To assess the state of bioethics, the Kennedy Institute of Ethics at Georgetown University assembled an all-star cast of seminal thinkers in the field this past weekend. Most of those gathered think the discipline is doing just fine.
And so it appears on the surface. Bioethical reasoning and bioethicists have become increasingly prominent in public discourse and policy. After all, President George W. Bush consulted two eminent bioethicists before his speech on human embryonic stem cell research last summer. Among the undoubted successes of bioethics is the establishment of brain death as a standard for death and the Belmont Report in 1979 that led to federal standards protecting human subjects in clinical trials, including the requirement for informed consent.
But beneath the harmonious surface lurks considerable disagreement both on ethical principles and actual norms. The dominant view in bioethics is that developed by James Childress from the University of Virginia and Thomas Beauchamp from Georgetown University in their seminal book Principles of Biomedical Ethics. They devised the four principles that have become known as the "Georgetown mantra": respect for autonomy, beneficence, nonmaleficence, and justice. Their justification for these principles has shifted over time. They acknowledge that they cannot ground these principles on a particular theory of ethics, but appeal instead to "common morality." What is this common morality?
For example, most people agree with the homey observations that it is generally wrong to kill the innocent or to lie. "Persons who are morally serious about living a moral life share the core values," said Beauchamp at the conference. He insisted, "common morality contains universally valid principles." Listening to Childress and Beauchamp, one could not help but think that the values held by "all morally serious people" are pretty much those held by the community of scholars one finds at America's leading universities. Still, according to Childress, their conception of the common morality "leaves various communal moralities with their own particularities." But is it precisely those moral particularities that are contested.
Just consider briefly the principle of justice. Justice generally means that persons should get what they deserve. But there can be no more contentious notion than what it is that people deserve. Do murderers deserve to die? How much of the goods of society does anyone deserve, and for what reasons? Most participants in this seminar adhere to a notion of "distributive justice" that would require that everyone have access to the same medical care, usually implying some form of socialized medicine. It seems all morally serious people sound a lot like left-leaning American professors.
Bioethicist David DeGrazia from George Washington University highlighted the problem by listing a series of propositions with moral content that the majority of Americans have regularly supported. DeGrazia's propositions included: homosexuality is wrong, women must change their last names when they marry, property rights are sacred, wealthy people have a right to send their kids to private schools, eating meat is morally unproblematic, and animals exist for human use. "In fact, I believe all those propositions are immoral," declared DeGrazia. And if assent stemming from a common morality cannot be achieved on these questions in America, what hope is there to achieve a consensus on morality across even more diverse cultures?
The strongest voice dissenting from the surface consensus at the conference was Rice University bioethicist H. Tristram Engelhardt. "Late modern understanding of ethics is about to run aground on the shoals of postmodernity," he said. "Bioethicists claim a consensus, but in fact there is only disarray." Engelhardt said that when he began to work in bioethics he had at first aimed at "redeeming some of the Enlightenment's hope for some moral consensus." However, he eventually was compelled to "diagnose controversy without resolution."
Engelhardt pointed out that people of good will do not agree on the morality of things like third-party reproduction, organ sales, abortion, cloning, and germline genetic intervention. Engelhardt agrees with postmodernists who argue that bioethics is often used as a way to advance interests predetermined by one's ideology. In the United States, "consensus" on bioethics has been forged by various national bioethical commissions. However, commission members are carefully chosen so that their conclusions will appear to be consensual. "Each president understood that it was very important to secure bioethicists who would endorse his politics," said Engelhardt. He concludes that "bioethics is about politics and politics is about power."
Engelhardt accepts that values exist in an incommensurable plurality. Various moral communities "do not share sufficient premises to resolve differences in ethical values" and "do not mutually recognize any authority competent to resolve differences." The paradigmatic example in America is abortion.
So how do we all get along if we cannot all agree on a common morality? Engelhardt suggests that all that seems to work are procedural institutions that allow diverse values to be expressed, like free markets and limited democracy. Even then there is no a priori moral justification for agreeing to abide by the procedures. But once such procedures have been agreed upon, they enable spontaneous orders to emerge that will have actual moral content, like the enforcement of contracts and the protection of various civil rights.
Engelhardt argues that any effort to construct a morality that can be shared by "moral strangers," that is, people living and believing in different moral communities, must have two cardinal characteristics: First, a recognition that there is no canonical warrant for a particular morality. One cannot in principle determine which moral intuitions should trump. This means that one cannot with sound argument, using discursive reason, reach secular agreement. Second, such a modest morality must recognize the fact of the actual plurality of moralities.
But some bioethicists apparently aren't going to be able to do that, and attempt to presumptively read any alternate opinions out of the game. See, for example, the presentation by Johns Hopkins University bioethicist Ruth Faden, who wondered about "authenticity." How do people really know that they "authentically" hold the values they claim to hold? After all people live in and are twisted by powerful institutional structures that may train them to express values which they would not hold if they were not oppressed or marginalized by those institutions. "Could a mother from West Africa who insists that her daughter should be circumcised really want that if she herself had not been oppressed?" asked Faden. Would she ask questions like that about a woman who opposes abortion because she's been brainwashed by the Roman Catholic Church?
Resorting to "authenticity" might rescue bioethics' claims to a common morality, but only by substituting the values held by bioethicists for people's real moral values. This is a perilous road -- appealing to authenticity overturns in a stroke the hard-won principle of respect for autonomy and brings back all of the old paternalism in which doctors know best, and priests know best, and politicians know best.