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Medical Education and the Paradigm of Bioethics – IV

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The regnant paradigm of bioethics is a highly rational, formal, largely deductive mode of argumentation that draws upon a “relatively small set of concepts”, opines Prof Ashoka, in the fourth part of his erudite research paper. A Different Truths exclusive.

What are the medical-educational effects of these developments? The answer can best be approached through a closer consideration of the conceptual framework in which bioethics is usually taught, and of the phenomena that are, and are not included in its orbit. To begin with, the regnant paradigm of bioethics is a highly rational, formal, largely deductive mode of argumentation that draws upon a “relatively small set of concepts” – chiefly, the principles of autonomy, beneficence, nonmaleficence, and justice, and the derived rules of truthfulness, privacy, confidentiality, and faithfulness.  Often referred to as “principilism,” and drawn largely from the Anglo-American tradition of analytic philosophy, this system of thought was brought to bioethics and made preeminent within it by its founding generation of philosophers and reinforced by the scientific positivism of biologists and physicians, and the analytical jurisprudence of the lawyers who accompanied them.

The importance that bioethical thought attaches to a coolly rational mode of analysis focused on autonomy-of-self bends it away from detailed attention to the empirical contexts…

The importance that bioethical thought attaches to a coolly rational mode of analysis focused on autonomy-of-self bends it away from detailed attention to the empirical contexts in which ethically relevant events occur, from how they are experienced, and from serious consideration of the play of both rational and nonrational social and cultural factors in moral life-including what sociologist Harold Garfinkel might have termed “good sociological reasons for bad bioethical outcomes.”

Values that give weight to feelings and relatedness, to a self-transcending sense of  solidarity with known and unknown others, to the community and the society, and to a special obligation to heed the plight of those who are disadvantaged and underserved, are overshadowed by what some bioethicists have critically referred to as the “autonomy unbounded” rationalism of the field’s  outlook.

Not only is bioethics disposed to minimise the role of social and cultural factors and regard them as epiphenomena; it is also inclined to look upon their invocation with wariness.

Not only is bioethics disposed to minimise the role of social and cultural factors and regard them as epiphenomena; it is also inclined to look upon their invocation with wariness. This stems in good part from the intellectual and moral commitment of bioethics to an Olympian ideal of universal ethical principles – sometimes called “common morality”-and from bioethicists’ connected concern about succumbing to “local meanings,” or what they term “cultural and ethical relativism.” Universal ethical standards exist, philosopher-bioethicist Ruth Macklin declares, in the contemporaneous form of “human rights,” which she defines as “rights that belong to all people, wherever they may dwell and whatever may be the political system or the cultural traditions of their country or region of the world.”  Along with numerous other American bioethicists, she rejects the idea that “human rights is a Western invention, or that it is a form of ethical imperialism to impose that Western concept on cultures with a different tradition.” While acknowledging that such ethical principles “require interpretation when they are applied to particular social institutions, such as a health care system or the practice of medicine,” and that “in the particulars, there is ample room to tolerate cultural diversity,” she nonetheless avers that the cultural espousal and societal implementation of human rights-based ethical universals constitute “moral progress.”  This kind of “stance against relativism, ” bioethicists are inclined to be­lieve, is a safeguard against dangerous forms of particularism that, as philosopher-bioethicist Daniel Callahan has written, can eventuate in “subservience to the interest of class and tribe, to our crowd, and the passions of the moment.” In their view it is also essential to what many bioethicists regard as one of the most crucial and difficult tasks of ethics: “to stand in judgment” on cultural precepts and social behaviours that “seem to be wrong, misguided, or evil.” The “against relativism” outlook of bioethics runs counter to the emphasis that the social sciences place on the importance of recognising and respecting the significance and the tenacity of historical, cultural, and societal differences in values, beliefs, conduct, and world views. It is a basic source of strain between the two fields.

Another characteristic of bioethics is its secular outlook, even though some of its founders and most esteemed participants have been theologians or religious ethicists.

