Download Anthropological and Sociological Critiques of Bioethics

Bioethical Inquiry (2009) 6:83–98
DOI 10.1007/s11673-008-9130-5
Anthropological and Sociological Critiques of Bioethics
Leigh Turner
Received: 25 October 2007 / Accepted: 16 October 2008 / Published online: 18 December 2008
# Springer Science + Business Media B.V. 2008
Abstract Anthropologists and sociologists offer
numerous critiques of bioethics. Social scientists criticize
bioethicists for their arm-chair philosophizing and
socially ungrounded pontificating, offering philosophical
abstractions in response to particular instances of
suffering, making all-encompassing universalistic claims
that fail to acknowledge cultural differences, fostering
individualism and neglecting the importance of families
and communities, and insinuating themselves within the
“belly” of biomedicine. Although numerous aspects of
bioethics warrant critique and reform, all too frequently
social scientists offer ungrounded, exaggerated criticisms
of bioethics. Anthropological and sociological critiques
of bioethics are hampered by the tendency to equate
bioethics with clinical ethics and moral theory in
bioethics with principlist bioethics. Also, social scientists
neglect the role of bioethicists in addressing organizational
ethics and other “macro-social” concerns. If anthropologists
and sociologists want to provide informed critiques of
bioethics they need to draw upon research methods from
their own fields and develop richer, more informed analyses
of what bioethicists say and do in particular social settings.
L. Turner (*)
Center for Bioethics, University of Minnesota,
N504 Boynton, 410 Church Street SE,
Minneapolis, MN 55455, USA
e-mail: [email protected]
Keywords Bioethics . Sociology . Anthropology .
Social sciences
Introduction
Skeptics, debunkers, critical interpreters of social
worlds, anthropologists and sociologists gain little
satisfaction from offering softened, rose-hued portraits
of their objects of study. Critical social theorists, neoMarxists, Foucauldians, postmodernists, symbolic interactionists—not one of these disparate social science
clusterings is motivated by the interpretive sensibility of
a Norman Rockwell. As Howard Becker (1968) and
Charles Bosk (2001) observe, social scientists are not in
the business of reproducing “conventional sentimentality”.
Rather, one of the self-described tasks of social scientists
is to peer past public facades to often rather shabby
“backstage” settings. A common interpretive move in the
social sciences involves proceeding beyond conventional
pieties and offering critical readings of social order, status,
power, and professional ideology (Berger 1963).
Describing what makes ethnographic data “rich” or
“thick,” Bosk (2001, 206) writes,
Rich data subvert official definitions, generally
accepted public understandings, and conventional
wisdom. Such data tell us what public records and
official statistics conceal. Such data are best
gathered backstage, behind the yellow tape and
the signs limiting access to authorized personnel.
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Bioethical Inquiry (2009) 6:83–98
Driven by a hermeneutics of suspicion, social
scientists do not simply repackage whatever selfserving tales their objects of study like to tell.
Summarizing the critical, debunking style of the
social sciences—a stance that seems to be as much
moral imperative as interpretive method—Bosk
(2001, 213) writes:
The most characteristic ways a social scientist
learns to think are organized to disabuse any
group of its own notions of its ‘specialness’.
Social science is a generalizing activity. One
implication of this is that when group members
claim special qualities, sensitivities, skills, or
privileges, ethnographers dutifully record these
sentiments. We take the sacred beliefs of a group
about itself seriously but not literally; and social
scientists do more. We point out how such
sentiments are shared by other groups and are
manipulated by those groups for their own
advantage; we show how altruistic beliefs cloak
self-interest. In short, what we do is take a
group’s sense of its specialness and inspect it;
and while inspecting it, we show how ordinary,
commonplace, and self-serving it really is. Few
groups are grateful for this.
Whether Bosk’s (2001, 217) brief account of a
deflationary style of thought fully encompasses all
that occurs in the social sciences is open to question.
As he notes elsewhere in his text, there are important
distinctions to be made between “studying up” and
“studying down” social hierarchies. Though exercises
in debunking perhaps make sense when assessing the
claims of the powerful, these same tactics can seem
grossly insensitive when exploring the social worlds
of low-status, marginalized groups. Still, admitting
the need for qualification and recognizing important
differences in methods, theories, and background
assumptions within disciplines and across the social
sciences, the suspicious interpretive stance described
by Bosk constitutes a fairly widespread ethos within
the social sciences.
Whereas professionals often describe their work by
drawing upon the rhetoric of beneficence and altruism, the task of the social scientist is in part to
unmask the self-interested behavior lurking behind
claims of serving the commonweal. In taking this
stance, social scientists propose to replace the selfaggrandizing narratives of their subjects with more
“realistic,” empirically “honest,” “grubby” accounts
of social life. For this reason social scientists
sometimes draw upon the imagery of “the mirror.”
“Fieldwork,” Bosk observes, “provides a mirror for
looking at who we are as over and against who we
would like to be” (Bosk 1985, 14). Describing the
value of sociological studies of bioethics, De Vries
(2003, 289) notes how sociologists “can hold the
mirror that allows bioethicists to see how the small
and large compromises required to get along in the
world have influenced their work.” The mirror offered
by the social sciences has special properties. It
promises to reveal viewers as they truly are rather
than as they envision themselves, or pretend to
envision themselves, to be. Such reflections are not
always appreciated by social actors wishing to see
themselves—and be seen by others—in a flattering
light.
The trope of the mirror has its limitations. With the
“crisis of representation in the human sciences”
(Marcus and Fischer 1986, 7–16), social scientists
increasingly recognize their own role in creating
interpretive categories and narrating social worlds.
Of course, contemporary social scientists do not need
to be taught a lesson on the role of researchers in
interpreting social life and narrating social worlds
within the constraints of particular literary genres and
disciplinary conventions. Ethnographers of biomedicine and bioethics are not in need of rescue from
residual positivism. When claiming to provide mirrors
on social life, they promise something valuable, albeit
possibly painful for bioethicists. If social scientists
can replace self-serving narratives with frank analysis
then they have much to offer bioethicists and anyone
else falling within the scope of the sociological
imagination or the anthropological lens. If ethnographers and other interpreters of social life can reveal
how bioethicists purport to serve the common good,
or the good of patients and vulnerable research
subjects, yet are in truth largely driven by selfinterest, then disclosure of unpleasant truths is surely
more honest than self-serving accounts to the contrary. The problem, though, is not that social scientists
provide a mirror upon whose surface we can see
bioethics with all its flaws. Rather, the chief limitation
with sociological and anthropological analysis of
bioethics to date is that too often social scientists
offer a “Fun House” mirror in which bioethics is, if
not quite unrecognizable, at least bent out of shape.
Bioethical Inquiry (2009) 6:83–98
Such a wounded response is just what might be
expected from someone flinching in response to what
Raymond De Vries and Janardan Subedi (1998, xvii)
call “the sociological dissection of bioethics.” Social
scientists pride themselves on revealing the unpleasant truths hiding beneath the surface. Recipients of
such treatment are unlikely to respond to unmasking,
unveiling, undressing, or dissection with appreciation.
