How sociology can save bioethics . . . maybe
José López, Sociology, University of Ottawa, Ottawa, Canada, K1N 6N5 e-mail: email@example.com
This paper argues for the importance of a broad sociological engagement with bioethics. It begins by considering why sociologists should be interested in bioethics and then goes on to explore the cognitive critique of bioethics developed by ethnographers. Some of these authors have also suggested that a more robust bioethics might emerge through the incorporation of the tools of ethnographic analysis. In this paper, it is argued that this is an important claim which needs to be analysed further and that Foucault's concept of discursive formations provides a useful framework for doing so. Once bioethics is redescribed as a discursive formation, the paper explores the challenges and obstacles that sociology and ethnography face in their attempt to open up a space for themselves in bioethics. The paper concludes by suggesting that sociologists and ethnographers need to reflect on the ways in which they might democratically secure legitimacy for their own claims in the field of social ethics.
In little over 30 years, bioethics has managed to position itself as a key node through which a variety of social, political and scientific activities are refracted. In the US, bioethics has not only participated in reshaping the relationship between doctors and patients through the development of informed consent, it has also carved a niche in the wider governance of biomedical research. Although the growth of bioethics is particularly noticeable in the US, it has made progress elsewhere1. This paper, however, will focus on developments in the US.
Dan Callahan (1999) has defined the task of Bioethics as ‘. . . the determination, so far as that is possible of what is right and wrong, good and bad, about scientific developments and technological deployments of biomedicine. What are our duties and responsibilities in the face of those developments?’ (1999: 276). Broadly speaking, bioethics has been concerned with the deployment of the tools of moral philosophy and applied ethics to critically determine the moral worth of practices associated with biomedicine.
For bioethicists this development is best understood as a response to the novel moral dilemmas introduced by the growth of new medical technologies and research programmes (e.g. Intensive Care Unit, Neonatal Intensive Care Unit, organ transplants, genetics) and the necessity of reining in the paternalism of the medical profession in the 1960s and 70s. However, as Stevens (2000) has argued, bioethics has not become ‘an established source of critical oversight’, instead it has become ‘an opportunity for ethics experts to cope with dilemmas generated by technologies, which came to be seen, ironically, as value-neutral in their creation even while they were problem-causing in their effects’ (2000: 150).
This paper begins by considering why sociologists should be interested in bioethics. This is followed by a discussion of how sociologists have engaged with the field. Particularly important is the work of ethnographers. Through their cognitive critique of the knowledge claims of bioethics, they have highlighted the inadequacies of mainstream bioethics as a way of identifying, understanding and resolving bioethical dilemmas. Some of these authors have also suggested that a more robust bioethics might emerge through the incorporation of the tools of ethnographic analysis.
Although there is much merit in this proposal, I believe that there are also problems. I argue that to date this strategy for opening up a space for sociology and ethnography in mainstream bioethics has not been successful. This is, in part, due to the fact that the legitimacy of bioethics as a form of socially sanctioned knowledge does not derive from the validity of its cognitive claims; its authority is linked to its embeddedness in other types of knowledge claims and social practices. I develop an analysis of the nature of these relations by drawing on Foucault's concept of discursive formations.
I then explore some of the obstacles and opportunities that sociology and ethnography face in their bid to engage in the ‘serious talk’ (Foucault 1992) of bioethics. I conclude by arguing that sociologists and ethnographers need to reflect on the ways in which they might democratically secure legitimacy for their own claims about ethical object(s).
Why should sociologists be interested in bioethics?
A general answer to this question might be: ‘In bioethics we find an ideal arena in which to extend our ideas about the creation and organization of new professions, the social context of morality and the role of expertise in society’ (DeVries and Subedi 1998: xvii). This argument is given further urgency, however, by Fox and Swazey's (1984) claim that, ‘Bioethics is not just Bioethics’:
. . . using biology and medicine as a metaphorical language and symbolic medium, bioethics deals . . . with nothing less than beliefs, values, and norms that are basic to our society, its cultural tradition and its collective conscience (1984: 336).
That bioethics might be in a position to work on and reconfigure wider societal values is due to the role which medicine, health and illness play in Western civilizations. This, of course, has been analysed at great length by medical sociologists and anthropologists since Talcott Parsons’ path-breaking analysis of the sick role.
As the medical anthropologist Byron Good (1994) has argued, medicine plays a special role in the alignment of values in the contemporary Western world:
Weber . . . held that civilizations are organised around a soteriological vision – an understanding of the nature of suffering, and means of transforming or transcending suffering and achieving salvation. In contemporary Western Civilizations, medicine is at the core of our soteriological vision (1994: 70).
Medicine, however, is not only a carrier of social morality, but, also a key element in the social control of populations. Thus, ‘In industrial societies, biomedicine along with the mental health, disability and welfare systems that closely relate to it have arguably become the major form of social control’ (Kleinman 1997: 39). A form of social control that through the mediation of new public health programmes is frequently embodied and experienced as a lived and ethical morality through practices of the self: ‘“Healthiness” has replaced “Godliness” as a yardstick of accomplishment and proper living. Public health and health promotion, then, may be viewed as contributing to the moral regulation of society, focusing as they do upon ethic and moral practices of the self’ (Lupton 1995: 4).