Still another characteristic of bioethics is its secular outlook, even though some of its founders and most esteemed participants have been theologians or religious ethicists. Questions of a religious nature-concerning human origins, identity, and destiny, the meaning of suffering, and the mysteries of life and death-continually arise in bioethics; but they are  generally defined as inherently insoluble problems pertaining to personal and private beliefs falling outside the domain of bioethics, or, more characteristically, are translated and assimilated into the field’s conceptions of ethics and the ethical. This is a complex phenomenon to which the religious backgrounds and histories of influential bioethicists have contributed, along with the rationalism, positivism, and individualism of the field’s intellec­tual culture. On a more macro level, the fact that bioethical issues with religious connotations have been projected into the public domain and the polity  of  American  society-a  society that is religiously pluralistic, intent on avoiding acrimoniously divisive religious controversy, and  pledged  to uphold  the con-situational tenet of maintaining separation between church and state-has exerted a major influence on the pattern of “screening out” the religious content of bioethics, or “reducing” it to ethics.

To date, however, relatively little change has occurred in the contours, content, style of thought, or the ideology of bioethics.

Impelled throughout the 1990s by criticisms of the mode of thought, the discourse, and the perspective of bioethics – coming as much from inside the field as from outside it – efforts have been made by scholars and professionals engaged in bioethics to alter its cognitive structure, its methodology, and its ethos. These efforts have centered on trying to break through the domination of the field by the abstract “principlism ” of analytic philosophy, as well as by the primacy accorded an autonomous, self-determined conception of individualism and individual rights; on endeavouring to achieve greater rapprochement between the rather polarised notions of individualism and community, and of universalism and particularism, that char­acterize the intellectual and moral framework of bioethics; on attempting to incorporate other philosophical systems into the matrix of bioethical thought (notably, casuistry, phenomenology, pragmatism, virtue ethics, narrative ethics, and feminist philosophy); and on promoting first-hand ethnographic methods of inquiry as a way to bring bioethics closer to how ethical quandaries are situationally and humanly experienced. To date, however, relatively little change has occurred in the contours, content, style of thought, or the ideology of bioethics.

Bioethics is an intellectual and social endeavour of great importance, not only because of its relevance to the moral formation and edification of physicians, but also because, as I have written elsewhere, “Bioethics is not just bioethics . . .and [it] is more than medical. Using biology and medicine as a metaphorical language and a symbolic medium, bioethics deals…with nothing less than beliefs, values, and norms that are basic to our society, its cultural tradition, and its collective conscience.”

Identifying what bioethics is and is not helps to clarify what medical educators should and should not expect of it.

Nevertheless, bioethics is not prone to inquire into the nature of its wider significance, or to teach about it. Nor does it usually deal with larger social and moral issues of medical significance – such as suffering and ill health caused by poverty, homelessness, prejudice and discrimination, or even what sociologist David Mechanic has called “the most glaring perversity of U.S. medicine” – the fact that  more  than 44 million people have  no health  insurance  and many more are  underinsured,  “despite  expenditures that far exceed those of any other nation.” Throughout most of its history bioethics has been inclined to treat problems of access to health care as social issues rather than ethical ones – drawing and maintaining a sharp dichotomy between the two. Quite recently, bioethics has begun to address some of the ethical problems posed by the rise of managed care in the United States. But thus far the ethics of physician-patient and physician-organisation relationships in this setting have been emphasised with relatively little consideration given to the ethics of healthcare organisations, or to the ethical ramifications of the dominant role that for-profit health organisations have come to play in the delivery of health care in the United States since the 1980s. Bioethics has consistently concentrated on a specific set of moral quandaries and critical choices, and contemplated a narrow range of alternative courses of action.  Characteristically, for example, when in the realm of what is called “clinical bioethics” it focuses on ethical issues that occur between physicians and patients at the bedside, it does so with sparse reference to their respective social and cultural backgrounds, their “lived lives,” the psychodynamics of what transpires between them, and the social milieu of the hospital in which these doctor-patient   encounters take place. Identifying what bioethics is and is not helps to clarify what medical educators should and should not expect of it. If my analysis is valid, then bioethics-at least in its present form­ is being asked to assume too much responsibility for defining the orientation, content, and scope of the non-biomedical aspects of medical students’ professional education and development.

(To be continued)

©Prof. Ashoka Jahnavi Prasad

Photos from the Internet


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