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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. 84 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 85 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 86 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…. 87 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 88 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 89 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,” 90 “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 92 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. 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