The very suggestion that social scientists offer
distorted accounts of bioethics might to some social
scientists provide further evidence that sociological
and anthropological reflections upon bioethics are
accurate. Angry denials are just what might be
expected when unpleasant truths come to light.
However, I want to challenge this response. Rather
than emphasizing how ethnography or sociology can
“save” bioethics (Hoffmaster 1992; Lopez 2004), I
argue that too often social scientists provide readings
of bioethics that are: not just critical but dismissive;
unfamiliar with the detailed topographical features of
scholarship, teaching, and practice in bioethics;
selective and therefore misleading and unfair; and,
generally detached from recognizable social science
research methods that might offer genuine insight into
what bioethicists say, think, and do. Less polemical
anthropological and sociological analyses would
potentially enrich both bioethics and the social
sciences. Here I second Klaus Hoeyer (2006) in
asking what might be gained by moving beyond
“hostile” analyses of bioethics to more productive
encounters between scholars in bioethics and the
social sciences.
Many sociologists and anthropologists criticize
bioethicists for their arm-chair philosophizing. However, one of the great limitations of sociological and
anthropological analyses of bioethics to date is the
volume of ungrounded analysis. Social scientists
criticize bioethicists for offering massive generalizations
rather than fine-grained, situated, thick description. I
suggest that too often anthropological and sociological
critiques of bioethics offer generalizations that obscure
the richness and diversity of bioethics. Social scientists
criticize bioethicists for failing to acknowledge and
respect social scientific research methods when making
particular empirical claims about social life. I argue that
many social science critiques of bioethics are detached
from detailed, careful research into bioethics as practiced
in particular social niches. Social scientists insist that the
“origin” tales and legitimation narratives of bioethicists
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are inevitably self-aggrandizing. I note that the “stories”
social scientists tell of bioethics seem rather self-serving.
By portraying and packaging bioethicists as sociological
dopes, social scientists disparage the interpretive insights
of bioethics and exaggerate the distinctive contributions
of their home disciplines.
The sociology and anthropology of bioethics is not
characterized by “thick description,” extended exercises
in participant observation, careful, detailed readings of
texts and arguments, or long-term immersion in the local
moral worlds of particular social settings within which
bioethicists practice their work. Detailed anthropological
and sociological analysis of bioethics as constellations of
moral theories and ecologies of social practices might
provide valuable insight into the strengths and limitations
of bioethics teaching, research, clinical work, policy
making, and social advocacy. However, too few examples
of such grounded research exist.
Depictions of Bioethics
Summarizing his anthropological analysis of bioethics,
Kleinman (1995a, 53) writes, “the portrait of bioethics
that I have drawn is all too black and white.”
Kleinman insists upon the “heuristic” value of this
approach. However, if social scientists have something useful to offer in the form of critical social
analysis of bioethics, it is to push exploration of
bioethics well beyond “black and white” portrayals of
complex social realities. I want to challenge such
accounts of bioethics for two reasons. First, social
reality is far more multihued than “black and white”
analysis can reveal. Bioethics, sociology, and
anthropology are all complicated areas of scholarship.
They cannot be easily summarized. Second, in the
narratives offered by sociologists and anthropologists,
too often social scientists wear white hats and bioethicists
wear black hats. We do not just get a “black and white”
sketch of reality; we are offered sociological and
anthropological narratives that divide the world
into compassionate, discerning social scientists and
hard-hearted, shallow bioethicists.
Though I cannot offer a thorough characterization
of the many different social science critiques of
bioethics—they are too numerous and too varied to
address in detail—I want to identify and challenge
three common social science indictments of bioethics.
These critiques have the status of received wisdom in
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the social sciences. Passed down as “sacred truths”
from respected senior scholars (Fox and Swazey
1984) to the latest generation of medical anthropologists
and sociologists, these claims function as starting points
from which to judge as opposed to tentative conclusions
reached after arduous work “in the field.”
First, challenging a common allegation of social
scientists, I suggest that bioethicists are not simply
“collaborators” with “biomedicine” or the “medical
industrial complex.” Though I take seriously social
science critiques of the many different ways in which
bioethicists ingratiate themselves to powerful social
actors, I argue that not all bioethicists are servants or
show dogs of established social authorities and
economic interests. Some bioethicists have close ties
to leaders in industry and some bioethics centers
accept corporate funding. However, other bioethicists
are sharp critics of medicine, biotechnology, and the
current social organization of health care.
Second, I argue that anthropological and sociological
accounts characterizing bioethics as dominated by
formalism, rationalism, deductivism, universalism, and
abstract “principlism” fail to do justice to bioethics as
both body of theories and collection of social practices.
This rendering of bioethics provides a reductionist
narrative that mischaracterizes bioethics and exaggerates
the distinctive contribution of the social sciences to
moral reflection. Not all bioethicists are principlists.
Not all bioethicists are moral universalists. In their
search for a foil against which to advance “situated,”
“contextualist” approaches to moral analysis, too many
sociologists and anthropologists fail to recognize the
over two decades of criticism principlist bioethics has
received from other scholars working in bioethics as well
as other fields of study.
Third, I challenge the allegation that bioethics is
reducible to an ethos of “individualism” or “autonomy”
concerned only with the patient-physician relationship
and the promotion of respect for individual choices.
Though bioethicists provide normative analysis of the
patient-clinician relationship, bioethicists engage social,
institutional, and professional domains well beyond
the boundaries of the individual patient-physician
relationship. Public health ethics, for example, is a
thriving area of study in contemporary bioethics.
Social science accounts that insist bioethics is
reducible to the patient-physician relationship can
make such a claim only by overlooking the extent
to which bioethicists address broader questions
Bioethical Inquiry (2009) 6:83–98
related to social justice, resource allocation, access
to health care, and inequalities in health and illness.
In defending aspects of bioethics I do not mean to
suggest that bioethicists should be complacent about
the quality of their work, the current boundaries of
their chosen academic turf, or the intellectual substance of bioethics. I make no effort to defend
bioethics in its entirety. Rather, I simply want to
suggest that some social science critiques of bioethics
rely upon selective, reductionist readings of both
areas of scholarly enquiry and different domains of
social practice. Why social scientists might offer such
narratives is a fascinating question. Whose interests
are being served here? How is academic turf marked
and defended, by whom is this task performed, and to
what end?
Take the Money and Stay
According to one social science critique of bioethics,
bioethicists are collaborators, ornaments rather than
guardians, comfortable insiders within the biomedical
complex. As Jonathan Imber (1998, 30) writes,
“bioethics is the public relations division of modern
medicine, whether physicians (or bioethicists) like it
or not…Instead of stripping the halo from the
profession, the bioethicist adds another, his or her
own, to that of the physician’s”. Similarly, De Vries
(2003, 289) describes bioethics as “the balm for the
troubles of physicians, hospitals, pharmaceutical
companies, medical device companies, and medical
researchers.” In a biting observation, he echoes Carl
Elliott in characterizing bioethics as “a show dog
rather than a watchdog” (2003, 289).