In light of the above, it is nothing short of surprising that sociologists have shown so little concern for investigating an ethical discourse and practice which is in a position to act as ‘a strange attractor’ for these phenomena (Bosk and Frader 1998: 106).
The sociology of bioethics
The work done in this field reveals two broad forms of engagement2. The first, drawing on the tools of political sociology and the sociology of the professions, has outlined the wider historical, political, cultural and economic conditions of the possibility of bioethics as a discourse and an institutionalised practice (see for instance Evans 2000, 2002, Bosk 1999, Chambliss 1996, Churchill 1999, DeVries and Conrad 1998, Flynn 1991, Fox 1989, Guillemin 1998, Imber 1998, Rothman 1991, Rosenberg 1999, Stevens 2000 and Wolf 1996). Below, I draw on some of this work when I redefine bioethics as a discursive formation.
The second, led mainly by ethnographers, has been concerned with pointing out the empirical deficit to which bioethics has been hostage3. It is argued that bioethicists misrepresent the ethical moment and lack a practical understanding of how moral values and ethical behaviours are embodied and lived by social agents. As I will show in the next section, through the production of ethnographic data, these scholars have also criticised the explicit universalistic aspirations of bioethical discourse and have highlighted the importance of both difference and context. This approach is frequently conjoined with the conviction that the practice of bioethics itself might be improved through the adaptation of methodologies and conceptual tools from the social sciences, primarily ethnographic ones. As is clear from the summary of my argument in the introduction, this is a claim which needs to be examined further. Before moving towards this objective, however, I will first summarise in the next two sections some of the arguments and findings produced by the ethnography of bioethics.
What is wrong with bioethics?
The disciplinary origins of bioethics in moral and analytical philosophy and theology has created a selectivity towards a formalistic, procedural, disembodied and universalistic way of identifying and resolving bioethical dilemmas. At present the hegemonic paradigm in US bioethics is Principlism4. For its defenders, Principlism brings together ‘. . . An analytical framework, elements of common moral language and a basic moral commitment to health care ethics that is neutral . . . and can be shared by all regardless of their background . . .’ (Gillon 1994: 333). It is the existence of a common and neutral moral language, independent of contextualised social relationships, capable of mediating ethical dilemmas in the diversity of social sites where biomedicine unfolds which is contested by ethnographically minded critics.
In their seminal and extremely influential text, Principles of Biomedical Ethics, Beauchamp and Childress (1994) present a series of principles (autonomy, beneficence, nonmaleficence and justice) which they maintain are compatible with a common morality which is universalistic in scope. They present a detailed analysis, often not found amongst their followers, which explores how these principles might be specified and balanced in order to deal with specific cases. As Wolpe (1998) has argued, however, the reality is that ‘. . . autonomy has emerged as the most powerful principle in American bioethics, the basis of much theory and most regulation, and has become the “default” principle of applied principlism, the principle to be appealed to when principles conflict’ (1998: 43). And it is precisely this aspect of the bioethical project which has been much criticised by sociologists (Fox 1989: 229).
A number of ethnographers have argued that autonomous action is not the property of individuals but of complexly-ordered social relations; it is not something which doctors or other healthcare professionals can unproblematically grant their patients. To take an example, Robert Zussman (1992), in his ethnography which documents ethical dilemmas in ICUs writes:
. . . we might argue that physicians have turned the imperatives of formal consent, whether to the initiation of new procedures or to the discontinuation of old ones, to their own purposes. Borne of and sustained by a doctor-patient relationship with neither intimacy nor a great deal of trust, formal procedures may become a means by which physicians withdraw from intense involvement with their patients. Protestations of patient autonomy in this context become little more than excuse for disengagement (1992: 221)5.
A related objection is the ethnocentrism associated with the notion of individual autonomy (Kleinman 1997, Fox and Swazey 1984, Good 1994, Lock 2001). Moreover, sociologists and anthropologists have pointed out how the focus on autonomy has marginalised other issues that might have rightfully fallen under its remit (DeVries and Conrad 1998: 235), i.e. social inequality, gender, professional power and race and ethnicity.
Ethnography and bioethics
In many ways these criticisms can be linked to the discursive carrier of bioethical discourse, namely analytical philosophy. Below, where I analyse bioethics as a discursive formation, I explore the wider conditions of the possibility of bioethics as a practice. Nonetheless, it can still be argued that to the extent that the ideal of analytical philosophy is premised on the alleged ‘rational’, ‘disinterested’ and disembodied activity of logical argumentation, it has projected this vision on the social world itself. Thus, as Hoffmaster (2001) argues, bioethics ‘. . . prescinds the messy details and attachments that give our lives meaning and vigor, the nagging contradictions that make us squirm and struggle, and the social, political and economic arrangements that simultaneously create and constrain us’ (2001: 1).
However, because ethnography locates its analysis of the flow of everyday life in institutional contexts, it is able to explore the way in which relations of power, institutional routines, cultural scripts and narrative techniques are used to identify and negotiate some events as ‘ethical dilemmas’ and displace others (Kleinman 1997: 55). These dimensions are exemplified in Chambliss's (1996) study of nursing, Beyond Caring. The ethnographic research, carried out over a period of 11 years at three different hospital sites, reveals how nurses rarely encounter ethical dilemmas which are openly scrutinised through an appeal to abstract philosophical argumentation. Instead they are folded into routines whose aim is to maintain order in the context of potential chaos.
