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Bioethics: An International, Morally Diverse, and Often Political Endeavor

Abstract

Bioethicists often remind health care professionals to pay close attention to issues of diversity and inclusion. Approaches to ethics consultation, where the perspective of the bioethicist is taken to be more morally correct or necessarily authoritative, have been critiqued as inappropriately authoritarian. Despite such apparent recognition of the importance of respecting moral diversity and the inclusion of different viewpoints, authoritarianism is all too often the approach adopted, especially as bioethics has shifted evermore into concerns for public policy. Yet, secular values and philosophical principles are not morally neutral; nor are the private moral convictions of bioethicists. Such analysis is always grounded in particular understandings of the right and the good, the virtuous and the just. Critical examination of common treatments and new alternatives is essential for the careful scientific practice of medicine. The same is true with regard to bioethics. Stagnating in customary or accepted claims of a common secular morality or a standard set of bioethical principles out of an unwillingness to explore the real diversity of moral thought, including traditional religious and cultural worldviews, fails to tap the human capacity to find innovative solutions to the complex challenges facing medicine.

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Notes

  1. “The defining characteristic of this approach to HCEC [health care ethics consultation] is its emphasis on the consultant as the primary moral decision maker. It may suggest to participants in the consultation that the moral values or perspectives of the consultant are more correct or important than the moral perspectives of other participants in the consultation. This assumption may lead to minimizing or excluding the values of key stakeholders (e.g., patients, surrogates). It may create the impression that the consultant’s expertise in ethical analysis amounts to moral ‘hegemony,’ which is problematic because it usurps the authority of primary decision makers. We do not support this approach” (American Society for Bioethics and Humanities Task Force 2011, 6–7).

  2. Here, one might consider attempts to treat minor children as independent decision makers and thereby seperate parents and their children (Barina and Bishop 2013; De Lourdes-Levy et al., 2003; Cherry, 2013; see, generally, Cherry 2016). Or, when clinical ethicists seek to sideline religious parents altogether (see Brummett, 2021).

  3. Engelhardt recalls, for example, that “There was a deep consanguinity between the cultural and educational movements and a political movement to secure at law patient rights and to forward what was generally a social-democratic political vision. It was no accident that Sargent Shriver and the Kennedy family found it quite appropriate to support the Kennedy Institute of Ethics, along with its Center for Bioethics. The language of rights to health care and concerns with equality in health care had important resonances with Senator Ted Kennedy’s long-time support of a substantial restructuring of American health care” (Engelhardt, 2009, 296).

  4. Consider the American Society for Bioethics and Humanities’ self-publication of their bioethics consultation manual: Core competencies for health care ethics consultation (1998), now in its second edition (2011).

  5. Such diversity includes significant disagreement regarding which moral principles matter (Veatch 2020; Campelia & Feinsinger, 2020), and when they are authoritative (Porter, 2020; Trotter, 2020), as well as whose morally content-full claims ought to frame public policy (Engelhardt, 1996). It also impacts moral assessment of particular controversial issues, such as lethal injection (Sawicki, 2022), ecological concerns (Katz, 2022), conscientious objection (Cantor 2009; Gamble & Gamble, 2022; McConnell 2021), euthanasia (Raus et al., 2021) and human challenge trials (Hausman, 2022).

  6. Consider, for example, the Fraser Institute’s annual report on the Canadian healthcare system, documenting increasing wait times for access to specialist treatment and important diagnostic tests. Patients experience significant waiting times for diagnostic technologies. Mackenzie Moir and Bacchus Barua document that “The wait for a computed tomography (CT) scan has decreased to 5.2 weeks in 2021 from 5.4 weeks in 2020. Saskatchewan, Ontario, Quebec, and Newfoundland & Labrador had the shortest wait for a CT scan (4.0 weeks), while the longest waits occur in Alberta (10.0 weeks). The wait for a magnetic resonance imaging (MRI) scan has decreased to 10.2 weeks in 2021 from 11.1 weeks in 2020. Patients in Ontario faced the shortest wait for an MRI (6.0 weeks), while residents of Alberta wait longest (24.0 weeks). Finally, the wait for an ultrasound increased in 2021 to 3.6 weeks from 3.5 weeks in 2020. Alberta, Saskatchewan, and Ontario have the shortest wait for an ultrasound (2.0 weeks), while Prince Edward Island has the longest: 16.0 weeks (chart 7)” (2021, 9).

