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Bioethics in social context
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1. P de Zulueta
1. p.dezulueta{at}ic.ac.uk

## Edited by B Hoffmaster. Temple University Press, 2001, US$69.50 (hc),$22.95 (pb), pp 230. ISBN 1-56639-845-2

Hoffmaster endeavours to enrich the dominant bioethical paradigm, based on abstract principles, with the lived experience of moral decision making. He proposes that bioethics involves not only the justifications for moral judgments, but also the understanding of the beliefs and values underpinning them. The “old” conventional bioethics, situated in “rationality and generality”, is to be replaced by a new “reoriented” bioethics, situated in the untidy world of “lived human experience”. In other words, context, in its widest sense, is to be integrated into the bioethical framework.

The relevance of social context in moral philosophy is not new, however. As MacIntyre tells us in After Virtue: “ . . . it also follows that we have not yet fully understood the claims of any moral philosophy until we have spelled out what its social embodiment would be”. He reminds us that Plato and Aristotle, amongst others, undertook this project. MacIntyre, like Hoffmaster, laments the loss of social embodiment in the “narrow conception” of contemporary moral philosophy. I submit that we are now witnessing the rejection of Cartesian duality and the revival, or restoration, of an old paradigm—reintegrating the social milieu, narrative, and the emotions, in our conceptualisation of moral philosophy.

Hoffmaster’s second goal is to raise the profile of social science research in the field of bioethics. He argues that the distinction between descriptive and normative ethics is artificial, and that the former is unfairly devalued. Tony Hope, in an editorial in this journal two years ago, somewhat tentatively suggests that “a more systematic approach to the empirical base might lead to new issues and new perspectives” for medical ethics. He describes philosophical medical ethics as the parent of empirical medical ethics. Hoffmaster, I suspect, would disagree, and would argue that they are both equal and complementary partners.

Does this book achieve these stated aims? The authors certainly do provide us with diverse perspectives, showing us how the social environment and dominant moral norms can shape moral attitudes and decisions. The related valuable work of English social scientists is notably absent—for example, Paul Atkinson’s work with training doctors, and Priscilla Alderson’s ethnographic studies of children and their parents in hospital. Nor does it read as a coherent, integrated account, as the chapters lack a clearly identifiable common thread.

Sharon Kaufman’s clinical narratives in the practice of geriatric practice provide us with a rich example of the complexity of “clinico-moral” decision making. She illustrates, with case examples, the power of the “technological imperative” in framing and constraining decisions in the care of frail and sick elderly persons—many of whom may be harmed by medical intervention. She also shows how decision making evolves, and may not even be perceived as the deliberate act of making choices, but as part of routine practice.

Margaret Lock’s ethnographic study in Japan sheds light on attitudes and practices towards the dead—in particular the definition of brain death and the use of the recently dead for organ donation. The resistance in Japan to equating brain death with human death is not, she believes, simply due to cultural and religious inhibitions, but is also linked to the dominant communitarian ethic, with the dying person anchored in kinship. The self is relational, and not individuated and atomised as in the West, with death viewed as an evolving process in which the family participates. Despite the lack of a significant cultural divide in attitudes towards death and afterlife, Lock proposes that there are few socially sanctioned channels in the USA—in contrast to Japan—for articulating concerns and disagreement.

Sydney Halpern interprets the changing attitudes and public discourse towards human experimentation as arising from a shift in emphasis from the collective good to the protection of individual rights. Moral judgments, he argues, are mutable, and contingent upon the social and cultural environment of the time.

Peter Conrad’s chapter on the media, genetics, and culture demonstrates the potential for oversimplification and distortion of scientific discoveries in the lay press. He argues that genetic optimism—the naïve positivist belief that we will find the basis for human behaviour in our genes, and be able to root out antisocial behaviour by genetic manipulation—can be equated with the fallacy of the “magic bullet” in therapeutics. He concludes that geneticisation reflects the current ideology of blaming individuals, rather than deficiencies and inequities in the social system. I would argue that genetic fatalism can also absolve individuals from moral responsibility, and allow them to blame their inheritance for wrongdoing, so that they eschew reform and redemption.

Beeson and Doksum, in contrast, explore how and why individuals reject genetic testing, underscoring the enduring themes of romantic love and family values.

Anspach and Beeson argue that bioethics discourse has neglected the emotions, and describe in detail their role in shaping values and moral decisions in medical life, as well as the interplay between emotions and power. They describe “moral dissonance” as the conflict between emotions and morals, and how its resolution can lead to a revision of moral decisions. Health professionals need to be able to move freely between emotional engagement and detachment, so that they can embody both fairness and imaginative sympathy towards their patients. Interest in the role of the emotions in moral life has developed in many quarters: neuroscience (notably Antonio Damasio); psychology (Daniel Goleman, amongst others); cognitive science (for example, Mark Johnson), and contemporary philosophy (Peter Goldie, Alasdair MacIntyre, Martha Nussbaum, Michael Stocker, and Bernard Williams, to name a few). Modern philosophers are building on the earlier work of Aristotle.

Cate McBurney’s ethnographic study of clinical ethics committees provides a chastening insight into to how they can marginalise front line staff (nurses) and patients themselves. Objectivity, they argue, is two edged, for it can indicate impartiality and fairness, but also objectification and indifference.

Patricia Marshall’s narrative account of working as a clinical ethicist reveals the conflicts and tensions in that role—particularly the compromise of being part of the institution in which the patient is held captive.

Perhaps Charles Bosk’s chapter on the role and moral standing of the social scientist is the most controversial and provocative. He argues that all social science research involves duplicity, the erosion of informed consent, and the violation of confidentiality. The research subject, flattered to be the object of attention, reveals more than originally intended, but relies on the researcher to safeguard these revelations—a trust that is liable to abuse. According to Bosk, the social scientist’s perspective is ironical, and debunks professional idealism. This debunking, in addition to compromised anonymity, can particularly damage high status professionals. Finally, he argues that there is role-based incompatibility between doing ethics and doing ethnography. Hoffmaster counterargues these claims, but cannot entirely remove the disquiet. On the other hand, at least some social scientists appear to demonstrate a profound respect and sympathy towards their research subjects—for example, Rayna Rapp’s work with pregnant women and genetic counsellors.

In conclusion, this book provides a valuable contribution to the expanding field of empirically based ethics, or “ethics in use”, revealing the moral decisions people make in the real world, and how and why they make those decisions

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