The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives ed. by Marcus Düwell et al. (review)

Globalization, at least for advanced societies, has resulted in what is essentially a single medical-industrial complex developed within a highly integrated collaborative bioscience. Yet one of the key differences within that complex hinges on whether or not health care is a right. Health care in the United States is dominated by an individual-based consumer model, while most European nations and Canada have adopted a communal responsibility for clinical care. This fundamental opposition is reflected in medical ethics characteristic of each system. A so-called “new bioethics” originating in Europe has been proposed to balance the autonomy-based approach dominant in the American system with a schema based on human dignity (Beyleveld and Brownsword 2001). How such a recalibration might affect American bioethics is uncertain, but such discussions reflect the ongoing evolution of American medical ethics from its original commitments to individual autonomy to more pluralistic formulations.

A Moral Dichotomy?

Extrapolating from case law, commentators have noted how autonomy became the lynchpin of medical ethics in the United States. In the post–World War II era, the basis of informed consent underlies the doctor-patient relationship, and in the opinion of many American bioethicists, autonomy thus trumps other ethical principles (such as beneficence, justice, and non-maleficence) (Annas 1989). When placed in the wider context of American political culture, the dominance of individual choice as a guiding politico-economic principle is reflected in the consumer model of health insurance, and that ethos also stretches beyond the commodification of health care to autonomy-based models of medical decision-making. Indeed, critics assert that medical ethics in its autonomy-oriented posture has been coopted by the very institutions ethicists once sought to criticize and transform. For example, Haliburton (2015) charges that an ironic reversal has taken hold: “The mainstreaming of bioethics has resulted in its domestication: it is at home in the institutions it would once have viewed with skepticism, and a central part of practices it would once have challenged” (3). On this view, autonomy has not only been transgressed, it actually serves heteronomy.

In contrast, Europe and Canada place less credence in autonomy as a governing precept, both in the domain of health-care services (universal access is a right of citizenship) and as a governing tenet of medical practice. According to the dominant European point of view, where autonomy is compromised—as in the setting of illness—patients need to be protected, and so dignity, integrity, and vulnerability become guiding, protective values (Beyleveld and Brownsword 2001). In sum, respect for patient autonomy becomes only one of several values in the calculus of care. Communal responsibilities—conceived in terms both of individual patient care and of the larger socioeconomic context of institutional and governmental accountability—take priority (Parizeau 2000).

These putative differences in moral attitudes reflect deeply held cultural standards. Medical ethics was born as a formal discipline in the late 1960s, and the initial concerns of American ethicists reflected complex social factors, all of which seemed to converge on a newly activated suspicion of authority (Jonsen 1998). In parallel with the loss of trust in government, education, and business, critics identified instances of patient abuse and unwarranted physician paternalism that demanded redress. If the ancient moral philosophy governing the doctor-patient relationship had become suspect, then a defensive posture that would assure patient rights was required. Thus a newly articulated medical ethics sought to build on an assumed beneficence, but one fortified with a new demand concerning the respect of patient autonomy in the guise of informed consent (Tauber 2005). The dominant voices advocated patient autonomy, not only because it was the most easily extrapolated from a rights-based politico-judicial culture, but also because it best captured what was missing: trust. From this cultural perspective, medical ethics is one piece of the deep moral crisis Americans continue to face. Medical ethics, and patient...