Bioethics in a Liberal Society: The Political Framework of Bioethics Decision Making

1. Introduction: The Liberal Framework

1 INTRODUCTION The Liberal Framework Developments in medical technology offer tremendous advantages in many very important areas of life. But in making available treatment options that did not previously exist, these developments can infringe on other very important areas of life in ways once unfathomable. Blood transfusions, which offer medical benefits to certain patients, pose to persons with particular religious beliefs a threat that did not arise before the development of this technology. Treatment options such as chemotherapy offer potential benefits, but they also have potential side effects that might threaten a patient ’s dignity in ways that other treatment options would not. And our ability to continually extend biological life raises questions about whether simply extending life is our goal, or whether a longer life is a valid aim only when a patient considers his or her life to be of a quality worth living. Judgment of the good by which “appropriate” treatment might be assessed , then, becomes a significant issue. There are many alternative frameworks by which this assessment might be made, as illustrated in a simplistic way by the examples mentioned above—the tension between extending biological life and quality of life or the use of blood products. Because medicine is, by nature, a social practice (involving the interaction, at a minimum, of patient and provider), the question arises: When the assessments of “better ” from competing perspectives conflict, which values, or whose values, should frame the assessment that decides “better,” or even “appropriate,” treatment? Understood in this way, the ethical questions surrounding the assessment of treatment become in large part political: Is there a privileged perspective that allows one individual’s views to take precedence? If not, how do we determine which perspective assumes priority? These are not questions about the ultimate moral worth of a particular perspective, but rather are political questions concerning how to adjudicate between competing frameworks for assessing “the good.” In a liberal society, the answers to these questions depend on the individual and on the values that shape and give meaning to that individual’s life. Liberal societies reject advocacy of substantive value systems at a social level in favor of a social system that defines value as determined, in substance or content, by individuals living in that society. In this, a plurality of values coexist, and no one of these, for social purposes, is given a privileged position. Although rejection of a “privileged” perspective on the good often results in liberalism being associated with moral skepticism (see G. Dworkin 1974), and although moral skepticism is surely one foundation on which a liberal state might be adopted, liberalism does not require moral skepticism as a foundation (see Gray 1986). Indeed, such competing theories as those offered by John Rawls and utilitarianism emphasize the role of individual judgment and hardly need subscribe to a moral skepticism. The core idea of liberalism is that the individual is held to be the seat of moral judgment (see Hall and Ikenberry 1989), and this requires only that one recognize a diversity of views concerning moral questions, opting for a political structure that remains neutral among these, regardless whether one (or even more) of these is correct. John Rawls (1971) takes the priority of “the right” over “the good” to be a starting point for his theory of justice, developing a political framework that he takes to embody a Kantian respect for autonomy. In emphasizing the priority of “the right,” Rawls’s theory of justice does not presuppose a privileged conception of the good but attempts to provide a political framework in the context of the good as understood through reference to the judgment of individuals . John Stuart Mill (1956), a utilitarian, appealed to the importance of autonomy not because the right assumes priority over the good but rather because utility is served by allowing each individual to construct her own life plan. For Mill, the good consists of human “happiness,” and this calls for maximizing the aggregate happiness of individuals living in a society. By Introduction 2 allowing individuals to construct their own life plans, their happiness is maximized . Although people may at times make poor decisions, the individual, Mill argues, is in the best position to judge her own good. This concern to respect individual judgment leads to a position of tolerance in social policy. A utilitarian argument for liberal tolerance of religious moral perspectives relies on the...