Bioethics Forum Essay
The Reactionary Recommendations of Project 2025: Why Bioethicists Should Care
Given its concern with making health and health care more equitable and just, bioethics should pay attention to the Mandate for Leadership: The Conservative Promise, best known as Project 2025. Produced by The Heritage Foundation, a conservative think tank, it builds on the aim promoted by the presidential administration of Donald Trump to dismantle the “administrative state” and continues as a focal point in his bid for re-election.
Project 2025 has far-reaching implications for the work of bioethics. The call to dismantle the administrative state not only impacts health and health care, it also seeks to undermine the trust that we have in government and policymaking.
To fully grasp what is at stake it is important to understand what constitutes the administrative state. Simply put, “it includes all the actors and activities involved in fashioning and implementing national regulation and administration,” from the career civil servants to political appointees, to the agencies established to ensure fair and unbiased regulatory oversight. The professional civil service serves justice and reinforces legitimacy in a democracy. But the values of justice and legitimacy, or the values of public trust in government for that matter, do not always serve the political beliefs or the political interests of the president.
Who likes bureaucrats and bureaucracy? Very few of us. But all democracies rely on an impartial, professional civil service to function. Civil service requires the discipline of competitive performance for employment or promotion. And it requires legal protection from arbitrary dismissal. The civil service bureaucracy provides an important check on the ideological power of the presidency. We believe that abolishing the procedural infrastructure of competent and effective governance is irresponsibly radical.
The U.S. built a professional civil service through reforms undertaken mainly in the early 20th century in response to a long history of corruption, graft, bribery, and the abuse of office for personal gain (e.g., the 1922 Teapot Dome scandal). For those who may doubt the value of civil service to the health and well-being of individuals and communities in the U.S., let us not forget what life was like before reforms came into being. Think of the workplace health and safety issues that lead to the Triangle Shirtwaist Factory Fire (1911), the radium girls (1920’s), and the meat processing scandal captured by Upton Sinclair in The Jungle (1906).
The early 20th century marked the development of protections for workers and broader society and the creation of the professional civil service. The modern era of oversight of food and drugs originated with the passage of the Pure Food and Drug Act of 1906 five months after the publication of The Jungle. The Department of Labor was established in 1913 to improve working conditions. It would be more than 50 years before an outgrowth of labor protections stemming from the historical events of the early 20th century would be fully realized. Specifically, the 1970 Occupational Safety & Health Act created the National Institute for Occupational Safety and Health and the Occupational and Safety Administration. Each of these agencies is identified in Project 2025 as the “divisions that most need reform and address.” (p 449)
Now, imagine these agencies left feckless and ill-equipped to render their missions without a professional civil service that operates free of political influence. Thestakes are high. As technologies such as artificial intelligence and gene editing become increasingly integral to biomedicine, they also become increasingly integral to bioethics and important to government policymaking.
Other major ethical and policy challenges include addressing climate change, eliminating health disparities, supporting universal health care access, and responding to the mental health crisis and the needs of an aging society. The list goes on. Without career civil servants to staff the administrative agencies, especially those at the center of Project 2025’s attack, we are at risk of losing the expert professionals and institutional memory that constitute the public health ethics and scientific integrity that is core to the mission of these agencies.
We are bioethicists who promote patient self-determination and shared decision-making for all, regardless of race, class, gender, ability, or national origin. Civil service is essential to reaching these goals. The law, ethics, and the ethos of a professional civil service forbid rulemaking, policies, and procedures that are arbitrary or capricious. In a word, civil servants are trustees, and it is the trust that we the people place in them that makes contracts, promises, and freedoms of all kinds, including freedom of choice, possible in our lives.
Bioethicists must be ready to respond to the inequities that would be furthered by the implementation of Project 2025. We must understand the implications of a dismantled administrative state to people’s health and well-being. And we must find the moral courage to speak truth to power as we aspire to answer a broader and more complex question: How can professional public administration work properly with a democratic citizenry to achieve fairness, individual freedom, and equitable access to the common good?