Many social science critiques of bioethics assert
that bioethicists serve the interests of powerful social
and economic forces. They pander to economic elites
and, in symbiotic or parasitic manner, thereby
advance their own interests. Advancing one possible
reading of bioethics, Kleinman (1995a, 51–52) writes,
From the vantage point of social theory the
argument might be advanced that bioethics has
received authorization to use abstract philosophical
terminology that shares a value orientation with
biomedicine in order to construct the moral domain
in health care so as to assure that professional
medical dominance will not be seriously threatened
Bioethical Inquiry (2009) 6:83–98
by lay perspectives and everyday life experiences
that might generate a deeper critique of that
medical-moral domain and the economic interests
with which it is inextricably tied. Professional
dominance is maintained, in this view, via the
development of a new profession—bioethics: a
handmaiden to the powerful medical bureaucracies
and associations of professionals, which itself gains
jobs, prestige, and a degree of influence from this
social assignment. An uncharitable social science
observer might even point to the exoticism so
characteristic of the extreme examples bioethicists
favor as evidence of mystification, this profession’s
unwillingness to challenge the everyday organization
and practice of care.
Having floated this trial balloon, Kleinman
(1995a, 52) recommends “caution in accepting this
analysis.” Though he elsewhere (Kleinman interview
in Honkasalo and Lindquist, 1997, 119) describes
bioethics as “a weak field,” increasingly “hegemonic,”
“more acceptable to medical and public health people
because it doesn’t raise the same kind of issues about
politics and political economy that medical anthropology raises,” and seeking to “usurp” areas of academic
terrain properly ruled by medical anthropology and
other disciplines, Kleinman (1995a, 52) acknowledges
“bioethics has opened up a legitimate space to examine
moral issues of illness and care” and recognizes “the
scholars at work developing the discourse in bioethics
are greatly heterogeneous.”
Whereas Kleinman (1995a, 52) attributes a
particularly dismal reading of bioethics to an “uncharitable
social science observer,” and does not accept responsibility
for such a reading, other scholars are more willing to
characterize bioethicists as outright “pawns,” “servants,”
or “handmaidens” of authority. According to Charles
Rosenberg (1999, 38),
As a condition of its acceptance, bioethics has
taken up residence in the belly of the medical
whale; although thinking of itself as still
autonomous, the bioethical enterprise has
developed a complex and symbiotic relationship
with this host organism. Bioethics is no longer (if it
ever was) a free-floating, oppositional, and socially
critical reform movement: it is embodied in chairs
and centers, in an abundant technical literature, in
institutional review boards and consent forms, in
presidential commissions and research protocols….
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By invoking and representing medicine’s humane
and benevolent, even sacred, cultural identity,
bioethics serves ironically to moderate and thus
manage and perpetuate, a system often in conflict
with that idealized identity. In this sense, principled
criticism of the health-care system serves the
purpose of system maintenance.
Later in his article Rosenberg (1999, 42–43) writes,
To some critics on the Left, bioethics is no more
than a kind of hegemonic graphite sprayed into
the relentless gears of bureaucratic medicine so
as to quiet the offending sounds of human pain.
Its ethical positions, this argument maintains,
are, in terms of social function, no more than a
way of allaying social and legal criticism, and
are merely the self-reproaches of a minority of
ethically-oriented physicians…finally, these critics
contend, it is not surprising that in a bureaucratic
society we have created a cadre of experts and a
body of knowledge to provide a soothing measure
of humanity, certified and routinized.”
Like Kleinman, Rosenberg offers a scathing
account of bioethics but then distances himself from
this analysis.
Whereas Kleinman and Rosenberg offer indictments
of bioethics and then detach themselves from these
allegations, Bosk offers a more straightforwardly
pugnacious account of how bioethics managed to
acquire a position of social authority. Challenging the
“triumphalist” and largely self-serving histories of
bioethics written by and for bioethicists, Bosk (1999,
64) writes,
The account of bioethics’ rise to prominence
offered here tempers this triumphalism by showing
how limited was the challenged presented to
organized medicine. Had space permitted a fuller
discussion, I would have shown that bioethics was
a contemporaneous alternative to a more forceful
challenge to medicine spearheaded by consumer
and patient activists. This later challenge was more
confrontational in tone, more insistent on structural
change, and more focused on the politics of health
care than was the bioethics movement. By
assimilating bioethics, organized medicine was
able to defang this other, broader challenge….
by pointing out how bioethics’ triumph is
related to how limited was its challenge to
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Bioethical Inquiry (2009) 6:83–98
organized medical interests, we are also in a
position to understand why bioethicists have
not raised a number of political issues that also
can be defined as ethical questions: the
presence of so many millions of Americans
without health insurance, the multiple ways the
production pressures of managed care undercut
the possibilities of the doctor-patient relationship
that bioethics celebrates, the inequalities in health
status between rich and poor, or the replacement of
professional values with corporate ones.
The intellectual independence of bioethics is “an
illusion,” Bosk (1999, 61) asserts. “Bioethics developed
within the institutional structure and with the institutional
resources of academic medicine, and this undoubtedly
influenced its critical thrust.” (1999, 61) Instead of
offering serious social criticism and trenchant guidance
for radical social reform, bioethics offers “defanged”
social commentary—just what one might expect from
docile show dogs rather than alert watch dogs.
Acknowledging variations among social science
critiques of bioethics, it is a commonplace of this
genre to characterize bioethicists as servants of
established social and economic authorities. Handmaidens, servants, balm, show dogs, institutional
graphite—these evocative terms capture the notion
of the bioethicist as servant, parasite, shill, and
sellout. Whereas social scientists are presumed to be
capable of offering credible social criticism—of
speaking truth to power—bioethicists are cast in the
role of false prophets, corporate tools, and accomplices to biomedicine. I wish to draw attention to
several noteworthy features of this social science
morality tale.
In castigating bioethicists, this story gives all the
good lines to social scientists. Though bioethicists are
cast as witting or unwitting dupes of established
social authorities, social scientists are invested with a
special purchase on moral authority and social insight.
While bioethicists nestle comfortably inside the belly of
the whale of medicine, social scientists perch uneasily
“on the margins,” maintaining their critical distance,
critical lenses sparkling, apparently uninfluenced by
power, money, and the prospect of influence. In this
story, as Renee Fox (1994, 50) observes, bioethics lacks
“a conception of social justice that pays special
attention to the plight of the poor, the disadvantaged,
the victims of social prejudice and discrimination.”
Arthur Kleinman’s (1995a) anthropological critiques of
bioethics similarly suggest that whereas ethnographers
recognize, witness, and give voice to the poor, the
vulnerable, and the powerless, bioethicists “fast-forward” their agenda by connecting themselves to
powerful players within the medical-industrial complex.