Chambliss's analysis, however, goes further by showing how ethical problems in nursing arise in the context of ‘conflict between nurses and other constituencies in the hospital’ (1996: 180). For instance, when considering the frequent conflict between nurses and doctors over whether to treat terminally-ill patients aggressively, ‘physicians tend, for a variety of reasons, to lean toward aggressive treatment, perhaps from fear of malpractice suits, belief in the efficacy of medicine, responsibility to save lives, or even a relative ignorance of the patient's suffering’ (1996: 95). This is in contrast to the ‘nurse's (work imposed) frustration of dealing, hour after hour, with a patient who isn't progressing and who is begging to be let alone’ (1996: 95). For Chambliss this leads to an ‘ethical’ dispute between two professional world views where one (held by the nurses) is in a subordinate position. Thus, ‘. . . distraught nurses may call on the hospital's ethics committee, not for an objective appraisal of the situation but for moral support in a professional conflict’ (1996: 95). Chambliss goes on to conclude that his ethnographical analysis reveals:
The problems nurses face are not logical quandaries, they are political conflicts; not random events but recurring patterns; not psychological ‘dilemmas’ but political conflicts; and they are decided not by the most thoughtful or educated persons but by the most powerful (1996: 182).
An ethnographically informed bioethics, however, is not limited to highlighting the power differentials in which ethical dilemmas are framed and resolved, it also provides a vehicle for ‘the discovery of the meanings and relationships in distinctive local worlds, and the interpretation of their actual impact’ in the attempt to produce ‘a coherent narrative out of interactions that are ambiguous and changing’ (Kleinman 1997: 54). For instance, Edwards's (1993) report on an ethnographical study undertaken in order to elicit the ethical conceptions of ordinary people with respect to assisted reproduction, reveals how people draw on existing knowledges and experience of kin relationships in order to make sense of the moral dilemmas associated with New Reproductive Technology (NRT). As Edwards argues:
People interpret what they see as the implications of NRT not through what they know of the techniques and philosophies of reproductive medicine, but through what they know about the practice and predictabilities of kinship. They do not, in other words, have to be technologically literate in the methods of NRT in order to think about the implications of certain reproductive possibilities for the social relationships they create and/or influence (1993: 83).
These two brief examples serve as an illustration of the theoretical and empirical insight that ethnography can provide for our understanding of ethics as a lived experience. Chambliss's work reveals how ethical questions are not separable from the relations of powers in which ethical dilemmas emerge and are resolved. Edwards's study points to how individuals draw on existing cultural resources which are embedded in their everyday experiences as a way of tackling ethical questions. They both articulate an understanding of ethical negotiation which is theoretically and empirically far richer than that provided by philosophical bioethics.
Ethnography's cognitive critique
One theme which re-emerges, in criticisms by ethnographers, is the lack of theoretical and empirical analysis of the unfolding of ethical life in everyday interactions in bioethics. This means that ethnography's principal bid to engage in serious talk in the field of bioethics is grounded in the opposition between the highly formalistic and abstract conceptual discourse of bioethics, and the richly nuanced account of moral dilemmas and embodied ethical behaviour which ethnography can provide. Indeed as Chambers (2000) has argued, this represents a ‘centering’ strategy that functions as ‘an entrance tale’ for many sociological and anthropological accounts of the field6: thus creating a place of epistemological, ontological and methodological privilege for ethnography7. In the words of one of ethnography's most vocal advocates: ‘the results of ethnographic investigations challenge both the dogmas that pervade the received view of medical ethics and the underlying philosophical model upon which “applied ethics” is predicated’ (Hoffmaster 1992: 1425).
The ethnographic project has however not only been one of critique. Implicitly or explicitly, it has also been concerned with exploring how ethnography's empirically-grounded explanatory tools might contribute to refurbishing the bioethical enterprise by providing it with a more productive and ‘realistic’ mode of analysis (see for instance, Benatar 1997, DeVries and Conrad 1998, Haimes 2002, Hoffmaster 1992, 2001: 1–11, Gallagher et al. 1998, Kleinman 1997: 41–67, Marshall and Koenig 1996, Spallone et al. 2000, Stolman 1993, Ten Have and Lelie 1998 and Winkler 1993).
Still, it is not clear that focusing on the cognitive weaknesses of bioethics and arguing that they can be overcome through ethnographical analysis has been effective in opening up a space for ethnography in mainstream bioethics. As Charles Bosk (1999) argues, it is still the case that ‘social scientists who came to many of these issues [the questions with which bioethics is concerned] before or contemporaneously with those philosophers, who identify themselves as bioethicists, now need to mount special pleas for our inclusion, our relevance to, and our importance for the discourse of bioethics’ (1999: 49).
To understand some of the reasons why this might be the case, I think it is important to note that the emergence of bioethics cannot be explained merely in terms of the validity of its cognitive claims. Yet if this is so, a strategy to open up a space for sociology within the field of bioethics which focuses exclusively on the superiority of the cognitive claims made by ethnography is unlikely to be successful. Lest I be misunderstood, I am not arguing that ethnographers working on bioethics are not cognisant of the extra-disciplinary dimensions of its success. Many highlight that, to a large extent, the legitimacy of bioethics derives from its social power to define problems as ‘ethical’ (and not structural) and solve them ‘ethically’ (and not necessarily equitably). But if this is the case, what are the implications for sociology or ethnography? If the claims to legitimacy in bioethics are secured, in part, outside the validity of its cognitive and explanatory apparatus, would this not also be true for sociology and ethnography?
