By Yeremias Jena, M.Phil
(Atma Jaya School of Medicine, Catholic University of Atma Jaya, Jakarta, Indonesia. Email: firstname.lastname@example.org)
Three mixed of personal and academic reasons have driven me to read and review this article of Angus Dawson. First, entering into bioethical field has obliged me to define myself. Being trained in the field of philosophy, what will be my contribution to bioethics? What kind of bioethics I am interested in and what area of bioethics will be my field of research? I have learned from Angus Dawson—a philosopher like myself but has an advantage of being trained also in law—how to define the field or discipline one interest in and the importance of proposing one contribution to bioethics.
Second, once decided to work as professional bioethicist, I should perceive myself as having a responsibility to reflect and develop methodology of bioethics which is part of responsibility of any scientist in the field. Angus Dawson has encouraged me to understand how Socratic Method can be applied also to bioethics and help “to save” bioethics from the dominance of medical ethics or other fields in years to come. It helps to keep bioethics as multidisciplinary field or discipline.
Third, this article inspired me to see and understand what are the needs of my country if I am talking about or discussing bioethical problems? Living in a country (Indonesia) where there is less attention being paid to public health, the idea of ethics of public health might be helpful as tool to address and analyze public health problems.
First, Angus Dawson argues that bioethics is in crisis and going to lose its future if the dominant ideology continues to dominate it. For him, medical ethics has been dominating bioethics since the very beginning of its birth. With its three dogmas, medical ethics engulfed bioethics and stripped away other bioethical problems which are equally important. In order to bring back bioethics into its identity as multidisciplinary field or discipline, we need what Angus Dawson called as “Socratic approach”.
Second, bioethics is not a medical ethics. Bioethics covers a much broader range of topics related to the creation and maintenance of the health of living things. Medical ethics is part or a field in bioethics. This should be common knowledge for any bioethicists, but why do we tend to forget that? And why are peoples equating bioethics with medical ethics? Why do medical ethics become so dominant in bioethical debates? Angus Dawson proposed four reasons. First, more people are engaged in projects in medical ethics than other disciplines, and as consequence, more literatures in medical ethics are coming out. Second, medical ethics are more exiting to work in due to the rapid development of medical technology, the issue of life and death which are more dramatic (It is interesting to coin this reason with the “public feature of bioethics” as Kopelman suggested in his article. The issue of life and death which are related to medical technology too often hit the media headlines in such a way as if bioethics were medical ethics). Third, issue in health care is much related to our life. Fourth, social context of the birth of bioethics colored by the movements of patient’s rights, general distrust of expertise, scandals in medical research, the generation of 1960s and 1970s that want always to change, to see their knowledge as something useful for social change.
Third, Angus Dawson argues that the domination of medical ethics has been more problematic than helpful. It is because of the three dogmas the medical ethics hold very tightly. First dogma: Individual autonomy (advance directives or informed consent) is seen to be the most important moral values or principle. By holding it tightly, one “tends to ignore the empirical and normative literature on the problem with such directives …. [or] in gaining consent from people, as well as those situations where, for methodological reasons, it may not be appropriate to seek consent”(Angus Dawson: 2010, p. 220). Second dogma: autonomy of the patient has change the relationship between physicians–patients from paternalism to a more consumerist model. Physicians and patients are suspicious strangers to each other, who are negotiating for a contract and act upon it once it has been agreed. The patients see the physicians as autocratic and paternalistic doctor, expert in his knowledge and skills but narrow. There is no obligation as existing prior to the voluntary contract. Patient-doctor relationship is similar to commercial transaction. There is no room for treatment base on care relationship. Third dogma: Ethics and ethical problems in medical ethics (especially as it has shown in various publications on medical ethics regarding public policy) are equated with law. The presumption is that if things are not restricted then we are free to do things.
Fourth, these three dogmas have negative influence on the development of bioethics. Angus Dawson said that a patient in his vulnerable condition cannot exercise his full autonomy. The reason why patient come to see a doctor is to seek help and care, and not to exercise his autonomy. That is why the consumerist model of relationship between patient-doctor will reduce care to profit making mentality. If this so happened then care as the primary reason for being a doctor will soon wither. Doctor-patient relations based merely on contract and law will lessened the value of responsibility of physician to his patient.
