Growing Respect for Opposition

The next forty years will see us through the most imperative issues in bioethics and public health today. We will face continuing challenges regarding health care reform, reproductive freedom, and euthanasia. We will confront growing disparities stemming from global development and cope with complex questions of social and environmental justice. We will grapple with the health effects of global climate change and with the implications of the rapidly expanding role of genomics in health research and practice. Bioethicists will face no shortage of contentious issues in the coming decades, but as I begin my career, I wonder if we are prepared to meet them.

With the topics of normative debate so ripe for discussion, it is the process of decision-making in bioethics that I believe merits more attention. The most pressing issue for bioethics may not be in the content of moral discourse, but rather in the way we engage in it. Fundamentally a discipline based in dialogue, bioethics depends on participation—on the articulation of values and principles and the willingness to deliberate with those who disagree. Particularly with the aim of informing policy, dialogue is a cornerstone of bioethics that is swiftly eroding.

Today, dialogue among bioethicists, policy-makers, and the public is far from robust, yet it will be key to addressing the bioethics debates of the future. While democratic theory has long underlain arguments for the inclusion of public reason in public policy, there are several factors that raise public engagement over the next forty years to new importance.

First, the normative dimensions of many of the policies we face will arise from the development of new technologies for which the harms and benefits are not yet known. Whole-genome sequencing, tissue engineering, nanotechnology, and stem cell therapy are just a few of the nascent technologies that hold uncertain consequences when introduced to medicine, public health, and consumer markets. Furthermore, the increasingly rapid translation of technology to the public results in access to technology before its consequences can be fully recognized. Coupled with what are often less-than-conclusive claims about benefits and about who will gain those benefits, these issues pose additional challenges to ethical decision-making. Relying on experts to review evidence and balance risks and benefits will not suffice when evidence is conflicting, benefits are unclear, and harms may be unrecognized. The controversy around direct-to-consumer genetic testing and the utility of personalized medicine are case examples where ethical policy development will require consulting many more diverse perspectives than have been sought in the past, including those of the public.

Second, we live in a society more pluralistic than ever before. Particularly in the United States, but globally as well, each society holds within it a growing number of value systems. The single most important issue facing bioethics stems from the diversity of accepted frame-works, beliefs, and moral values held by the population today. The work of bioethics in reaching one well-justified and decisive course of action is no longer sufficient. As scholars have recognized, policy-making in pluralistic societies will not be a matter of choosing the single justified option, but rather, choosing from several mutually exclusive options that are each justified under a reasonable, yet distinct, set of values.¹

In response to the changing nature of policy-making in pluralistic societies, a number of bioethics scholars have suggested that the principles of deliberative democracy may be the way forward.² Requiring thoughtful criticism of arguments, wherein the underlying values are made explicit, deliberative democracy aims to generate decisions that are, if not endorsed by all, at least reasonable to all parties as consistent with a recognized moral framework. Deliberative democracy is an appealing strategy to facilitate the decisions necessary for public policy development. The practical application of deliberative democracy, however, and its role in policy formation are not yet well determined. Deliberative democracy requires participation—public engagement with the policy process and mutual respect among citizens. Above all, deliberative democracy requires participants to acknowledge and respect alternative positions and be open to persuasion. Though it is an ideal model for bioethics forums, extending the practice of...