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Bioethics in the public square: reflections on the how
  1. Amy Tannery Campbell
  1. Department of Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York, USA
  1. Correspondence to Professor Amy Tannery Campbell, Department of Bioethics and Humanities, SUNY Upstate Medical University, 618 Irving Ave, Syracuse, New York 13210, USA; campbela{at}upstate.edu

Abstract

As bioethics gains more prominence in public policy debates, it is time to more fully reflect on the following: what is its role in the public square, and what limitations relate to and barriers impede its fulfilment of this role? I contend we should consider the how of bioethics (as a policy influencer) rather than simply focus on the who or what of bioethical enquiry. This is not to suggest considerations of latter categories are not important, only that too little attention has been paid to parallel or resulting policy involvement—involvement that will require specialised skills and knowledge that we can develop with a proactive (vs reactive) stance. Moreover, and equally critically, this how of public policy involvement will require more transparency regarding influences (eg, philosophical, ideological, cultural, socio-political) on what bioethicists bring to the table and what constituency base each represents—a humility as to the scope of one's role. In this vision, bioethics is not one single person or belief system for a policymaker to call to guide or give support to a position; rather, it offers tools—formed and utilised by a diverse disciplinary range of individuals—to help guide ethical analysis of biomedical endeavours, with the goal of infusion and diffusion of ethical enquiry and prioritisation in health policymaking, and greater humility among bioethicists who inform this discussion.

  • Bioethics
  • public policy
  • health policy making
  • clinical ethics
  • legal aspects
  • education

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Entering the public square

A case study: human embryonic stem cell research (hESCR) guidelines

In late 2006, the International Society for Stem Cell Research released guidelines for conducting human embryonic stem cell research (hESCR).1 ,2 Such guidelines were widely distributed to inform discussions of how to move the field forward across the globe.3 While focus was placed on the content of those guidelines for informing the what of policy support for hESCR, what of the process behind their development? This necessarily is a critical question to address in order to better understand how such guidance might meaningfully inform policy discussion across a diverse host of nations. And it is this issue—the how to inform policy debate—that I argue deserves more attention. As bioethics gains more prominence in public policy debates, it is time to more fully reflect on the following: what is its role in the public square, and what limitations relate to and barriers impede its fulfilment of this role?

Some may choose to focus the debate in coming years on the who of bioethics: should bioethics be a profession or a specialisation within a separate profession (eg, medicine); and should bioethicists ‘professionalise’ by adhering to a certain code of practice, say?4 Over the years, bioethics has picked up a range of disciplinary scholars and ways to specialise in the field; today, we even see certificate, Master's and PhD bioethics-specific programs.5 And so we encounter an ever-growing number of the ‘who’, often an adjunct to another profession, for example, as philosopher, doctor, nurse, lawyer, theologian or sociologist, in an ever-expanding field of study.

This interdisciplinary mix expands the focus of the ‘profession’—to include not simply academic theory-generation, but also clinical, research and public policy involvement. This expansion points to another area of emphasis for bioethics: the what of bioethics. Adherents of this line of enquiry debate what bioethics should address, often turning to the ‘sexy’ emerging issues that capture the media's fancy, such as nanotechnology, the possibilities for creating life, or how to genetically manipulate life.

I contend, however, that as bioethics and bioethicists engage in more public policy debates, it is imperative that we put more emphasis on answering the how of bioethics as a public policy influencer. This is not to suggest considerations of the who or what of bioethical enquiry are not important, only that too little attention has been paid to parallel or resulting policy involvement—involvement that will require specialised skills and knowledge that we can develop with a proactive (vs reactive) stance. Moreover, and equally critically, this how of public policy involvement will require more transparency regarding influences (eg, philosophical, ideological, cultural, socio-political) on what bioethicists bring to the table and what constituency base each represents—a humility as to the scope of one's role.

Engaging in the public square

Will (should) bioethicists enter?

I take it to be a given that bioethics will enter the public policy arena more and more, whether methodically or not (and leave it to others to debate the should of such involvement).6 Consider, for example, the role of a leading bioethicist in shaping the health policy views of the US federal administration (Ezekiel Emanuel).7 Also, more and more health decisions have been seen in a bioethical light (eg, how to make coverage decisions regarding costly medical treatments8–10), while bioethics issues have moved from the bedside or research laboratory to the policy setting (eg, stem cell funding,11 ,12 healthcare rationing).13 ,14 This is not a new phenomenon: years ago ‘bioethics’-like enquiries considered how best to ethically distribute organs.15 Yet today, public policy involvement has moved from an occasional to a critical mission among many bioethicists. Indeed, a prominent US bioethics body—the American Society for Bioethics and Humanities16—routinely holds its annual meetings in Washington, DC, where it is better able not simply to take the pulse of Washington but also to influence that pulse.

Who leads the charge?