Fifth, not only that. Chose to remain dogmatist means willing to let occurred the extinction of bioethics. Bioethics cannot be limited only to medical field. There are other fields related to life that should be address too, be it the problem of environment, food, animal, public health, or even life style. Angus Dawson suggested Socratic methodology to be applied in bioethics. This is what he means by “a cup of hemlock”. With “a cup of hemlock” at hand, we can (1) deconstruct the three dogmas being dominating medical ethics [“deconstruct” is my word, not of Angus Dawson], and (2) in order to bring back into existence the multidisciplinary feature of bioethics. (3) Then to induce the importance of addressing public health problems (I think it would be interesting to analyze further this point by relating it Kukla’s notion of “conscientious autonomy” in which she suggested care ethics as more important element than autonomy given the fact that patients are vulnerable. By then we can discuss the elements of dialogue, responsibility, curing, and nurturing in physicians-patients relationship. Cf. Rebecca Kukla: 2005).
Sixth, but why is public health ethics? First, human’s life is interconnected. Autonomy is important but it cannot be separated from other important values such as equity, reciprocity, solidarity, the common good, and welfare. People are not fully autonomous if they had less access to common good, if there is no equity in accessing health care, and if there is no social solidarity. Second, how about consumerist relationship between doctor and patient? The main characteristic of this relationship is portraying individual as monad, fully autonomous, free to decide without any interference. This description of human relation is fanciful and unrealistic. We are living in a web society where every stake holder has its own role in it, be it individual, groups, societal, system, or environment. For example: our life is influenced by our food choices, smoking and drinking habits, or by exercise patterns. Third, the starting point of thinking about public policy is not on how to incarcerate someone, but on how to encourage people to live well in order to achieve good life, and that in a web society, everyone has obligations to others. For example: vaccination is part of one’s responsibility to the others.
First, this study helps to develop bioethics as multidisciplinary discipline operating second-order principles.
Second, Socratic methods help bioethicists to be critical to what they have done and what they are going to do? It helps also to focus on which bioethical problems that caused more damage on humanity and to address also that problem.
Third, the article gives optimism about the future of bioethics.
This article takes part in the ongoing debate about methodology and kinds of bioethics as science. This debate can be traced back even to the writing of Daniel Callahan (Daniel Callahan: 1973, ‘Bioethics as a discipline’, The Hasting Center Studies, 1, 66-73) or the witness of Albert R. Jonsen (David E. Guinn (ed.): 2006, Handbook of Bioethics and Religion. New York: Oxford University Press)—just to named two among the founders of bioethics in USA. While debate on the kinds of bioethics can also be traced back to the article of Diego Gracia (Diego Gracia: 2001, ‘History of Medical Ethics’, in: Henk ten Have and Bert Gordijn (eds.), Bioethics in a European Perspective. Netherlands: Kluwer Academic Publishers, pp. 17-50) or William E. Stempsy (William E. Stempsy: 2007, ‘Medical Humanities and Philosophy: Is the universe expanding or contracting’, Medicine, Health Care and Philosophy 10, 373-383). Other current articles discussing the method and development of bioethics are Who Needs Bioethics by Hallvard Lillehammer (2004: Stud. Hist. Phil. Biol. & Biomed. Sci. 35, 131-144), Who’s Arguing? A Call for Reflectivity in Bioethics by Jonathan Ives and Michael Dunn (2010: Bioethics 24, 256-265), The Transformation of (Bio)ethics Expertise in a World of Ethical Pluralism by Jozsef Kovacs (2010: J Med Ethics 36, 767-770), Bioethics as Public Discourse and Second-Order Discipline by Lorreta M. Kopelman (2009: Journal of Medicine and Philosophy 34, 261-273), Does Bioethics Exist? By L. Turner (2009: J Med Ethics 35, 778-780), or The Death of Bioethics (As We Once Knew It) by Ruth Macklin (2010: Bioethics 24, 211-217), and many other articles.