  7. Waltzman, Womack, Thomas, and Sarmiento conclude: “First, injury rates are underestimated because this study only included children treated in EDs. Many children with a TBI do not seek care in EDs (10) or do not seek care at all. Second, the estimates cannot be used to calculate relative risks for TBIs associated with SRR activities because there are limited data on national participation in SRR activities, especially for unorganized sports. Therefore, it is difficult to tell whether decreases in injuries result from interventions, decline in participation, or a combination of both. Third, because NEISS-AIP was not developed to identify specific diagnoses, actual TBIs might have been missed, and some injuries classified as TBIs might not have been. Fourth, because NEISS-AIP only included one diagnosis and body part injured, TBIs might be missed in cases where multiple injuries were present” (2020, 872).

  8. Here one might consider that oncogenic human papillomavirus (HPV) infection has been identified as a major cause of cervical cancer, as well as of other types of oropharyngeal and anogenital cancers (see, e.g., Herrero et al., 2015).

  9. https://www.eurotransplant.org/cms/index.php?page=legislation1.

  10. Some libertarians might reject, for example, the idea that states are acting in a morally legitimate fashion when they decide to confiscate organs at death without explicit permission. After all, states are not generally morally in authority simply to confiscate all of one’s savings that one has otherwise left to one’s assigns and heirs. That the state claims that it will use the confiscated wealth to benefit others does not thereby make the taking any more morally justified.

  11. Here, some patients may raise concerns regarding inappropriate end-of-life care. Non-heart-beating donors, for example, may be given anticoagulants and vasodilators to support oxygenated blood flow, treatments designed to benefit the organ and future organ recipient, rather than the donor patient.

  12. Indeed, one might even object on economic grounds. State confiscation of organs seems particularly problematic once one realizes how financially valuable human organs can be. Instead of the spouse and family of the recently deceased receiving payment, the organs are confiscated, a practice legalized by the very government that prohibited the selling of valuable human organs in the first place. What a gruesome form of death taxes—a direct levy by the government on valuable property that would otherwise have been entailed to the recently deceased’s estate (see, e.g., Cherry, 2015, 2017).

  13. “ASBH is an educational organization devoted to fostering ‘dialogue, collegial endeavors, and membership with persons from diverse cultural, ethnic, and racial backgrounds.’ Racism and racial injustice stifle this aim. In 2019, ASBH adopted the following strategic priority: ‘Define diversity, equity, and inclusion goals for ASBH as an organization and how those values will be reflected through ASBH programs.’ We remain committed to this priority, including supporting a sense of belonging for ASBH members, conference attendees, and communities we serve and providing an environment for free expression of diverse points of view, scholarly exchange, and respectful debate and discussion on difficult questions and issues both within the organization and on behalf of ASBH members” (2020, https://asbh.org/asbh-statement-on-racial-injustice-and-professionalism).

  14. See also Julie Cantor: “Medicine needs to embrace a brand of professionalism that demands less self-interest, not more. Conscientious objection makes sense with conscription, but it is worrisome when professionals who freely choose their field parse care and withhold information that patients need. As the gatekeepers to medicine, physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization, and birth control? Do not practice women’s health. …Conscience is a burden that belongs to the individual professional; patients should not have to shoulder it” (2009, 1485). Such viewpoints seems to ignore the fact that a Roman Catholic OB-GYN should be able openly to offer Roman Catholic women’s health, advertising any particularly limits on her practice, including refusals to provide abortion, sterilization, and birth control. Many patients may welcome such an opportunity.

  15. For some insight into the conflicts between standard American bioethics and religion see Parks (2021), Camosy (2021, Goss and Bishop (2021, Engelhardt (2017).

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Correspondence to Mark J. Cherry.

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Cherry, M.J. Bioethics: An International, Morally Diverse, and Often Political Endeavor. HEC Forum 34, 103–114 (2022). https://doi.org/10.1007/s10730-022-09482-y

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Keywords

  • Bioethics
  • Moral diversity
  • Inclusion
  • Clinical ethics