Bioethics, as it more fully engages in the public square, should recognise that among its numbers are individuals with any number of beliefs, areas of expertise and strengths, and who represent a global society reflective of a myriad of cultural, and not simply socio-political, influences. Caution thus is urged to avoid overstating our unanimity as a singular voice, belief system or approach to an issue. The risk is that bioethics can be co-opted to justify (vs critically analyse) pre-existing scientific, and political, positions, by finding the sympathetic individual and claiming she speaks for all bioethicists.17 We should be cognisant when speaking out not to open the door for others to use what we say and to ascribe to it the label of ‘the’ bioethics position.18 We should also guard against coercing consensus by declaring one vision of ‘the good’ based on the most powerful, most vocal, most Westernised, etc, argumentation. Revisit the initial case, for example: a concern might be, say, that we label certain principles as ‘international guidelines’ for hESCR that should have universal effect when such are agreed upon by only a powerful few (individuals, interest groups or nations). This is not to imply there is never a place for international guidance, or that ethics is always relativistic. The experience with research ethics abuses and development of the Nuremberg Code19 comes to mind as an imperative use of collective voice. However, care must be taken not to substitute times that call for international decisive action with more numerous times where a more politically or culturally informed understanding of the ‘good’ is foisted on others as an ‘international’ good.

It is better, therefore, to shift our attention to an end goal that seeks a more effective (and honest) sort of consensus: a unifying belief in ethics as a critical element in the health policymaking process. That is, while having breadth and depth of expertise and values related to the content of policy, we are unified in wanting ethics to be a key infusion within that content via an ethical policymaking process.20 ,21 For example, we might add to a deliberative democratic approach to policymaking—with its expectation for parties to explain reasoning behind policies endorsed22—a critical touchstone for such deliberative discussions: ethics. Thus do we arrive at the issue of how to frame our role within this process.

How to frame bioethicists' role?

To have an effective place in the public square and role in the public policy process, we must figure out how to put that which we study and apply (eg, bioethics principles) in understandable terms. We should become more familiar, through empirical investigation and by other means, with the language that most effectively informs and influences local, state or province, national, regional and global policymakers and their constituents—where a more pragmatic philosophical discourse or clinical or legal understanding may help. As applied in our case, bioethicists engaged in hESCR policymaking would be expected to study and more fully reflect upon the historical, cultural and political concerns that inform existing national policy approaches to safeguarding ‘human dignity’, say.

This guiding role should not be foreign to the field—bioethicists have played this role in a number of ways internationally, for example, through Unesco and the International Bioethics Committee,23 and in the USA, on congressional and presidential commissions.24 ,25 It is a diplomatic-like role, but one where bioethicists are not completely neutral arbiters but are guided by approaches and values they are expected to make transparent and justify. Bioethics, as a field, can bring this structured, mediating, analytical, educational and advisory role to the policy development process in a systematic way.

Further, as in clinical ethics where caution is urged about developing an identity as the ‘ethics police’ or awarding an ‘ethics stamp of approval’, bioethicists should avoid being seen merely as rubber-stamping scientific technology or institutional policies, or as cops ferreting out those who transgress certain norms. Other individuals can fill these roles; ours, again, is one of ethical guidance and analysis. In the context of our case example, the goal might be a rather more humble (and more pragmatic) one: a process by which nations may view their public policy discussions of hESCR through an ethics, and not purely scientific or economic, prism.

Envisioning a role in the public square: concluding thoughts

Critically, in this vision ‘bioethics’ is not one single person or belief for a policymaker to call to guide or give support to a position. Instead, bioethics should be seen as a series of tools—formed and utilised by a diverse disciplinary range of individuals—to help guide ethical analysis of biomedical endeavours. For health policy this would mean that as policy is developed, bioethics could inform a process for analysing the ethical implications of policies and policymaking. Bioethics can also be a mechanism through which to monitor ethical implementation and evaluation of policies. This would be in tandem with—but not substituting for—the traditional role of regulators in implementing laws and judicial bodies in interpreting them and adjudicating among competing parties.

In sum, this vision of a publicly engaged bioethics is more that just a consensus-seeking and policy paper-drafting endeavour; rather, the ‘outcome’ becomes an ethics-informed process. This could involve, say, developing a ‘bioethics policy consultation’ model that builds on bioethics (and other professional) training and adds to it localised and global policy-related knowledge (eg, policy analysis, policy development, policy structures) and skills (eg, influencing policy). Armed with this more focused skills development, and attuned to the power of process (the ‘how’ to use what we do, what we know, etc), my hope is that bioethicists more fully and effectively, albeit perhaps more slowly and humbly, engage in the public square. Pictured through another metaphor: it would not be about having one seat at the table, but helping create the menu and make the meal. From this more considered approach might bioethicists hold a different but perhaps even more critical power—that of infusion and diffusion of ethical enquiry and prioritisation in health policymaking.

Acknowledgments

Ms Campbell thanks Dr Robert Baker for his review of and comments on an earlier draft of this paper.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.