restricted access 10 Bioethics as Politics: A Critical Reassessment
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c h a p t e r t e n Bioethics as Politics A Critical Reassessment h . t r i s t r a m e n g e l h a r d t j r . , m.d., p h.d. authority, power, and politics: exploring the third spatialization of disease Bioethics is biopolitics, although it is surely not only politics, because it is a medical morality that has been understood in terms of the political agendas it can serve. It is impossible to appreciate the rapid emergence of bioethics at the end of the twentieth century apart from its roles in authorizing health care policy and law. It is not just that bioethics received an important impetus to its development through explicitly political establishments such as the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. More significantly, that commission, and subsequent analogues such as the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, the National Bioethics Advisory Commission, and the President ’s Council on Bioethics, employed bioethicists and engaged bioethical reflection in ways that presupposed that bioethics is able morally to authorize particular appropriate health care policies and laws. This was the case, although bioethical disagreement was early apparent.1 Bioethics was regarded as a source of secular, political authority. Its practice became integral to what Michel Foucault characterized as the third spatialization of disease: the nesting of medicine, its descriptions , and its diagnoses, as well as therapeutic interventions, within social structures of authority and power (Foucault 1973, 16). Bioethics took shape as a way of directing clinical choice, the governance of health care institutions, and the formation of health care law. It was engaged in the service of shaping social reality. Or to put matters in a di¤erent idiom, politics o¤ered the higher social truth within which the interminable disputes of moral theorists and proponents of di¤erent ethical viewpoints could be set aside in what appeared to be a single, normative approach to health policy and law. A Hegelian Sittlichkeit, a socially authorized morality, could be created and established at law as normative, within which a particular account of a proper bioethics would be rendered oªcially normative and authoritative for the governance of health care institutions and the shaping of health care policy.2 If this could be accomplished , bioethics’ troubling pluralism could be set aside (indeed aufgehoben) in a legally established morality (i.e., the higher truth of the moral domain where pluralism reigns). In this discussion, I first o¤er a brief account of the appearance of bioethics and the constitution of dominant expectations regarding the field, expectations that bioethics could not in principle fulfill. In the course of giving this account, I then indicate why we confront a robust, irresolvable, moral pluralism that brings into question many of the promises made on behalf of bioethics. In advancing this account, I do not endorse a moral relativism, but rather I indicate why a moral pluralism is unavoidable, given the limits of secular moral epistemology. We are confronted with a plurality of moral understandings among which one cannot conclusively choose on the basis of a sound rational argument. Having given this account of the emergence of bioethics and of the unjustifiable expectations regarding its abilities, I advance a brief account of why, though bioethics could not accomplish what it promised as a normative endeavor, it nevertheless appeared to do so anyway, in both the clinic and for public policy, by serving goals of governance and political order. I conclude with a set of warnings for the future: the predicament of our moral context requires recognizing the unavoidability of moral pluralism and the need to rethink the character of bioethics’ role as biogovernance and biopolitics. why bioethics gained authority so quickly An indication of the power of the social forces shaping the emergence of bioethics is the rapidity with which the field took shape. No sooner had the term, originally coined by Van Rensselaer Potter,3 been recast by André Hellegers and Sargent Shriver,4 than an entire scholarly field, along with a cadre of practitioners , came into existence. By 1978 the field could claim not just a body of publications and an influence on the National Commission for the Protection of Human b i o e t h i c s a s p o l i t i c s 119 Subjects of...