Before examining some of the consequences associated with this question, I will briefly sketch an analysis of the ascendancy of bioethics in the US that embeds the validity of its cognitive claims in a wider social context. I draw on Foucault's concept of discursive formations as it provides a particularly useful way of thinking about the relationship between socially sanctioned knowledges and their wider social, cultural and political conditions of possibility. I also draw on the emerging work on bioethics’ political and social context. Once I have briefly redescribed bioethics as a discursive formation, I return to the challenges and opportunities that sociology faces in its attempt to open up a space for itself in the field of bioethics.
Bioethics as a discursive formation
Central to Foucault's analysis of discursive formations is the distinction between connaisance and savoir (1992: 15). A discipline is ‘. . . the locus of connaisance whereas the discursive formation is the locus of savoir’ (Gutting 1995: 251, italics in original). The latter ‘. . . refers to the conditions that are necessary in a particular period for this or that type of object to be given to connaisance and for this or that enunciation to be formulated’ (Foucault 1992: 15, translator's note 2, italic in original). To describe bioethics as a type of savoir requires not only an exploration of the concepts, theories, techniques of argumentation, methods of analysis and substantive explanations that are instantiated when dealing with its object – the bioethical dilemma. It also necessitates an understanding of the social arrangements that might explain the emergence of the object in social space as well as the viability of bioethics as a legitimate and socially effective form of connaisance.
Discursive formations are defined by Foucault (1992: 40–70) as consisting of four types of rules or relations: rules concerned with the formation of objects (What is the object of knowledge? Which are the social sites in which it emerges? Who is authorised to define it?), enunciative modalities (Who can produce knowledge of this object? From which institutional sites? What is the relationship between the producer of knowledge and the object?), concepts (What are the logical and methodological rules? On what criteria are statements accepted or discarded? Which concepts are mobilised from other discursive formations?), and finally strategies (Which overarching theories or themes are deployed? Which theories from other discursive formations do they articulate with? What functions does the discourse play in related fields of non-discursive practices?).
The first two sets of rules (objects and enunciative modalities) draw our attention to the social processes that authorise individuals and institutions to identify and speak about determinate objects of knowledge. In the next section, I will explore the historical emergence of these two facets with respect to US bioethics. I will then move on to discuss some aspects of the other two sets of rules (concepts and strategies). Developing a comprehensive account of bioethics as a discursive formation is beyond the scope of this paper, not least because the historical and political sociological scholarship which would make this task possible is still in its infancy. Nonetheless, I think that a preliminary sketch of bioethics as a discursive formation will prove useful.
The formation of objects and enunciative modalities in US bioethics
The origin of Principlism, which as I noted above is the hegemonic form of mainstream bioethics, is linked to the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, set up by the US Congress in 1974, which published The Belmont Report in 1979 (see Jonsen 1998: 99–106). The commission was charged with identifying ‘. . . the principles that should underlie the conduct of biomedical and behavioral research involving human subjects, and to develop guidelines which should be followed to ensure that such research is conducted in accordance with those principles’ (Gert, Culver and Clouser 1997: 73). The report produced a series of principles to serve as a ‘rational justification for decisions and policies’ relating to research on human subjects (Jonsen 1998: 103). The three principles, thought to be aligned with the US ‘cultural tradition’, were ‘respect for persons, beneficence and justice’; these were to be translated into practice as ‘informed consent, risk/benefit assessment and the just selection of the subjects for research’ (1998: 103–4).
For Evans (2002), it is significant that the initial object of bioethics, the need to regulate experimentation on humans, emerged in the context of a commission whose task was to provide a series of principles that could be used as the basis of bureaucratic oversight. He argues that this produced the conditions for a ‘formally rational’ and ‘highly calculable system’ that lead to the following outcomes:
First, the ends had to be portrayed as universally held by citizens, but had to be applied without a method of determining empirically what the ends of the citizens were. Second, the ends had to be applicable to any problem that arose, since it would complicate decision making to have different principles for different types of research. Third, maximal calculability could be had by creating one commensurable, universal ends scale, such as utility (2002: 85).
Evans goes on to argue that the wider institutionalisation of these principles was made possible by a series of contingent events. Particularly important was the acceptance of the principles by the Department of Health, Education and Welfare and its demand that all federally-funded scientists abide by them. This meant that institutional review boards (IRBs) overseeing grants for public money applied the principles. Moreover since journals refused to publish research unless it had been cleared by IRBs, this meant that the principles also infiltrated private research (2002: 89). Equally important is the fact that the intellectual entrepreneurs of Principlism, Tom Beauchamp and James Childress, would develop these principles further and derive a fourth – nonmaleficence – in their influential text Principles of Biomedical Ethics8. They thus contributed to formulating rules of formation for concepts and theories that provided the emerging discursive formation with methodological rigour, theoretical cohesion and intellectual respectability.