Social scientists criticize bioethicists for their
triumphalist creation narratives. And yet, it is hard
not to find the narratives of social scientists somewhat
self-serving. Surely the story that social scientists
acknowledge and address social suffering, poverty,
global inequalities, homelessness, and lack of access to
health care whereas bioethicists are indifferent to broad
questions of justice and toady to social and economic
elites is just a little too tidy (Bayer et al. 1988;
Beauchamp 1985; Callahan 1990; Callahan 1999;
Churchill 1987; Miles 1993; Zoloth-Dorfman 1995b).
We need social analysis that moves beyond depicting
bioethicists as so superficial that they might well be
labeled sinners and social scientists as so discerning and
attuned to the suffering of the vulnerable that they
might be regarded as saints.
When criticizing bioethicists for their symbiotic
relationship with biomedicine, social scientists offer
remarkably little textual analysis, historical research, or
ethnographic evidence to support their claims. For all the
criticisms directed toward the self-serving, uncritical
work of bioethics, it is not entirely clear what justifies
these allegations. The bioethics literature contains many
contributions responding to social justice issues and
broad questions of social policy. For example, if their
scholarly publications can serve as one form of evidence,
American bioethicists would, on balance, seem to be as
appalled as U.S. social scientists at the absence of
publicly funded “universal” health care insurance, the
rise of for-profit HMOs, the continuing presence of
major inequities in access to health care, and the
exclusion of over forty-seven million Americans from
access to health care (Bayer et al. 1988; Beauchamp
1985; Callahan 1990; Churchill 1987; Emanuel 1995;
Jecker and Jonsen 1997; Miles 1993; Miles and Koepp
1995; Pellegrino 1995; Zoloth-Dorfman 1995a;
Zoloth-Dorfman and Rubin 1995). Both bioethicists
and social scientists condemn the fragmented, chaotic,
socially stratified, profit-driven nature of health care in
the United States. Public displays of dissatisfaction with
the status quo provide no insight into disciplinary
affiliation. Bioethicists and social scientists have similar
responses to many different social injustices.
Bioethical Inquiry (2009) 6:83–98
I do not mean to defend bioethics in its entirety.
Bioethicists need to better attend to global issues and
not just address questions of social justice and access
to health care in wealthy societies (Farmer and
Campos 2004). Perhaps bioethicists pay too much
attention to “microsocial” questions of “clinical
ethics” and pay insufficient attention to broader social
and structural considerations. However, any thoughtful response to these matters requires a sophisticated
encounter with bioethics as a body of scholarship.
There are many different “voices” within bioethics.
Some of these voices address social justice and public
policy issues of long-standing concern to social
scientists.
If social scientists often seem unwilling to
acknowledge scholarship in bioethics that does not
support stock criticisms made by social scientists,
too often they are equally disinclined to engage in
careful empirical analysis of what bioethicists
actually do. Are most bioethicists complicit in
maintaining existing social inequalities and serving
the interests of technological and economic elites?
Do some bioethicists resist corporate interests or the
interests of powerful physicians and other social
actors in the clinic, the boardroom, and policy making
arenas (Andre 1997a; Andre 1997b; Freedman 1996)?
Are bioethicists servants of the status quo? Do they
always play the role of institutional and social
“graphite” or do bioethicists sometimes play the role
of “fly in the ointment”? Do bioethicists replace one
form of so-called expert knowledge with another set of
claims to expertise or do they sometimes offer
something more modest? Careful investigation of these
questions will require directing attention toward different
realms of social practice (Kelly et al. 1997). Clinical
ethicists are likely to have an orientation to ethical
issues emerging within particular social institutions.
Whatever topics they address in their publications, as a
practical matter clinical ethicists are not well-positioned
to regularly influence broad questions of national or
transnational social policy. On a day-to-day basis,
clinical ethicists are presumably attuned to “micro-social”
considerations emerging within particular institutional
confines. In contrast, individuals engaged in
bioethics-related work in universities, think tanks,
government agencies, and nongovernment organizations
are perhaps better positioned to address larger-scale,
“macro-level” ethical issues and social problems.
Assertions about what bioethicists do are connected
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to precisely whose work is being assessed. The
reduction of bioethics to hospital-based clinical
ethics overlooks bioethics scholarship addressing
the larger social, political, and economic issues that
interest many social scientists. The equation of
bioethics with clinical ethics constitutes one form
of reductionism in social science critiques of
bioethics.
Too many sociologists and anthropologists fail to
respect the standards of their own disciplines when they
offer catch-all critiques of bioethics. Unimpressed
by the tendency of bioethicists to engage in
abstractions and offer unreal, otherworldly “solutions”
to murky, perplexing, tragic social contexts, Kleinman
(1995a, 48–49) writes,
On several occasions, I have heard philosophers,
who have otherwise made trenchant criticisms of
epistemological and ontological positions, intervene
in a discussion of medical ethics by adverting
to the example, ‘Suppose a Martian were to
land on earth and were faced with such a
problem.’ The illustration is probably meant to
explode conventional common sense. Yet it is a
telling method to introduce into the discussion of a
particular case, because it so cavalierly steps
outside the powerful constraints of real worlds.
Happily or unhappily, there are no Martians; there
are unfortunately, many, many humans on our
planet who are faced with desperate choices in
situations in which the concrete details of historical
circumstances, social structural constraints like
limited education and income, interpersonal
pressure, and a calamity in the household or
workplace are at the core of what a dire ethical
dilemma is all about.
I, too, have endured such presentations. They are
as insufferable and unhelpful as Kleinman suggests.
However, such an observation offers no generalizable
insight into bioethics. Given the dearth of empirical
research on bioethics—scholarship relying upon
ethnographic research methods or, for that matter,
any recognizable method of social science inquiry—it
is unclear why social scientists are prepared to make
broad statements about what bioethicists do and
whom they serve. Social science critiques of bioethics
would be more valuable and more accurate if there were
fewer philosophical musings by social scientists and
more socially situated, empirically based, “contextual,”
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“thickly described” sociological and anthropological
characterizations of the substance, boundaries, and
shortcomings of bioethics.
Top–Down and Bottom–Up
Within social science commentaries on bioethics,
distinctive vocabularies are used to describe the
respective methods and theories of bioethicists and
social scientists. Bioethicists are typically described
as top–down deductivists; social scientists characterize themselves as bottom–up inductivists or interpretivists. Like automatons, bioethicists supposedly
apply abstract, general principles that are largely
irrelevant to the social circumstances and settings
they are meant to illuminate. In contrast, social
scientists engage in arduous labor to enter into, situate
themselves within, and interpret highly particular
social settings. Authoritarian, elitist bioethicists
“impose” their vernaculars and categories; egalitarian
social scientists respectfully, democratically attend to the
“voices” of various social actors.
By now, the terms social scientists use to describe
their craft and the work of bioethicists will seem
familiar. Whereas bioethicists engage in thin, analytic,
conceptual, deductivist, abstract, formalistic, universalistic,
absolutistic, rationalistic logic-chopping guided by the
“mantra” of “principlism,” social scientists engage in thick,
locally situated, complex, substantively “rich,” highly
contextual, “bottom up” moral engagement. Clearly, these
labels do not function as neutral terms of analysis. They are
badges of moral approval and disapproval; they help
distinguish and separate the methodologically saved from
the damned.
