Observing Bioethics (review)

This is a beautiful book. From the page design to Eve Siegel's elegant jacket featuring Rembrandt's Anatomy Lesson of Doctor Tulip, Oxford University Press has produced a volume that befits the luminary status of its authors, sociologist Renée C. Fox and historian Judith P. Swazey. This team of participant observers has documented, enlightened, and challenged the "happening that deeply involves . . . the collective conscience of American society" (p. 84), known as bioethics, from the moment of its conception.

The authors' ambition is "not [to] evenhandedly, comprehensive[ly], fastidiously follow the entire trajectory of bioethics"; their "focus [is] the . . . emergence of bioethics . . . its early intellectual, professional . . . development, and its global diffusion" (p. 12). The first part of the book is an excellent, historiographically insightful, concise history of the birth of bioethics. Among the authors' sources are "44 face-to-face, semi-structured interviews [with] first- and second-generation" bioethicists (p. 9). Using these data, they rebut currently fashionable revisionist constructions of bioethics as conservative, demonstrating that its founders actively participated in the "civil rights and anti-war movements and . . . women's movement [and] carried their militant individualism, antipaternalism, and antiauthority convictions with them into the new field" (p. 154).

Observing Bioethics has some limitations. The title is something of a misnomer. The book might accurately have been titled "Interviewing Bioethicists." The authors do not observe bioethicists' everyday activities: researching/teaching (seven in ten), clinical ethics consultation (three in five), institutional review board work (two in five), nonclinical consultation (one in five), or expert witnessing (one in ten).¹ Moreover, the authors impose a solipsistic reading on U.S. bioethicists' focus on autonomy, even though their interviewees protested, "Neither at the inception of bioethics, nor in the later phases" was "autonomy . . . meant to be the autonomy of the individual versus the community" (p. 156). Bioethicists insist that appeals to autonomy just assert patients' and research subjects' rights against paternalistic clinicians and exploitive researchers.

Undeterred by their own data, in the second half of Observing Bioethics Fox and Swazey ruminate on a pseudo-dilemma: how could U.S.-style bioethics, suffused with parochial American individualism, become "internationally diffused" (p. 215)? Intertwined with these ruminations is a debate over "ethical relativism." One interviewee, Ruth Macklin, a leading opponent of "double standards" that permit researchers to perform research in developing countries that would be impermissible in developed countries, expresses her opposition using different discourses. Sometimes Macklin appeals to "human rights," at other times to "universal principles," and at times to "common morality." Philosopher Bernard Gert introduced the latter expression to bioethics to indicate that morality addresses the common vulnerabilities of people everywhere. Gert does not believe in universal principles: his theory of common morality was intended as a critique of Tom Beauchamp and Jim Childress's notion of universally embraced moral principles (principlism). In a Borg-like assimilation, however, Beauchamp and Childress blunted the rhetorical force of Gert's critique by rechristening their own theory of universal principles "common morality." By muddying the linguistic waters, they hid the conceptual differences between their ethics of common principles and Gert's ethics of common vulnerabilities. Interviewing Beauchamp and his Georgetown colleagues (pp. 158-60)—but not Gert and other critics—Fox and Swazey interpret "common morality" to mean universal moral principles. Since American moral principles are not universally accepted, the authors puzzle at length about the international appeal and dispersion of bioethics. The Gert-Macklin position offers an explanation: bioethics' international appeal is a testament to the shared vulnerability of patients and research subjects everywhere.

Fox and Swazey may miss a few tricks here and there, but they are almost never dull and are often provocative and, more often than not, insightful—especially about the founding of bioethics and its founders. No reader in search of fresh insights will close this book dissatisfied.