Bioethics Forum Essay
Continuing the Dialogue on Bioethics and Populism
Franklin Miller’s recent post in Bioethics Forum responded to our essay, “Bioethics and Populism: How Should Our Field Respond?” in the current issue of the Hastings Center Report. There, we suggested that rising global authoritarian populism presents opportunities for (and, one might even say, places responsibilities on) the field of bioethics. We proposed that bioethics might be able to help with our society’s increasing polarization by recognizing “that below the policy disputes are morally salient reasons people might have for diverging views. Bringing these values to the fore could help all parties see that they have legitimate moral concerns.” We also encouraged bioethics to focus more on issues of justice, given the reality that much of the discontent fueling populism derives from growing income and health disparities. Lastly, we called for bioethicists to promote civic learning: “Given the reality of fake news sites, the lack of substantive debate, the framing of most policy questions in ‘win’ or ‘lose’ terms, the echo chambers on the Internet, the erosion of public schools, and the economic threat to institutional and individual integrity, it is an understatement to say that we now face a crisis in how the public learns.”
Miller’s main criticism was that “most of the normative problems posed by authoritarian populism, such as tight restrictions on immigration and economic nationalism, are outside the domain of bioethics, as generally understood.” He also felt that our essay “gives the impression that bioethicists all do, or should, subscribe to a stance of liberal progressivism,” and that we had “conflated bioethics scholarship with political advocacy.”
Miller’s comments were critical, nuanced, and important. To address as many of his points as possible, we’ve chosen to write separate responses below, discussing different but related aspects of his critique.
Our goal in writing our essay was to spark discussion about the implications for our field during this turbulent, polarized time, and, therefore, we thank Franklin Miller for his response to our paper and the opportunity to clarify it. We hope many others will now share their views as well. It would be very exciting to hear how various bioethicists of all political persuasions, and with numerous vantage points, view these issues. After submitting this post, we will go silent, awaiting comments – we hope – from many colleagues, both those who agree and those who disagree.
Mildred Solomon responds:
Although both Bruce Jennings and I readily “cop” to being progressives, our essay does not advocate one political orientation over another, and we do not believe, “that bioethicists all do, or should, subscribe to . . . liberal progressivism.” Rather, our essay begins with the importance of preserving constitutional democracy, which is that set of established norms and protections that allows for debate across the full political spectrum.
Through their laws, established checks and balances to ensure the independence of different branches of government, written constitutions, and informal norms, constitutional democracies create the playing field upon which the full range of political thought – from conservative, market-oriented approaches to progressive, welfare-oriented ones — can assert views and compete for electoral support. We began our essay articulating the historical reality that unchecked authoritarian regimes erode constitutional democracies, silencing people regardless of political orientation and rendering dialogue across difference impossible. Often, they also exclude people from the benefits of society through nationalism and xenophobia, making some groups’ health and well-being far more vulnerable. Our goal was to ask: facing such societal threats, what might be the implications for bioethics?
Rather than advocating one particular political orientation, we argued that bioethics could make some important contributions and self-adjustments. First, bioethicists are well trained in modes of analysis that can identify underlying value conflicts. As we noted, too often heated political debates are just focused on technical questions (Is health care a form of interstate commerce?), rather than substantive explorations into the underlying values at stake. Upon deeper reflection, it is sometimes the case that both conservatives and progressives actually share common values but may not realize they do. Or, they may prioritize different values, all of which may warrant deep respect.
Too often, however, those worthy-of-respect values do not get surfaced. Bioethicists have the skills to bring those values forward in nonpartisan ways that just might enable people across the political spectrum to hear one another. In our essay, we used the example of how the debate about the Affordable Care Act might have been enriched, if conservative and progressive notions of fairness had been brought forward, heard, and debated. Similarly, we referenced an excellent paper by Madison Powers and Ruth Faden, which appeared in the 2003 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. In that paper, the authors demonstrated that a commitment to reducing certain kinds of health disparities is consistent with many theories of justice, including libertarian and egalitarian ones. Their paper is an example of the ways in which bioethics scholarship can articulate values that would otherwise be left implicit, opening the door for more meaningful dialogue across the political spectrum.
Our essay also called on bioethics to examine its own biases and preferences. The discontent that fuels authoritarian populism is real and deeply related to the social determinants of health. Being bioethicists at this particular moment in time, we might want to ask ourselves some questions: Have we paid as much attention to the social determinants of health and health disparities as we should? Should we focus more than we have on issues of justice (in all of the competing conceptions of that term), especially for marginalized persons or those whose discontent is so palpably fueling populism?
Another bias we urged for reconsideration is bioethics’ continuing embrace of a very thin notion of autonomy that conceptualizes persons as solitary, highly self-reliant individuals, while missing that confident, self-actualizing individuals typically do not spring into full bloom on their own, but are nurtured in loving relationships and robust communities, where there is adequate income security and neighborhood safety. We underscored that “independence is nurtured in interdependence.” Far from being a partisan, communitarian sentiment, as Miller characterized our claim, the interdependence of human beings is a social and biological fact, one that – in ordinary times — people of all political persuasions should have no problem accepting. In fact, accepting the intimate relationship between individuals, families, and communities could actually be a common starting point for both progressives and conservatives.