According to another common social science
critique of bioethics, bioethicists are largely ignorant of
political economy, structural inequalities, cultural, social,
and intellectual history, class and socio-economic status,
power, gender relations, ethnicity, culture, and the local,
situated, interpersonal character of moral life. In
contrast, social scientists are attuned to the “textured,”
“thick” inter-subjective, culturally and historically
situated, politicized, historical, embodied nature of
inter-subjective moral existence. This binary
characterization of moral insight neatly divides
social scientists and bioethicists from one another.
Bioethicists are characterized as formalists, deductivists,
positivists, rationalists, utilitarians, and absolutists. In
Bioethical Inquiry (2009) 6:83–98
contrast, social scientists get all the affirmative
labels. Their work is “situated,” “contextual,”
“local,” “ethnographically sensitive” aware of power
relations, historically informed, “rich,” and “engaged.”
The terms social scientists use to describe
bioethicists reveal a measure of sanctimony. Social
scientists perceive morality and social life in all
their richness whereas bioethicists parse the world using
the crude tools of conceptual analysis, logic-chopping,
and moral deductivism. In this dualistic vision of the
respective approaches of bioethics and the social
sciences, bioethicists offer superficial characterizations
of moral engagement whereas social scientists, thanks to
the tools of their disciplines, offer legitimate moral
understanding. Emphasizing differences between
bioethics and anthropology, Kleinman (1995a, 45)
writes,
In the anthropological imagination, a distinction
can be made between the ‘ethical’ and the ‘moral.’
Whereas ethical discourse is a codified body of
abstract knowledge held by experts about ‘the
good’ and ways to realize it, moral accounts are
the commitments of social participants in a local
world about what is at stake in everyday experience.
Drawing upon “abstract concepts of justice and
beneficence,” (Kleinman 1995b, 1669) bioethicists
suffer “a failure to take into account the local worlds
in which patients and practitioners live.” Bioethics
offers “ungrounded analysis of the sources and
consequences of ethical choices” (1995a, 48).
Bioethics, Kleinman (1995b, 1669) insists, suffers from
“ethnocentrism, psychocentrism, and medicocentrism,”
uncritically draws upon “orthodox sources of the
self in the Western philosophical tradition,” manages
to “avoid serious engagement with… alternative
ethical traditions”, and constitutes “one of the last
tenacious holds of ethnocentric mentality.” According to
Kleinman, bioethicists are ethnocentric, abstract and
inattentive to social inequalities, power relations,
poverty, and local understandings of health, illness,
and morality. “In contrast with the bioethicist, the
ethnographer begins with the lived flow of interpersonal
experience in an intensely particular local world” (1995,
53). Highly specific, situated communities become
the setting for grounding moral analysis in the
concrete historicity, micropolitical economy, and
ethnicity of a local world. Even within such a
Bioethical Inquiry (2009) 6:83–98
localized flow of experience, perspectives and
preferences are further defined by gender, age,
and other social categories of persons. (1995a, 53)
Whereas bioethicists offer tidy normative analyses,
anthropologists testify to the murkiness of moral life.
Bioethicists engage in “the dehumanizing imposition of
hegemonic principles” (1995b, 1670). In contrast, “the
ethnographer discovers the murky indeterminancy
of real lives and the messy uncertainty of real
conditions—conditions in which moral dilemmas
and contradictions are inherent in the field of
transactions, in the flow of social life itself”
(1995a, 54).
Bioethicists and ethnographers would seem to be
characterized by remarkably different degrees of selfawareness, reflexivity, and moral insight. Whereas
bioethicists are unwitting servants to unwieldy,
abstract, hegemonic universalistic moral principles, the
ethnographer is “self-reflexively critical of her own
positioning and the commitments and problems it
entails” (Kleinman 1999, 77). Immersed in particular
social worlds and yet critically distant from local
forms of knowledge, sympathetic to the exercise of
non-judgmentally understanding particular local
practices yet expert in the use of local and trans-local
moral vocabularies, respectful of local moral worlds yet
opposed to various forms of oppression and making
recourse when necessary to “global ethical discourse”
(1999, 79), ethnographers somehow manage to avoid
the many different methodological, epistemological,
and moral pitfalls to which bioethicists succumb.
Kleinman’s account of the morally discerning,
sensitive, self-critical, reflexive ethnographer and the
abstract, stratospheric, obtuse bioethicist resembles
commentaries offered by other social science critics of
bioethics. According to Patricia Marshall (1992, 52),
bioethics is guided by “the ‘positivist approach of
Anglo-American philosophy’” and “the cognitive
emphasis of analytic philosophy.” Bioethics, Marshall
(1992, 52) argues, is characterized by “rationalistic
thinking and a deductive, utilitarian orientation to
problem solving” that “provides an illusion of
objectivity and logic.” Cognitivist, Cartesian,
enmeshed within untenable dualisms, bioethicists are
distant from lived social realities.
Informed by the legacy of Cartesian duality, the
analytic style of bioethics contributes to a
distancing of moral discourse from the complicated
91
human settings and interactions within which moral
dilemmas are culturally constructed, negotiated,
and lived. In this discourse, issues of personhood,
body parts, organ replacements, genetic cloning,
and the like are confronted as abstractions rather
than experiential realities. (1992, 52)
Similarly, Jessica Muller (1994, 450) writes,
“bioethics emphasizes logic, codified rules and
techniques, and rigorous, precise, objective thinking.”
In contrast,
anthropological inquiry also offers the contextual
perspective. It recognizes that decisions about
matters of health and illness are not made in
isolation but are made in the context of a web of
everyday activities and social relationships. The
focus is not on the individual alone but takes into
account the setting and cultural group. Consequently,
ethical issues should be examined in context; the
ethical ramifications of a situation cannot be
addressed without considering the associated
economic, legal, social, or policy issues.”
(1994, 459).
Furthermore, anthropologists are capable of
sympathetically hearing “voices” ignored or dismissed
by bioethicists. “The researcher can explore for a
particular group which issues are defined as moral
issues, how moral questions are framed, and which
moral values are invoked. Ethical issues are situated in
the moral discourse employed by the people themselves
rather than in the language of the bioethicist” (1994,
458). Whereas bioethicists wield an esoteric, elitist
vocabulary, anthropologists speak the language of the
people.
Sociological critiques of bioethics closely track
standard anthropological criticisms of bioethics.