Bruce Jennings, MA, a Hastings Center fellow, is an adjunct associate professor in the Department of Health Policy and the Center for Biomedical Ethics and Society at Vanderbilt University.
Virginia A. Brown, PhD, MA is a research scholar in Health Equity and Population Health at The Hastings Center. @VirginiaABrown
Thank you Bruce and Virginia.
Soon after I began to hear about the Project 2025 documents I read through them quickly to discern impacts on rural America and particularly rural regions with disproportionate disadvantaged communities (where I live). I wanted to get word out to rural readers and published a piece in The Daily Yonder (quite early in the cycle of attention to Project 2025). Thank you for amplifying concerns among the bioethics community.
But the bioethics community is a surpassingly small electorate.
By contrast the rural electorate is much larger and significantly more powerful where it matters, in the Electoral College process. Why draw that comparison? Hearing the argument that “The call to dismantle the administrative state not only impacts health and health care, it also seeks to undermine the trust that we have in government and policymaking ” many rural voters would consider that they already have little ‘trust’ in the administration state, since hundreds of rural hospitals have closed in the past decades and presently “700 rural U.S. hospitals are at risk of closure due to financial problems, with more than half of those hospitals at immediate risk of closure” ( https://www.beckershospitalreview.com/finance/703-hospitals-at-risk-of-closure-state-by-state.html ). I get – and likely you do too – many announcements of webinars and reports on how to preserve or restore or increase Public Health Authority (PHA). I attend many of them and ask, ‘What did PHA – federal or state – do to prevent many of these rural hospital closures? What do you – experts in PHA – advise, now, to prevent hundreds more rural hospital closures?’ Guess what I hear in response?: mostly, basically, nothing. But, Certificate of Public Need, Medicaid allocations, etc are all lively concerns of federal and state Public Health Authorities.
Further evidence of neglect of rural health equity comes from what we are learning coming out of the Covid pandemic emergency. Persistent and pervasive negelct of rural communities’ health equity instantiated persistent and pervasive disparities in health infrastructure and health outcomes that produced disproportionately adverse experiences with Covid. See e.g. https://www.sciencedirect.com/science/article/abs/pii/S0277953623005373
In the late 20th century the rural electorate began to consolidate around national narratives that highlighted neglect and threat, as factories (textiles, furniture, machinery, etc) closed, and other employment was lost to ‘globalization’ and ‘financialization’ (corporate purchasing then closure of ‘local’ banks, ‘local’ merchants, ‘local’ service companies, etc) . In the same period Republican politics of ‘culture wars’ amplified this narrative conjoining economic anxiety with cultural anxiety (e.g. see https://www.politico.com/newsletters/politico-nightly/2024/02/22/they-surveyed-10-000-rural-voters-heres-what-they-learned-00142795 ) . See e.g. this graph: https://dailyyonder.com/tracing-the-divide-urban-and-rural-voting-preferences-started-to-diverge-in-the-1970s/2021/05/20/ Generally, Democratic politics fancied the values of global social and cultural elites and confirmed to rural Americans that there was, indeed a war, that they had already been losing and dare not keep losing.
Trump was an excellent entertainer for the electorate, and deal maker and/or bully, with powerful and wealthy interests, to consolidate and enlarge and electorate experiencing all the more economic and cultural anxiety. And, correct me if I’m wrong: bioethics elites, for the most part, made little or not progress toward researching, discussing, policy advocacy toward ensuring rural health equity, equitable attention and support for SDOH in rural communities, constructing a narrative revealing and sustaining the social-ecological and environmental-ecological integrity and vitality of rural America.
So, when many in rural communities read “Bioethicists must be ready to respond to the inequities that would be furthered by the implementation of Project 2025. We must understand the implications of a dismantled administrative state to people’s health and well-being” … many might say … Yeah, right? We were ‘dismantled’ decades ago and bioethics barely cared. Yeah, right!