase in the ’70s and ’80s, and a political-empirical phase from the ’90s to the present. Much as been written and said about the first two phases, but little about more recent history.
By the late 1980s, just as I was starting serious study in the field, philosophical bioethics had created a standard canon and had begun to rest on its achievements. Physicians, who found the language of philosophers alien but had been taking courses in bioethics, began re-engaging the field (or, in some cases, reclaiming it as their own).
The general public, policymakers, and many of the new young students entering the field of bioethics by this time also began to complain that philosophy did not supply enough concrete answers to their pressing questions. They wanted solutions to social policy problems such as the distribution of health care resources, cost-containment, and physician-assisted suicide.
The physicians who became involved began to do the scholarship that physicians did best – empirical research. Simultaneously, the demand for relevance led to a shift in bioethical discourse to the level of policy and politics.
The move to the empirical and to policy was not calculated to be synergistic, but it proved to be so. Policymakers were happy to have empirical data upon which they could draw to justify their decisions.
I think this is where bioethics remains today. There are still scholars doing serious philosophical and theological work in the field, but the mainstream has shifted to empirical studies and policy concerns.
Where should bioethics go next? I will make six suggestions. I am sure they will not be uniformly popular, but I’d like to think they might provoke some interesting discussion.
1. I think we should avoid the temptation to make bioethics a clinical profession. Sadly, I think this is where at least one of our national organizations – the American Society for Bioethics and Humanities – is headed. ASBH already has a task force in place designed to deliver a program for making that organization a national accrediting body much like a medical board.
I think this is seriously wrong-headed. I completely understand the desire to set standards so that not just anyone can call herself a bioethicist and act incompetently, even harming patients in a hospital. However, one could accomplish this goal by establishing general standards while leaving it up to individual institutions to determine how they will assure that such standards are met.
Local institutions should have the freedom, given good reasons, to establish local variations. This would mean a program of credentialing at the local level without establishing a national accreditation program.
Establishing a national accrediting body has too many problems:
- It centralizes too much power in that group,
- It risks making the organization a group for bioethics consultants rather than for scholars from various disciplines who are interested in bioethics, many (if not most) of whom are not engaged in bioethics consults,
- It risks narrowing the intellectual playing field by suggesting that bioethics is a practice rather than a field of scholarly inquiry;
- It makes bioethics consultation too analogous to medical practice and runs the danger of being co-opted by medicine when it should be something that is not exclusively medical,
- It denigrates the vitally important role of nonethicists in ethics consultation. Expertise is important; however, the inclusion of nonexperts helps to ensure the best answers and the best care for patients – consultation conceived of as an enterprise best served by engaging the many as well as the wise.
2. We should forswear our recent turn to politics and start engaging again in basic scholarship. Politics is important, and I do not suggest that we should retreat to our ivory towers, smoking pipes and thinking great thoughts without any concern for the political aspects of bioethics. But too much recent discourse in the field has degenerated into spin control and sound bites. It has turned in too many instances into the making of clever statements that have punch, but little serious weight.
Too much of what passes for bioethics today has become discourse about what bill or candidate to support; about the latest transgression of the canons of political rectitude that should provoke our moral outrage. This is not the kind of serious scholarship our society needs.
Our best hope lies in pursuing the fundamental questions. This will often take us back to basic inquiries such as those of moral psychology; the meaning of altruism; the meaning of the common good; what it means for human beings to flourish; the place of medicine in a well-ordered society; and critical thinking about rights, casuistry, utilitarianism, pragmatism, and other very basic questions that are essential to serious thinking about bioethical questions. In the end, this will not only be more productive, it will be a lot more fun.
3. Similarly, I’d like to see a revival of interest in the philosophy of medicine, nursing, and the healing arts in general. Partly this is selfish, since I edit Theoretical Medicine and Bioethics, which publishes such work. Although there is still a lively discussion in this field in Northern Europe, in the United States, the conversation almost stopped dead in its tracks 15 years ago.
There are some hopeful signs that this is changing. There is a serious uptick in interest in the philosophy of medicine among young philosophers – there is now a North American list serve.
There are also changes in the questions being asked. While they used to be about concepts of disease and health, now there is increasing interest in the nature of medical knowledge and evidence, the concept of disability, the logic of diagnostic reasoning, and an abiding interest in phenomenological understandings of the physician-patient relationship. Once again, it seems implausible to me that we can address the serious ethical questions that confront us in medicine without a more fundamental understanding of medicine.
4. We should continue to pursue the goal of truly interdisciplinary scholarship. The academy, in general, talks a great talk about being interdisciplinary, but delivers very little. Bioethics remains perhaps the last great hope for interdisciplinarity truly to flourish. Bioethics has done a decent job, but we can go much deeper. The work will be hard, but rewarding.
The wrong way to go about this, however, is to make bioethics into a homogenous mush. I am, frankly, quite troubled by the proliferation of degree-granting programs in “bioethics.” A smattering of sociology, philosophy, literature, law, and political science does not constitute a discipline that can interact with other disciplines in a productive dialogue.
Bioethics is not a discipline. It is a fascinating field of inquiry that can productively attract scholars from many disciplines in a dialogue. Each can learn from the other, and all can contribute to a richer understanding of the questions that confront us.
There is plenty of work to do in finding out how better to facilitate interdisciplinary scholarship. Exactly what can a sociologist do for a philosopher or a historian for a lawyer? Can it develop beyond a series of pictures at an exhibition to form some sort of coherent unity? Bioethics is the field in the best position to explore these questions.
5. I think it is time we started working on new theories of bioethics. Surely we did not exhaust all the possibilities with five books in the 1970s, now appearing in new edition after new edition.
All the new books in bioethics are about topics – cloning, or advance directives, or research in the developing world. Where are the new, comprehensive views? Who will write these?
6. Finally, let me suggest that medical schools would do well to embrace programs designed to train clinicians in philosophy and theology, just as they now train clinicians in molecular biology and neuroscience. For the field of bioethics to be respected in academic medicine, it needs to embrace its basic sciences. It is all well and good to do empirical studies in health services research and the psychology of medical decision-making, but these methods are descriptive, not prescriptive.
We might be able to produce a core of such dually trained experts – one or two per medical school – and a cadre of interested philosophers, health services researchers, clinician-educators, psychologists, lawyers, and chaplains working with them as an interdisciplinary team conducting research, teaching, and doing ethics consultation. A philosopher who knows the practice of medicine experientially, or a physician who is trained in the “basic sciences” of philosophy or theology, will be better prepared to do bioethics than a philosopher or theologian lacking in experiential knowledge or a well-intentioned clinician who does not know any theory.
At any rate, these are some rapid-fire thoughts about the future from one who loves the field and wants to see it flourish.
Dan Sulmasy, OFM, M.D., PhD, a Hastings Center Fellow, is the Kilbride-Clinton Professor of Medicine and Medical Ethics at the University of Chicago. This is essay is based on a talk given on the future of bioethics at the Fellows meeting of The Hastings Center’s 40th anniversary celebration in New York.