Renee Fox offers a similar commentary on the
limitations of bioethics. Describing the “conceptual
framework” of bioethics, Fox (1999, 8–9) writes,
The regnant paradigm of bioethics is a highly
rational, formal, largely deductive mode of
argumentation that draws upon a ‘relatively
small set of concepts’…Often referred to as
‘principlism,’ and drawn largely from the
Anglo-American tradition of analytic philosophy,
this system of thought was brought to bioethics and
made preeminent within it by its founding
generation of philosophers, and reinforced by
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Bioethical Inquiry (2009) 6:83–98
the scientific positivism of biologists and
physicians, and the analytical jurisprudence of
the lawyers who accompanied them…The
importance that bioethical thought attaches to
a coolly rational mode of analysis focused on
autonomy-of-self bends it away from detailed
attention to the empirical contexts in which
ethically relevant events occur, from how they are
experienced, and from serious consideration of
the play of both rational and nonrational social
and cultural factors in moral life….Values that
give weight to feelings and relatedness, to a
self-transcending sense of solidarity with
known and unknown others, to the community
and the society, and to a special obligation to
heed the plight of those who are disadvantaged
and underserved, are overshadowed by what
some bioethicists have critically referred to as
the ‘autonomy unbounded’ rationalism of the
field’s outlook.
Acknowledging the emergence of alternative
approaches such as “casuistry, phenomenology,
pragmatism, virtue ethics, narrative ethics, and
feminist philosophy,” (1999, 11) Fox nonetheless
insists on the continuing “hegemony” of principlist
bioethics.
These efforts have centered on trying to break
through the domination of the field by the
abstract ‘principlism’ of analytic philosophy, as
well as by the primacy accorded an autonomous
self-determined conception of individualism and
individual rights…To date, however, relatively
little change has occurred in the contours,
content, style of thought, or the ideology of
bioethics. (1999, 11)
Other sociologists offer similar critiques of bioethics.
According to Jose Lopez (2004, 878), “The disciplinary
origins of bioethics in moral and analytical philosophy
and theology has created a selectivity towards a
formalistic, procedural, disembodied and universalistic
way of identifying and resolving bioethical dilemmas. At
present the hegemonic paradigm in US bioethics is
Principlism.” Charles Bosk (1999, 65) writes,
The purpose of bioethical inquiry, I assume, is to
clarify which principles should guide action
when decision is difficult. In bioethics, descriptions
of motives, intents, and purposes need to be fairly
one-dimensional or the balancing of values gets too
complex for application. The goal of social science,
especially as practiced by ethnographers (again,
this is my assumption), is to show how actors shape
and trim their actions to fit their principles and how
these same actors shape and trim their values and
principles to fit their actions. Where bioethicists
seek clarity, social scientists look for ambiguity and
complexity.
Satirizing the philosophical abstractions of bioethics,
Robert Zussman (2000, 8) writes,
For a sociologist, opening a textbook of medical
ethics is a bit like a flight into Never Never
Land. We are the Lost Boys in the world of
pirates, Indians, and mermaids. Here, however,
the fantastical creatures take the altogether
extraordinary form of erudite discussions of
Kantian or utilitarian ethics that grow even more
astonishing with every additional distinction.
Bioethicists, various social scientists claim, typically
draw upon a deductivist principlist framework. This
universalistic, abstract philosophical model is indifferent
to variations in social context, practically useless,
ignorant of or disrespectful toward the voices of
members of particular communities, unaware of the
salient moral norms of particular communities, and
indifferent toward social, economic, cultural, and
institutional contexts.
Replying to social science critiques of bioethics, a
defender of principlist bioethics might argue that many
social scientists overstate their case. The version of
principlist bioethics espoused by Beauchamp and
Childress has undergone revision over time. For years
Beauchamp and Childress have acknowledged that
discretion, practical judgment, and attentiveness to social
context need to be exercised when “specifying” and
“applying” particular principles to specific circumstances.
Furthermore, Beauchamp and Childress would challenge
claims that they are heavy-handed deductivists. They
acknowledge that particular cases, situations, and social
settings can lead to the refinement of how principles are
defined and interpreted. However, I am not interested here
in attempting to defend principlist bioethics from the usual
criticisms of this mode of reasoning. Rather, I want to
suggest that common social science characterizations of
bioethics obscure the complexity of bioethics as an area
of study, offer a reductionistic account of bioethics instead
Bioethical Inquiry (2009) 6:83–98
of engaging in the difficult work of careful critical
engagement, and exaggerate the distinctive contributions
anthropology and sociology can make to the study of
ethical issues related to health, medicine, illness, and the
body.
In response to these critiques of bioethics, I wish to
note that bioethics, much like medical anthropology
and medical sociology, draws upon numerous methods,
theories, traditions of inquiry and deliberation, and
baseline assumptions from which interpretive work
proceeds. True, “principlism” has historically had an
important place in bioethics. However, bioethicists draw
upon many other methods, theories, or frameworks for
analysis. Scholarship in bioethics includes work in
casuistry (Arras 1991; Toulmin 1981; Toulmin 1982),
situation ethics, virtue theory (Pellegrino and
Thomasma 1988), feminist ethics (Baylis 1996;
Mahowald 1996; Rubin and Zoloth-Dorfman 1996;
Sherwin 1989; Sherwin 1992; Warren 1989),
hermeneutics and interpretation theory (Carson 1990;
Davis 1991) narrative ethics (Carson 1995; Montgomery
Hunter, 1991; Nelson 2000), deliberative democracy,
communitarian social thought (Callahan 1990),
pragmatism (Winslade 1995; Winslade 1997),
phenomenology (Leder, 1990), discourse ethics,
utilitarianism and cost-benefit analysis, organizational
ethics, and continental philosophy. Some of these
approaches have played prominent roles in the history
of bioethics. Other frameworks offer sharp critical
analysis of “mainstream” approaches. In bioethics,
opposition to “principlism” is as old as the principlist
approach itself (Arras 1991; Toulmin 1981; Toulmin
1982). There has never been just one party line or way
of doing bioethics. Furthermore, just how much
“theories” of ethics influence the work of clinical ethics
activities is unclear. What role do any of these theories
play in particular social settings? Critiques of theoretical
approaches in bioethics do not provide insight into
bioethics as social practice.
The “bioethics community” is not monolithic.
What counts as “mainstream” and what gets labeled
as “marginal” scholarship will differ among networks
of scholars. Their guiding frameworks do not begin
from identical philosophical presuppositions or end
with similar interpretive insights. “Bioethics” does not
speak with one voice, side with just one political
party, or argue down one narrow channel bed. As an
area of study or disciplinary crossroads, bioethics is
more a site of multiple disagreements and conflicts
93
than a social space where one mode of analysis has
“hegemonic” status. Principlist bioethics gives particular
weight to prima facie principles. In contrast, situation
ethics, narrative ethics, pragmatism, and casuistry, or
case-based ethics, begin with a highly skeptical stance
toward the place of “universal principles” in ethical
reflection. Casuists, pragmatists, and situation ethicists
draw attention to the importance of local knowledge,
particular cases, and specific circumstances. Pragmatists
and proponents of case-based reasoning have no
particular interest in securing “universal foundations”
for practical recommendations for action. Pragmatists
and advocates of case-based reasoning share the interest
of ethnographers in attending to social, cultural,
economic, and institutional contexts of moral
deliberation. There are many areas where social
scientists and bioethics display shared concerns,
common interests, and overlapping intellectual
histories. Just as casuists and pragmatists share the
skepticism of the social scientist toward “universal ethical
principles,” proponents of feminist bioethics (Sherwin
1989; Warren 1989) do not need ethnographers to
remind them to attend to structural inequalities and
differentials in power and social authority. Feminist
bioethics and feminist social theory emerging from
sociology and anthropology share many common
concerns. Issues of power, inequality, discrimination,
and justice are not reducible to any one academic
discipline or scholarly crossroads.