David Rothman (1991), in Strangers at the Bedside, argues that important changes in the relationship between doctors and patients also created opportunities for bioethics to expand its jurisdictional claims. To the extent that relationships of trust between patients and doctors became eroded through the specialisation of medicine, the delivery of healthcare in hospitals, well-publicised scandals in the field of medical research, and the anti-authoritarian and anti-paternalism of the social movements of the 60s and 70s, the need for a new form of oversight emerged. In this context, the new bioethics dealing with the regulation of human subject experimentation was well positioned to expand its jurisdiction:
The new rules for the laboratory permeated the examining room, circumscribing the discretionary authority of the individual physician. The doctor-patient relationship was molded on the form of the research-subject; in therapy, as in experimentation, formal and informal mechanisms of control and a new language of patient's right assumed unprecedented importance (Rothman 1991: 107).
It must be stressed that the redefinition of principles intended to regulate human research into principles underpinning bioethics was neither a given nor uncontested. Analyses of the jurisdictional conflicts underpinning this contestation, as exemplified for instance by the work of Evans (2000, 2002), Guillemin (1998), Rothman (1991), Stevens (2000) and Wolpe (1998), need to be further developed. However, even at this stage it is possible to begin outlining what the rules of the formation of objects and enunciative modalities might look like.
The rules concerning the formation of objects have three dimensions: surfaces of emergence, authorities of delimitation and grids of specification. The grids of specification refer to the indices used to demarcate the bioethical dilemma as a specific object of expertise. In bioethics these are generated by superimposing the normative templates of autonomy, justice, beneficence, non-maleficence over individuals in medical and biomedical research contexts. However, as we have seen above, these are not independent from the surfaces of emergence or the social loci in which bioethical dilemmas emerge (e.g. the state regulation of biomedical research, the regulation of the medical and healthcare professions, the individual as the locus of liberal autonomy, the patient and his or her body, and the deployment of new technologies) or the authorities of delimitation, i.e. those individuals who are authorised to identify a particular instance as involving a bioethical dilemma (e.g. the bioethicist, the policy maker, the researcher, the doctor, the lawyer, the nurse).
Equally, the rules of the formation of objects cannot be understood in isolation from the rules of enunciative modalities. These refer to those individuals who are authorised, not only to identify bioethical dilemmas, but to intervene in them (e.g. the bioethicist or bioethically-trained professional), as well as the institutional sites from which they do so (e.g. President's Commissions and other expert panels, regulatory bodies, bioethics centres, IRBs, bioethics and medical journals, and the mass media). The last dimension of enunciative modalities deals with the relationship between the subject making a statement and the object. Thus, a bioethicist may be present in the negotiation of a bioethical dilemma taking the role of the stranger at the bedside, but he or she can also be at a distance examining research and healthcare protocols, addressing reported cases or indeed even imaginary ones.
Having briefly sketched out the rules of formation of objects and enunciative modalities, in the next section I will explore some of the dimensions of the rules associated with concepts and strategies.
The formation of concepts and strategies
The rules for the formation of concepts have three dimensions. The first refers to the order of succession or relations between statements. In bioethics, we find rules for the derivation of general principles from a common morality, but also rules of philosophical analysis concerned with the development of deductive reasoning and the avoidance of contradiction, and rules for the employment of deontological and/or consequentialist reasoning. The second dimension establishes the types of statement which are accepted and those that are rejected; thus, statements that appeal to rational, calculable and universal criteria would be accepted whereas emotional, religious and idiosyncratic belief statements would be rejected9.
This second dimension would also have rules that authorise statements from other discursive formations; of particular importance for bioethics would be concepts and forms of legal argumentation and analysis, of economic modelling and cost/benefit analysis but also concepts and forms of argumentation found in medical discourse and liberal political theory. The significance of the connections with elements from other discursive formations is twofold. They provide bioethical statements with conceptual tools and modes of analysis and they also allow bioethical statements to draw on the authority and legitimacy of these other forms of socially sanctioned knowledges.
For instance, given the centrality of the court system in the US as a mode of resolving moral and political disputes, the close relationship between bioethics and law is not to be underestimated10. Similarly, as Chambers has argued, the medical technique of the ‘case study’ has played a crucial role in the development of principle-centred bioethical discourse, providing it with a mode of analysis analogous to medical discourse and also some of the legitimacy associated with medical practice (1999: 45–112).
Finally, the third dimension deals with procedures of intervention; that is to say, ways of working in the conceptual field: rules for the specification and balancing of principles in concrete cases, for identifying paradigmatic cases, for the application of imaginary cases to resolve specific dilemmas as well as rules for the development of cases projected into the future.
The last set of rules of discursive formations deal with the formation of strategies or theories. In bioethics we find principalist, consequentialist, deontological or casuistic strategies, as well as liberal-rights-centred ones. Another dimension refers to what Foucault calls ‘the economy of the discursive constellation’. Here he is pointing to the ways in which theoretical strategies establish homologies with those of other discursive formations (e.g. the medicocentrism of medicine (Kleinman 1997), the rights-centred theories of freedom in political liberalism (Charlesworth 1993)).
The last dimension of the rules of formation for strategies points to the function that statements perform in non-discursive fields of practice. Without attempting to be exhaustive, two examples will serve to highlight the significance of this dimension. The first addresses the role that bioethics plays in the humanisation of scientific medicine, the second how bioethics has strengthened the relationship between freedom, choice and technology in Western liberal societies.