The tension between broader and narrow conception of bioethics has been present since its birth (Van Rensselaer of the University Wisconsin Vs Andre Hellegers of Georgetown University). Bioethics is viewed in its broader notion as it was depicted by Van Rensselaer of University of Wisconsin (cf. Diego Gracia: 2001, pp. 17-18; William E. Stempsey: 2007, p. 377). Edmund D. Pellegrino has warned us that too narrow conception may lose insights of various points of view, traditions, values, different cultures, other fields of bioethics. “Traditional model of bioethics” (named by Pellegrino) is not recommended (William E. Stempsey: 2007, p. 377).
As one of the first generation witnessed the birth of bioethics and helped to shape its autonomy as a discipline, Daniel Callahan considered bioethics as “not yet a full discipline” (Daniel Callahan: 1973, p. 68). Why? “Most of its practitioners have wandered into the field from somewhere else, more or less inventing it as they go. Its vague and problematic status in philosophy and theology is matched by its even more shaky standing in the life science, disciplinary standards, criteria of excellence and clear pedagogical and evaluative norms provides, however, some unparalleled opportunities. It is a discipline not yet burdened by encrusted traditions and domineering figures. Its saving grace is that it is not yet genuine discipline as that concept is usually understood in the academic and scientific communities. One has always to explain oneself, and that leaves room for creativity and constant re-definition; there are many advantages in being a moving target.”(Daniel Callahan: 1973, p. 68).
It is interesting to note that when the philosophers and theologian entered the field of bioethics, especially in medicine, they learned to take of their shoes because the field they are entering is “a holy ground”. Albert A. Jonsen said, “I had crossed a frontier into a strange land. I had to learn a new language, filled with the words of anatomy, physiology, pathophysiology, and pharmacology. I had to learn the culture of medicine and hospitals. I had to converse with men and women who did not share my faith or even my interests. … Above all, I have to learn the values that prevail in the world of medicine so that I could even ask ‘ethical’ questions or dare to teach ethics”(see David E. Guinn (ed.): 2006, p. 24). Daniel Callahan also has warned the philosophers that they should not apply “disciplinary reductionism” when once they enter the field of bioethics. (Daniel Callahan, pg. 69. By this Callahan warned the philosophers and theologian not to apply directly ontological concept they are accustomed with to bioethical problems).
Bioethics should be a second-order discipline in the sense that is it “inherently interdisciplinary and compatible with there being subspecialties in one of the disciplines associated with bioethics (Loretta M. Kopelman: 2009). Or, as Ruth Macklin (Ruth Macklin: 2010) put it, bioethics is a “multidisciplinary field in which ‘reasonable people could disagree” (Ruth Macklin: 2010, p. 212).
Considering the interdisciplinary feature of bioethics, I would propose the reason why bioethics is being engulfed by medical ethics with its three dogmas as described by Angus Dawson. It so happened because bioethicists and other stake-holders are a condition which I call “the forgetfulness of its raison d’être” [inspired by the forgetfulness of being of Martin Heidegger]. The spirit of “take of one’s shoes” help bioethicists to be opened to learn new culture and field in order to deliver ethical problem in ordinary language and/or in more conceptual way has been disappeared.
What Angus Dawson diagnosed as the “disease” of bioethics has been proven by some facts he described. Ruth Macklin even more radical when she predicts that bioethics will be extinct in 2050 if bioethicists continue to disagree one another and forget to address “the high price of pharmaceutical products and the cost of hospitalization, in order to make those resources affordable in low-resources countries as well as to what has become a majority poor population in industrialized countries” (Ruth Macklin: 2010, p. 127).
If Socratic approach (hemlock) were applied too rigidly in medical ethics, wouldn’t there be another turning away of bioethics as interdisciplinary discipline when philosophy finds its momentum to come into power? Are we going to put bioethics as part of philosophy of medicine as suggested by William E. Stempsy (2007)? These questions are importance by the fact that not all bioethicists in the field now are philosophers.