Serious, inquisitive engagement with bioethics
ought to recognize the complexity of this area of
scholarship. Bioethics is much like medical sociology
and medical anthropology. The field’s diversity makes
it difficult to describe. When social scientists equate
bioethics with principlism, they engage in a
reductionistic act. They tidily summarize a complicated
web of scholarship, policy work, social activism, media
activity, and occupational roles and offer a simplified
account of the history, substance, and practical “work” of
bioethics.
Critical analyses of an academic discipline or even
the contributions of a particular scholar often draw
upon close readings of “key” texts. Too many social
science critiques of bioethics are not based upon
careful textual or empirical analysis of different
approaches in bioethics. If many social scientists pay
insufficient attention to the presence of diverse
traditions of intellectual inquiry within bioethics, they
are even less attentive to the everyday social practice of
94
bioethics. Do practicing bioethicists display ignorance or
indifference toward particular social, economic, and
cultural contexts? Do bioethicists working in clinical
domains or policy making arenas typically offer abstract
philosophical frameworks that fail to illumine complex
social worlds? If social scientists fail to fully
engage text-based scholarship in bioethics, they
are thus far even less attuned to bioethics as
various social practices. Can stock social science
critiques of bioethics be fairly applied to practitioners of
bioethics? What role, for example, do clinical ethicists
play when addressing ethical issues in particular health
care arenas? Do ethicists engage or ignore the “voices”
of patients and family members? Assuming there is at
least a tenuous link between theory and practice—itself a
debatable proposition—what role do moral theories play
in specific health care settings? Is the work of clinical
ethics closer to “applied” moral philosophy, social work,
or perhaps a secularized form of pastoral care?
Social scientists regularly attend to the gap between
theory and practice, ideology and performance. Publications by clinical ethicists reveal sensitivity toward many
of the issues addressed by social scientists. Much like
anthropologists and sociologists, clinical ethicists attend
to structural inequalities in gaining access to health care
services, power differentials and distinctions between the
social status of poor, vulnerable patients and elite, expert
medical practitioners, and the role of institutions in
structuring and framing moral issues (Andre 1997b;
Emanuel 1995; Forrow et al. 1993; Jecker and Jonsen
1997; Miles 1993; Spielman 1995; Zoloth-Dorfman
1995a). Though bioethics is an area of scholarship, it is
also an occupational role and form of social practice
(Andre 1997b). By failing to “thickly describe”
bioethicists in the particular social settings within which
they function, social scientists obscure the gap between
the theory and practice of bioethics.
Because anthropological and sociological critiques
of bioethics are rarely based upon careful empirical
research, it is difficult to know whether social science
critiques of bioethics can be deservedly applied to
specific practices of bioethics. Scholarship by clinical
ethicists, to select just one “constituency” within
bioethics, suggests considerable overlap between the
concerns of social scientists and the interests of
practicing ethicists. Whether careful ethnographic
research, or social science scholarship drawing upon
other research methods would support this claim is
presently impossible to determine.
Bioethical Inquiry (2009) 6:83–98
Bioethics Does Not Equal “Principlism”
Common social science critiques of bioethics provide
a reductionistic reading of bioethics as both area of
scholarship and social practice. What bioethicists do
as a matter of everyday practice in clinical settings is
little studied. Publications by clinical ethicists suggest
awareness of the importance of culture, structural
inequalities, power differentials, organizational
constraints, and gender differences in shaping everyday
experiences of moral life. Whether these narratives are
self-serving, flattering tales or credible portrayals of
the everyday practice of clinical ethics is difficult
to determine. We have clinical ethicists’ narratives
characterizing their own work. We do not have many
detailed anthropological and sociological studies of the
practice of clinical ethics or other domains within which
bioethics as practice can be examined.
By offering reductionistic readings of scholarship in
bioethics, social scientists exaggerate the distinctiveness
and profundity of their contribution to the study of
situated, local moral worlds. Philosophy, law, and the
social sciences all have practitioners of the general and
the abstract—advocates of “grand theory”—and
specialists in the local and specific. Bioethics has
its totalizing theorists and systematizers as well as
its specialists of the particular just as anthropology
and sociology contain both proponents of all
encompassing social theories and the detailed study
of specific social settings. Bioethics, much like
medical anthropology and medical sociology,
includes scholars attuned to the local, situated,
culturally and historically shaped character of moral
life. In neglecting this latter body of work social
scientists exaggerate the extent to which bioethics
needs to be “saved” by sociology, ethnography, or
anthropology.
Bioethics as Hyper-Individualism
A third common social science critique of bioethics
focuses on the purported individualism of “American
bioethics.” According to this critique, bioethicists are
obsessed with defending autonomy and individual
liberty. They neglect community, family ties, social
relations, and interpersonal obligations. This critique
can be traced to one of the earliest sociological
analyses of bioethics. In “Medical Morality is Not
Bioethical Inquiry (2009) 6:83–98
Bioethics—Medical Ethics in China and the United
States,” Fox and Swazey (1984, 339) write,
It is the individual, seen as an autonomous, selfdetermining entity rather than in relationship to
significant others, that is the starting point and
the foundation stone of American bioethics.
Elaborating, they state (Fox and Swazey, 1984, 354):
The emphasis that bioethics places on individualism
and on contractual relations freely entered into
by voluntarily consenting adults tends to
minimize and obscure the interconnectedness
of persons and the social and moral importance
of their interrelatedness…it is striking how
little attention bioethics pays to the web of
human relationships of which the individual is
a part and to the mutual obligations and
interdependence that these relations involve.
The characterization of bioethics offered by Fox
and Swazey resembles subsequent sociological and
anthropological critiques of bioethics. According to
Muller (1994, 450–451):
Bioethics is a field whose origins lie in the branches
of Western (primarily Anglo-American) philosophy
and law that give primacy to the individual and
emphasize individual rights, self-determination, and
privacy….the framework that has dominated much
of bioethics has been the four-principles approach
developed by Beauchamp and Childress. At the
heart of this moral code is the principle of respect for
autonomy. Reflecting the deeply rooted American
belief in individualism, as well as bioethics’
grounding in Western law and philosophy, autonomy
has become a centerpiece of contemporary theories
about how patients and physicians in health care
settings should related to one another.
In many social science critiques, bioethics is
guided by the lodestar of autonomy. The individual,
rather than society or social relations, is the primary
locus of analysis. This presumption leads Bosk (1999,
54–55) to argue that bioethics is almost exclusively
defined by its focus on the patient-physician relationship.