It is important to realise that bioethics is but the most recent of the non-medical debutants invited to participate in ‘medical society’. The context for this was (and is) the perception that something had been lost due to the reorientation of medical education towards the natural sciences, first signalled by Flexner's 1910Report on Medical Education in the United States and Canada. Since the institutionalisation of a natural-science-based education, medical schools ‘through the medium of such “non-biomedical fields”’ have sought to supplement the perceived humanistic deficit by attempting to ‘. . . augment their efforts to teach what are alternatively called “behavioral”, “social”, “psychological”, “humanistic” and “ethical” components of health and illness, of “knowing patients as persons” . . .’ (Fox 1999: 2). As a number of scholars have pointed out this is now a function that bioethics has undertaken with much success (Bosk 1999, Churchill 1999, Elliot 1999, Evans 2000, Fox 1989, Imber 1998, Rosenberg 1999, Kleinman 1997: 41–67 and Stevens 2000).
Medicine, technology and choice
Bioethics has without doubt participated in the contemporary institutionalisation of what Habermas has identified as the close, if contingent, link between modern notions of freedom, understood as freedom of choice, and forms of scientific and technological control in liberal society (2003: 24).
Drawing on Charles Taylor's (1989) work on the historical emergence of the modern self, Gerald McKenny (1997: 17–24) has claimed that the genesis of the links amongst freedom, choice and technology can be traced to the interaction and development of three important historical trends.
First, is ‘the valuation of ordinary life’ as the site of salvation associated with Protestant Christianity, which radical enlightenment thinkers such as Jeremy Bentham reworked as the need to respond to the balance of pleasure and pain in ordinary human nature. The second is the formulation of the ideal of scientific and technological control of nature as a moral responsibility to pursue the good of the community through the elimination of unnecessary suffering and harm. The third trend is the valorization of the individual associated with Descartes and other inward looking philosophies, but perhaps more strongly developed by Romanticism in which an individual is not only unique and original, but it is ‘. . . this uniqueness and originality [that] determines how he or she ought to live’ (McKenny 1997: 20).
For McKenny these three historically contingent trends help us to understand the specifically modern expectation that ‘. . . the expansion of the reign of technology over the body should be accompanied by, and in fact should make possible, the expansion of the reign of human choice over the body, and that medicine should enable and enhance whatever pattern of life one chooses’ (1997: 20).
To the extent that bioethics, when confronted with a new issue in biomedical research or care, sees its primary roles ‘. . . as safeguard[ing] individual autonomy, calculate[ing] potential risks and harms, and determine[ing] whether or not a just distribution will follow’ (McKenny 1997: 8), it reproduces and strengthens the link between freedom, choice and technology. This is because bioethics subordinates ‘questions about the place of illness and health in a morally worthy life’ to ‘questions about which preferences technology should fulfil’ (McKenny 1997: 7). As Evans (2002) has demonstrated with respect to the contribution of bioethics to the Human Genetic Engineering (HGE) debate, the desirability of the goal of freeing ourselves from disease, illness, ‘abnormality’ and ‘imperfections’ through HGE has not been put into question. Instead the debate has focused on the best way of achieving this end.
Whatever the success, adequacy or cognitive validity of bioethics as a knowledge-producing discourse which might be called to analyse and mediate the relationship between a doctor and a patient, or a particular technology and a defined cultural community, its legitimacy and authority are in part secured through the way it is embedded in an ecology of socially sanctioned knowledges (e.g. law, medicine, economics, moral and political philosophy, and political liberalism), as well as practices of governance and self-government (e.g. regulation of research and healthcare provision, the governance of free individuals through technological choice). The emergence of its objects, concepts and theoretical strategies and the social institutions from which they do so, instantiate highly complex forms of social relations, and it is in this sense that we can begin to understand the significance of Fox and Swazey's (1984) claim that ‘bioethics is not just bioethics’. In the next section I discuss the challenges and opportunities associated with how ethnography might secure a place for itself not in the discourse of bioethics, but in the bioethical discursive formation.
Ethnography's cognitive critique: modifying concepts
The cognitive critique of bioethics developed by ethnographers attempts to intervene in the rules concerned with the formation of concepts (in the Foucauldian sense), and in thus doing, also attempts to modify those concerned with objects (e.g. What is an ethical dilemma?) and strategies (e.g. How should ethical dilemmas be governed?). Ethnographers argue that the methods used by bioethics to represent ethical dilemmas are incapable of capturing the highly contextualised nature of ethical behaviour embedded in social relations. Equally, they argue that this analysis operates in an empirical vacuum. However, even if one accepts that the methods provided by ethnography are cognitively better suited than those of bioethics at the level of the formation of concepts, this might not be the case in the context of rules of the formation of objects, enunciative modalities and strategies. Why might this be so?
First, ethnography's claims might very well be accepted (see for instance Alvarez 2002, Callahan 1999, Jennings 1998). However here ethnography runs the risk of tokenism because as a practice, which is highly skilled and laborious, it cannot be easily folded into the daily activity of clinical ethics consultations or other social loci in which bioethical dilemmas unfold. It is in danger of being incorporated into existing practices with its critical intent erased. For instance, Crigger (1998) describes a very general, and decidedly non-ethnographic, exercise in content analysis of the major themes covered by the Hastings Center Report as an ‘intellectual ethnography’11. Similarly, Stolman (1993), reviewing an ethnographic study which explores the efficacy of a form for eliciting patients’ preferences for treatment (Ventres et al. 1993), comments that as an analysis which does not correspond to the basic tenets of ethnographic research, it produces predictable and unconvincing results.