Finally, we thank Miller for acknowledging the foundational role The Hastings Center has played in the development of our field. That role was, in part, what led us to this essay. Increasingly, in our view, bioethics has become a highly specialized academic field with fairly narrow interests, mainly (though not exclusively) related to ensuring compassionate and just health care and the protection of human research participants. Yet, the vision that animated The Hastings Center from its earliest days was broader. It aimed, and still aims, to ask questions about what it means to be human, how we should live together, what we owe one another, and what sorts of communities we wish to build.
We appreciate his critique, but disagree with his conclusion that we have, “conflated bioethics scholarship with political advocacy.” On the contrary, we see bioethicists as having particular skills that can help political debate return to its better self, where real discussion of the values at stake might take place. And we call for more such opportunities to do so through what we term “civic learning,” particularly in states and municipalities. Civic learning, through a wide variety of civic innovations at state and local levels, can be an antidote to the Internet’s echo chambers and a way for friends and neighbors to come together when action at the national level is so difficult.
Second, we believe that rising authoritarianism will threaten human health and well-being in a variety of ways – from, for example, limiting health care for undocumented immigrants, the disproportionate incarceration of African Americans, the privileging of commercial interests over scientific validity, and the removal of regulatory protections that will threaten public safety and environmental quality. These moves (often accompanied by rising authoritarianism and the cronyism that comes with it) should cause us to reflect more deeply on the kinds of problems bioethics should take on, not only through direct political activity which is available to all of us as citizens, but also through our scholarship as bioethicists and public intellectuals.
Bruce Jennings responds:
In writing “Bioethics and Populism,” our primary goal was to stimulate reflection about our field at a time when partisan polarization and ideological disagreement is shadowed by a much more fundamental and disturbing prospect—the displacement of constitutional democracy and its core values, such as the rule of law, impartial public service, and honest public debate based on evidence and reasoned deliberation. This transformation has already taken place in several political cultures and it is neither unreasonable, nor premature, to become concerned about the continuing viability of these values in the United States. So, I too thank Franklin Miller for his response, and welcome the opening of a serious conversation on the responsibilities of our field in this uncertain time.
Miller has two basic disagreements with our position. First, he does not find the threat of authoritarian populism as great or as immediate as we do. He writes, “Despite the tilt towards authoritarian populism of the Trump administration, I see no evidence to suggest that we are in or approaching such a constricted environment; but if it were to occur, much more important than the threat to bioethics would be the consequences for the role of journalism and freedom of public expression in democratic politics.”
Second, he sees bioethics as a clearly delimited domain of special expertise, and thus in the face of defending civil liberties, he asks, “Why should bioethicists in their capacity as bioethics scholars, as distinct from informed citizens or public intellectuals, take on this role?”
In regard to the first disagreement, I wonder what counts as relevant evidence. Scientists at the Environmental Protection Agency, who are now proscribed from discussing climate science and evidence for anthropogenic climate change, might be forgiven for feeling constricted already. Is biomedicine really so powerful that it cannot be characterized in ways that undermine its public support? Interference with science is always open to those who provide the funding for it, and that extends all the way down the food chain to bioethics.
Moreover, while Solomon and I were concerned about deleterious effects on bioethics, our main concern was not to defend the specific interests of that field, but rather to make the point that all those who serve society by pursuing scientific research, fact-based investigation, and careful, consistent argumentation are in this together. Bioethics is not in one well-protected silo while journalism and civic discourse are in another more-vulnerable one. The vulnerability created by the acquisition of power by authoritarian populism is shared, and the voices committed to the values of constitutional democracy and to their greater realization in practice are heard or are stifled together.
The boundaries of discipline and subject matter expertise are not as sharp as Miller takes them to be. In the health domain, he seems quite comfortable with bioethics taking a stand against vaccine denial, but where is that line to be drawn exactly? Successful public health practices are not unaffected by the state of journalism; surely mistrust of vaccines and refusals of childhood immunization efforts grow, at least in significant part, out of misinformation campaigns and similar trends that have already undermined the integrity of journalism and public information.
Regarding the second disagreement, Miller’s idea is that we can be concerned about the broader state of our political culture as citizens, but should not be in our role as bioethicists. This strikes me as out of touch with our current reality. This dualism of citizen vs. private person or citizen vs. professional expert is belied by the fluidity of contemporary society and the reach of media technology.
It is true that many in bioethics share Miller’s perspective on our field’s identity, function, and role. Debates about whether bioethics should take advocacy positions and concerns about bioethics being too “political” have been ongoing for many years. In “Bioethics and Populism,” Solomon and I tried to express an alternative view that stands outside the usual debate, but Miller’s reading suggests to me that we did not make our point sufficiently clear.
Our view is political, but it is not partisan, and it is not ideologically committed to any particular point on the left-right ideological spectrum, as Miller mistakenly believes it is. Bioethics is a discourse of many perspectives and many types of expertise; and, as such, we regard it as an important interlocutor in a broad and pluralistic civic culture of political and social values, including but wider than health. Bioethics is only one voice in our constitutional democracy, to be sure, but it is an important voice, nonetheless. Not all bioethicists can become intellectual celebrities (thank goodness), but we all can and should be “public intellectuals.” That is not a different identity from being a bioethicist; it is constitutive of being a bioethicist. We cannot simply, like Candide, tend our own institutional and disciplinary gardens. Especially not today. It may feel safe to do so, but that sense of security is historically short-sighted, and may be short-lived. We shall see.
Mildred Z. Solomon is president of The Hastings Center. Bruce Jennings is a senior advisor to The Hastings Center.