He writes,
Although at certain points the bioethicist’s
critique seems to be a broad indictment of
95
medical practice, it is actually quite limited. For
the bioethicist, the problem is not one of
structural arrangements, the distribution of power,
privilege, and authority, or the culture of medicine
itself—all of which call for the expertise of the
social scientist and suggest the need for more
radical, structural change than bioethics has
wrought. The problems of medical practice, as
defined by bioethicists, are ones of values in a
relationship. Place the right values in the
doctor-patient relationship and the problems
disappear. From the perspective of bioethics, it
was as if everything was right with the way
medicine was practiced except for what was said
and how it was said in certain very exceptional
circumstances….If one assumption of bioethics is
that the problems of medicine are located at the
level of the individual doctor-patient relationship
and consist of the inappropriate values operating
within that relationship, then a second assumption
is that bioethicists can fix or ameliorate the problem
by correctly analyzing that values problem.
Bosk is correct to note that ethical analysis of the
patient-physician relationship is an important strand
in the history of bioethics. The literature on truth
telling, information disclosure, advance care planning,
advance directives, and informed consent builds upon
notions of patient choice and patient decision-making.
Just as many medical sociologists and anthropologists of
medicine have studied patient-physician communication
and interaction, many bioethicists have addressed ethical
issues related to patient-physician communication.
However, bioethics is not reducible to the notion of
patient autonomy or to the ethics of the patient-physician
relationship (Benatar, 1997; Callahan, 1984; Childress,
1990; Veatch, 1984). The bioethics literature on access
to health care, health insurance, priority setting and
resource allocation, goals of medicine, and social justice
typically builds upon notions of shared concerns, the
common good, and human solidarity. Many bioethicists
draw upon notions of social justice to develop
normative arguments for universal access to health
care. These arguments are not just based upon claims
that access to health care promotes autonomy and
individual liberty. Rather, proponents of publicly
funded universal health care typically describe public
access to health care as a general community good and
a matter of human solidarity. Similarly, discussions of
96
priority setting and resource allocation are not reducible to
ethical frameworks predicated on individual autonomy.
Arguments concerning how to allocate resources
commonly involve attending to communal notions
of what constitute “core” health care goods. They
respond to questions about how limited resources
should be shared. These frameworks draw upon the
rhetoric of community and shared moral obligations.
They suggest that humans are embedded in complex
interpersonal webs.
The concept of respect for patient autonomy plays
an important role in the history of American bioethics.
However, bioethics is not reducible to the concept of
autonomy, analysis of the patient-physician relationship,
or the American context. When bioethicists discuss
such topics as truth telling, informed consent, and
advance care planning they typically draw upon the
language of autonomy and choice. However, when
addressing other subjects, such as public health,
intergenerational obligations, family obligations,
resource allocation, and access to health care, they often
draw upon notions of community and relationality.
Whether or not bioethics seems “individualistic” is in
part a question of which topics are explored. In addition,
bioethics has changed over the decades. Whereas articles
on truth telling, informed consent, and the right to
die in the 1970s and 1980s emphasized patient
autonomy, later work in narrative ethics, feminist
ethics, and communitarian ethics placed greater
emphasis on relationality, family ties and obligations,
and community. When Fox and Swazey wrote “Medical
morality is not bioethics” in 1984 they could draw upon
many sources to argue that bioethicists were overly
influenced by a highly atomistic notion of self and
society. Subsequent sociological and anthropological
critiques of bioethics reiterate the criticisms of Fox and
Swazey without acknowledging that during the
1980s and 1990s bioethics became considerably
more multifaceted. The “atomism” and “individualism”
of bioethics continues to serve as a foil for more
relational, socially situated characterizations of moral
experience.
Conclusion
In questioning some of the standard criticisms of
social scientists, I have no wish to endorse bioethics
in its entirety or dismiss the many valuable insights
Bioethical Inquiry (2009) 6:83–98
found within the anthropology and sociology of
bioethics. Bioethics has its lamentable features; these
facets of bioethics deserve to be unmasked and
subject to careful criticism.
By challenging some of the standard social science
critiques of bioethics, I hope to suggest that several
stock criticisms of bioethics are dependent upon a
reductionist reading of bioethics rather than a fair,
carefully researched, empirically based characterization
of bioethics in its many different dimensions. It is
possible that empirical research might challenge my
claims and lend weight to the criticisms of bioethicists.
Perhaps bioethics is as abstract and individualistic as
anthropologists and sociologists suggest. However, in
the absence of careful empirical research supporting the
allegations of social scientists, many of the standard
critiques of bioethics seem rather exaggerated.
As sociologists note, bioethicists are inclined to tell
self-serving tales when narrating the origins, history,
and substance of their field. Social scientists provide
similarly self-aggrandizing narratives when criticizing
bioethics and offering “the sociological imagination”
or “ethnography” as richer sources of moral insight
and social commentary. Perhaps an alternative history
of bioethics, medical anthropology, and medical sociology
might focus on shared concerns and overlapping interests.
There seems to be at least some common ground.
Acknowledging differences within each clustering,
bioethicists, medical sociologists, and medical
anthropologists are all concerned with the manner
in which corporate values can turn humans into
commodities, biotechnologies can “medicalize” all
aspects of human existence, disparities in access to
health care and basic social goods can raise basic
questions about the extent to which humans express
concern or indifference toward one another, and the
vocabularies and categories of “biomedicine” or
“the medical-industrial complex” can efface the
concerns of the sick and the suffering. Recognizing
features that distinguish bioethics, medical sociology,
and medical anthropology from one another, there are
nonetheless areas of mutual concern. We are certainly
well past the time when it was possible to simply nod in
agreement at the claim that bioethics engages in
normative work whereas the social sciences provide
“descriptive analysis.” Whatever might be said of
the work of such scholars as Margaret Lock (2001),
Arthur Kleinman (1997), Nancy Scheper-Hughes
(1995) and Renee Fox (1994), there is a moral
Bioethical Inquiry (2009) 6:83–98
dimension to their work. They are not disengaged
social observers content to leave moral commentary
to others. Indeed, it is this normative dimension to
the social sciences that makes anthropologists and
sociologists such trenchant critics of what they
regard as abstract, “thin” moral analysis in bioethics.
Perhaps we should see clashes between scholars in
bioethics and the social sciences as an example of
“the narcissism of minor differences.” If we dispense
with the notion that bioethicists are “prescriptivists” and
social scientists are “descriptivists,” just what is it that
distinguishes bioethicists from anthropologists and
sociologists? The readings many medical sociologists
and anthropologists offer of bioethics fail to acknowledge
areas of mutual concern and common cause. Perhaps most
importantly, by failing to use research tools from their
home disciplines, sociologists and anthropologists leave
many important issues unexplored. How do moral
theories influence the practice of bioethics? Under what
circumstances do bioethicists accommodate themselves to
corporate interests and other powerful social actors?
When—if ever—do bioethicists act as catalysts for social
change? Many important questions still need to be
explored within the anthropology and sociology of
bioethics. If social scientists move beyond offering
reductionist analyses they could make a valuable
contribution to the careful, critical study of bioethics.
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