Both instances illustrate how the claims of the methodological value of ethnography can be incorporated without significantly modifying the object of bioethics (autonomy, justice, beneficence and non-maleficence) or indeed the formation of concepts (philosophical analysis and appeal to universal principles). For example, when the bioethicist Callahan (1999) casts a favourable eye on the contribution of the social sciences, he states that ‘There is, in short, no ethical theory that effectively instructs us about how to make legitimate use of survey research data in making moral judgments or shaping public policy’ (1999: 286). He goes on to suggest that this is no less true of ethnographic work, in this way revealing how ethnography's critical edge can be easily neutralised in the bioethical discursive formation.
Second, the object of bioethics is inseparable from the historical emergence of its enunciative modalities in the arena of public policy and the governance of technological change in liberal societies. Consequently, the cognitive claims of bioethics are, in part, sustained by their convertibility into relatively straightforward and efficient principles of bureaucratic regulation and calculation which are congruent with political liberalism, the modern rationalised state (Evans 2000) and the contemporary demand for ‘transparency’ associated with the audit culture. Might an ethnographically inspired bioethics be able to produce an alternative model capable not only of mediating bioethical dilemmas as they occur in everyday interaction but also at the level of the governance of liberal polities? Perhaps, however, as Fox and DeVries argue, the sociology of bioethics thus far has been strong on critique, but weak on proposing alternative or successor models (1998: 271).
Any attempt solely anchored in a cognitive critique will encounter limited success unless it can secure the social legitimacy of its claims by establishing connections with other socially authorised knowledges, practices of democratic governance and link its own object – a broader notion of ethical life – to normatively sanctioned social sites that can legitimately intervene to resolve bioethical dilemmas. In the next section I explore this point further.
Modifying objects, enunciative modalities and strategies
On the face of it, it would seem that sociology is ideally placed to make ethics its object. After all, as Donald Levine has argued, ‘The modern social sciences derive in good part from the quest of Western philosophy to fashion a rational, secular and social ethic’ (1995: 105). However, he also adds that:
. . . the ethical concerns that propelled philosophers into creating the social sciences seem to have dropped out of sight . . . The quest for a rational ethic was the booster that launched the social scientific disciplines into orbit. Once the disciplines were launched, the booster dropped away and disappeared (1995: 317).
Citing Horowitz (1993), he goes on to suggest that although the traces of the ‘ethical booster’ still pervade contemporary social science they exist as ‘ghosts in the social-science-machine’ (1995: 317).
Chambliss, in his conclusion to the ethnographic study of the social organisation of ethics in hospitals, argues that:
Morality is rooted in collective life. Since Durkheim, sociology has understood that moral beliefs are rooted in group membership and loyalty, and that such beliefs are arrived at neither through rational debate nor in isolation from other people. Durkheim also provided a model for the empirical study of morality, a topic too often left to philosophers and theologians (1996: 185).
This is true. But Durkheim's claims were not only descriptive but also prescriptive (Miller 1996: 251). In attempting to identify the new form of ethical behaviour –i.e. organic solidarity – compatible with the ‘moral crisis’ of industrial society (Durkheim 1984: 339), he was also prescribing a model of ethical behaviour that corresponded with specific social types (differentiated society): ‘If there is one rule of conduct whose moral character is undisputed, it is that which decrees that we should realise in ourselves the essential features of a collective type’ (Durkheim 1984: 329).
Durkheim claims that ‘solidarity is not only a duty not less obligatory than others, but is perhaps the very source of morality’ (Durkheim cited in Miller 1996: 254). In identifying morality as the object of sociological study, Durkheim linked morality to practices of individual self-government. In industrial society, he argued that ‘We must limit our horizons, select a definite task, and involve ourselves utterly, instead of making ourselves, so to speak, a finished work of art, one that derives all its value from itself rather than from the services it renders’ (1984: 333). He also connected this object, and the authority of the sociologist to speak of this phenomenon, to rules for the formation of concepts in the Rules of Sociological Method, enunciative modalities (the university and the educational system, the professions, the empirical sociological treatise, the state) and to theoretical strategies (analogies with biology and evolutionary theory, the division of labour) as well as non-discursive practices (the governance of free individuals, the resolution of class-based conflict through meritocratic practices, the cult of individual and modern restitutive law). Thus Durkheim's development of a science of morality is not only an attempt to introduce a new empirical method but an attempt to ‘float’ a socially-sanctioned knowledge embedded in discursive and non-discursive practices for the governance of industrial societies.
My point is not to argue that we should return to Durkheim's science of morality. But that we should reflect on the wider social and historical conditions of the emergence of ethics as an object (in the Foucauldian sense) in sociology not only as a discourse but at the level of a discursive formation(s) (see Levine 1995). This would also involve trying to understand the disciplinary and extra-disciplinary reasons why ethics has been banished to its existence as ‘the ghost in the social-science machine’12 and why it appears now to be making a resurgence. This would allow us to link the ethical object of sociology to wider social processes as well as rules for enunciative modalities, concepts and theoretical strategies13. In other words, we might consider the value of exploring what are the social practices and discourses (e.g. human rights discourse, cultural citizenship, multiculturalism, cosmopolitanism, practices of the self) with which sociology might establish alliances in order to democratically establish legitimacy for its ethical object. I noted above that if the legitimacy of bioethics is secured despite its cognitive claims, this would be no less true for sociology and ethnography.