I think Socratic approach has its own power to not only prevent bioethicists falling into any dogmatic mind and attitude, but also an effective tool to encounter some wishful thinking arose by certain bioethicist. I am thinking about a rather strange proposal of L. Turner (2009). In one of her latest article entitled Does Bioethics Exist? she argued that bioethics will have no future if bioethicists do not have (1) a shared mode of normative analysis; (2) a common way of thinking; (3) an overarching framework of moral deliberation; (4) a recognized set of tools with which to reason and to debate; and (5) a widely accepted ethics decision-making (L. Turner: 2010, 778-780). Considering principlism as ideal shared modes of normative analysis which are not the case nowadays, L. Turner tried to promote dogmatic features of bioethics which is opposed very strongly by Angus Dawson. Turner proposal is a kind of wishful thinking expressed by a bioethicist who is impatient to argue things and to come up with conclusions where all perspectives and disciplines related to bioethics have their own say. This is bioethics.
3. Some final comments
Three critical questions could be addressed to Angus Dawson. First, depicting contractual relationship of doctor-patient in such a way as a result of patient’s freedom and autonomy may fail to see the middle ground where there is no full autonomy as such as well as there is no full paternalism without any concern to care. In fact being a doctor is a call to save life. Every physician understand it very well when they vowed, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” Saying that physicians change their care into duty relationship based on contract sounds alien given the fact that doing good and caring is very foundational of being doctors.
Moreover, I would perceive this article of Angus Dawson merely as a philosophical reflection based on intellectual or ontological claim rather than evidence-based critics. We cannot simply base our claim that bioethics has been colonized by medical ethics without referring it to some based-evidence studies as a strategy to communicate to other bioethicists who were trained with heavily positivistic science mind.
Second, Socratic Method presupposes leveling up knowledge and philosophical skills. Whose skills and which criteria? Is it the skills of the philosophers or theologians to be set as benchmark, or the skills of other disciplines like medicine, sociology, anthropology, literature, and so on? As I said before, too poisonous hemlock may not be helpful for bioethics.
Third, in discussing bioethical problem, let say public health problem, are we going to talk it ethically by referring it to some ethical principles or moral foundations in order to make our argumentations sound philosophically? Or, is it sufficient to weighing argumentations and ethical justification without referring it to certain moral ontology? Which rationality are we going to apply in discussing public health or public policy where the problem of justice or equality concerned has been the core business of philosophy? I am afraid that philosophical thinking and argumentation will create antipathy among bioethicists than solution to a problem.
Angus Dawson: 2010, ‘The Future of bioethics: Three dogmas and a cup of hemlock’, Bioethics 24, 218-225.
David E. Guinn (ed.): 2006, Handbook of Bioethics and Religion. New York: Oxford University Press.
Daniel Callahan: 1973, ‘Bioethics as a discipline’, The Hasting Center Studies, 1, 66-73.
Diego Gracia: 2001, ‘History of Medical Ethics’, in: Henk ten Have and Bert Gordijn (eds.), Bioethics in a European Perspective. Netherlands: Kluwer Academic Publishers, pp. 17-50.
Hallvard Lillehammer: 2004, ‘Who needs bioethicists?’, Stud. Hist. Phil. Biol. & Biomed. Sci. 35, 131-144.
Jonathan Ives and Michael Dunn: 2010, ‘Who’s arguing? A call for reflexivity in bioethics’, Bioethics 24, 256-265.
Jozsef Kovacs: 2010, ‘The transformation of (bio)ethics expertise in a world of ethical pluralism’, J Med Ethics 36, 767-770.
Lorreta M. Kopelman: 2009, ‘Bioethics as public discourse and second-order discipline’, Journal of Medicine and Philosophy 34, 261-273.
L. Turner: 2009, ‘Does bioethics exist?’, J Med Ethics 35, 778-780.
Rebecca Kukla: 2005, ‘Conscientious Autonomy. Displacing Decisions in Health Care’, Hasting Center Report 35, 34-44.
Ruth Macklin: 2010, ‘The death of bioethics (as we once knew it)’, Bioethics 24, 211-217.
William E. Stempsy: 2007, ‘Medical Humanities and Philosophy: Is the universe expanding or contracting’, Medicine, Health Care and Philosophy 10, 373-383.