Bioethics’ principlism has managed to achieve this wider socially-sanctioned legitimacy. This legitimacy is however open to contestation, but sociology and ethnography are not likely to dislodge mainstream bioethics unless they connect their model of ethical analysis and negotiation to wider individual and collective practices. In the context of the ethical pluralism that characterises contemporary Western societies (Moon 2003), this is a challenging task14. However, as Kleinman argues, the social sciences have the potential to:
. . . deeply humanize the process of formulating an ethical problem by allowing variation and pluralism and the constraints of social position to emerge and receive their due, so that ethical standards are not imposed in an alien and authoritarian way but, rather, are actualised as the outcome of reciprocal participatory engagement across different worlds of experience (1997: 67).
This is unlikely to be achieved unless the social sciences are able creatively and reflexively to establish their empirically-rich analysis of lived ethical behaviour as a legitimate knowledge compatible with democratic modes for the social governance of difference.
In this paper I have argued that the bioethics phenomenon should be of interest to sociologists because of the central role it plays in aligning core societal values. I have outlined the cognitive critique developed primarily by ethnographers, but have also argued that the cognitive critique, alone, is unlikely to secure a place for ethnography and sociology in the field of bioethics. This is because the legitimacy of bioethics, as a socially sanctioned knowledge, does not derive from the validity of its cognitive claims. I have drawn on Foucault's concept of discursive formations to explore how the rules of discursive formation can be used to illustrate the sources of bioethics’ claims to legitimacy, and have also used this analysis to outline the challenges faced by sociologists and ethnographers. I have concluded by arguing that sociologists and ethnographers need to reflect on the ways in which they might democratically secure legitimacy for their own ethical object(s).
It can of course be argued that there is no need for sociology to save bioethics. Indeed bioethics is doing well and not in need of saving (DeVries and Conrad 1998: 233). Perhaps it is best to accept that bioethics and sociology each do their own thing. However, to the extent that ethnographers feel that they can add something to the discourse of bioethics, then they must also be committed to finding a place for their knowledge claims not only amongst their sociological peers but more broadly in the public sphere. I think that an understanding of how bioethics and sociology exist as discursive formations provides a useful avenue for thinking about how this might be achieved, whether our goal is to save bioethics or not.
I would like to thank the referees and editors for their extremely useful comments. I would also like to thank Telsing Andrews, Joseph Burridge, Renee C. Fox, Oonagh Corrigan, Carine Vassy and Bryn William-Jones for having read and commented on different versions of this manuscript.
See ‘The History of Bioethics’ entries in Reich (1995).
See Fox (1989: 224–76), DeVries and Conrad (1998), Hoffmaster (2001) and Weisz (1991).
These two forms are not mutually exclusive. For instance Chambliss's ethnography identifies the ethical as reflecting ‘the conflict of powerful interest groups’ in the hospital (Chambliss 1996: 94) and can be seen as contribution to political sociology.
Although a variety of paradigms coexist in bioethics (Jonsen 1998: Chs. 10 and 11), it is dominated by Principlism (Gert, Culver and Clouser 1997). Still, a number of challenges have arisen within the field: see for instance Gert, Culver and Clouser (1997), Pellegrino and Thomasma (1993), from the perspective of narrative bioethics Chambers (1999) and Nelson (1997), from a casuistic framework Arras (1991), Jonsen and Toulmin (1988), and in the form of feminist, race and ethnic critiques see contributions in Wolf (1996).
See also Anspach (1993) and Chambliss (1996).
For Chambers, ‘Centering provides order and coherence to our descriptions and arguments by providing a compelling metaphor or a narrative that possesses what rhetoricians refer to as energia. Such rhetorical energy works by drawing on the reader's imagination in a manner that is distinct from how academic disciplines normally think their disputes proceed’ (2000: 23).
Chambers (2000) argues that this opposition, between abstract and concrete knowledge claims, also served as an entrance tale for bioethics itself through the opposition between the abstract and formal analysis of traditional moral and ethical analysis and the applied ethical work done by bioethics.
In successive editions Beauchamp and Childress have modified their position in response to a variety of critiques. For some commentators, they have departed so much from their initial position that the fourth edition announces the ‘Beginning of the End of Principlism’ (Emanuel 1995). However Gert, Culver and Clouser (1997: 72) maintain that it is the first edition of Principles of Biomedical Ethics that has had the widest impact on the bioethical world.
These rules are particularly visible in Beauchamp and Childress’Principles of Biomedical Ethics.
See Chambers (1999: 61).
Fox and DeVries (1998) make a similar point. The impracticality of ethnography as an everyday bioethical modus operandi is also signalled by Bosk (2001).
Of course, the ethics of research has been a subject of much debate amongst ethnographers, see Murphy and Dingwall (2001) for an excellent review. I cannot deal with it here but it would be interesting to explore why the broader notion of ethics found in early sociology is currently circumscribed to the ethics of research.
On thinking about sociology as a discursive formation see Woodiwiss (2001).
It is equally problematic that the most serious engagement with ethics developed by a sociologist locates moral practices outside of the social (Bauman 1993).