authoritarian versus responsive communitarian bioethics by amitai etzioni

8/8/2019 Authoritarian versus responsive communitarian bioethics by Amitai Etzioni

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Authoritarian versus responsivecommunitarian bioethics

Amitai Etzioni

ABSTRACT

A communitarian approach to bioethics adds a corevalue to a field that is often more concerned withconsiderations of individual autonomy. Someinterpretations of liberalism put the needs of the patientover those of the community; authoritariancommunitarianism privileges the needs of society overthose of the patient. Responsive communitarianism’s mainstarting point is that we face two conflicting core values,autonomy and the common good, and that neither shouldbe a priori privileged and that we have principles andprocedure that can be used to work out this conflict butnot to eliminate it. Additionally, it favours changingbehaviour mainly through the creation of norms and by

drawing on informal social control rather than by coercion.

Communitarianism is often viewed as the polaropposite of liberalism, as seeking to pre-empt indi-vidual choices by relying on communal normativecriteria and authorities. Common good consider-ations are to replace respect for autonomy.1

Accordingly, for example, people with infectiousdiseases are to be incarcerated, the way Cuba dealswith those who contract HIV.2 Organs of those whohave died or have been executed can be harvested,

because doing so serves a compelling public interest.I refer to this way of thinking as authoritariancommunitarianism. (A less radical version of thiskind of communitarianism strongly privileges thecommunity even if does not fully dismiss consider-ations of autonomy or liberty.) Authoritariancommunitarianism has been championed by theleaders and some public intellectuals of East Asiannations, especially Singapore and Malaysia.3 4

One major reason many, especially in the West,reject this kind of communitarianism on normativegrounds is that they hold autonomy in high regard. Another reason is methodological, a reason thatdeserves to be briefl y discussed because it points to

a rather different kind of communitarianism. Themethodological point draws on the precept thatsound normative positions cannot be derived fromone overarching value. Societies are complex beings,composed of people who hold different values andhave different needs and interests. It follows thatone is much more likely to reach a normatively defensible position if one draws on multiple values,rather than presumes that one value pre-empts ortrumps all the others. Moreover, one should not beunduly troubled by the resulting tensions andcontradictions that result from drawing onmultiple values, such as liberty and equality, or, in

the case at hand, autonomy and the common good,among other core values. We shall see that there are

fruitful ways to work out these differ-encesdwithout making all other values subordi-nate to one.

This methodological approach is embodied inanother branch of communitarianism: responsive(or liberal) communitarianism.i This communitari-anism seeks to balance autonomy with concern forthe common good, without a priori privilegingeither of these two core values. And it seeks to rely on society (informal social controls, persuasion andeducation) to the greatest extent possible andminimise the role of the state (law enforcement) inpromoting compliance with the norms that flowfrom these values. Thus, preference should be given

to programmes that encourage people to have theirHIV status tested, ensuring that the test resultsremain confidential, and readily available to thepatientsdrather than requiring such tests orconducting them without knowledge of thepatients. Responsive communitarianism is oftenconfused, or treated as part and parcel, withauthoritarian communitarianism, though the twodiffer as much as social democratic socialism differsfrom Soviet socialism.

I should note in passing that this essay does notlay out the communitarian position why a thickconcept of the good is justified, because this posi-tion has been spelt out repeatedly, subjected tocritical examinations, and these criticisms havebeen responded to. Rather than rehashing thesearguments, this essay builds on the points previ-ously made, that the case for a thick concept of thecommon good can be entertained. Those whoseviews differ may nevertheless find some interest inthe following discussion because it shows the valueof making the said assumption for bioethics.

Although responsive communitarianism’sstarting point is the recognition that the tenserelationship between autonomy and the commongood must be worked out rather than assuminga priori that one of these core values trumps the

other, the treatment should be expected to differfrom one society to another and among different

Correspondence toDr Amitai Etzioni, The Institutefor Communitarian PolicyStudies, The GeorgeWashington University, 1922F St NW, Suite 413,Washington, DC 20037, USA;[email protected]

Received 19 May 2010Revised 25 August 2010Accepted 2 September 2010

i The responsive communitarian position was first articulated bya group of scholars and activists in the early 1990s, includingWilliam A Galston, Mary Ann Glendon, Philip Selznik, Jean BethkeElshtain, and Amitai Etzioni. They issued a platform that found manyendorsers across much of the political spectrum; the platform textcan be found at http://www.gwu.edu/ wicps/RCP%20text.html.See also: Amitai Etzioni, The New Golden Rule: Community and Morality in a Democratic Society (New York: Basic Books, 1997);and Amitai Etzioni, Genetic Fix: The Next Technological Revolution(New York: Macmillan Publishing Co, Inc, 1973);‘Communitarianism,’ The Oxford Companion to Politics of the World (London: Oxford University Press, 2001): 158. For a critical

treatment see Elizabeth Frazer, The Problems of Communitarian Politics (Oxford: Oxford University Press, 1999).

Etzioni A. J Med Ethics (2010). doi:10.1136/jme.2010.037846 1 of 7

Ethics JME Online First, published on October 28, 2010 as 10.1136/jme.2010.037846

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historical periods. Thus, in totalitarian societies and theocracies,such as those in Singapore and Iran, those who advocate thebalance that responsive communitarianism favours would needto promote autonomy, while in societies in which individualismis rampant such as the United States was in the 1980s, theadvocates of responsive communitarianism would need topromote more attention to the common good. That is, societiesoften need to move in opposite directions from one another to

achieve the same balance.In effect, responsive communitarianism, which arose in the

USA in 1990, was a direct response to the Reaganism andThatcherism of the 1980s, and the findings of Robert Bellah andhis associates (later echoed by Francis Fukuyama and reinforcedby Robert Putnam) that the USA had become excessively indi-vidualistic.4e7 That is, it sought to move the US and the UK (and other relatively liberal societies) towards a more balancedposition, one that pays more mind to the common good.Responsive communitarianism in Southeast Asia calls for moreliberalism.

It is might be a mistake to refer to this position as valuingpluralism, because it does not suggest that different values holdfor different societies in different historical periods. The corevalues are the same. Only the direction societies need to modify their normative profile in order to move towards the ideal one,one of a carefully crafted balance between autonomy and thecommon good, is contextual.

To put it in different terms, strong rights presume strongresponsibilities. The right to be tried by a jury of one’s peersassumes that the peers will agree to serve on a jury. The right tohealthcare assumes that people will realise they have to vote fortaxes to be imposed to pay for such services, and so on. There arealso common goods that are morally compelling, for instance,our stewardship of the environment. To discharge our obliga-tions to these goods entails assuming social (and interpersonal)responsibilities. I turn next to explore the implications of these

communitarian precepts for bioethics.

EARLIER TREATMENTS OF COMMUNITARIAN BIOETHICSMedicine is overwhelmingly non-communitarian in the sensethat it rarely concerns itself with the common good. The indi-vidual patient’s good is at the centre of nearly every discussion.Moreover, one is hard put to find a bioethicist who considershim/herself a communitarian. Those who do draw on commu-nitarian deliberations do so mainly to criticise the excessivereliance on the value of autonomy but typically not to embraceconcerns for the common good (Michael Gross, personalcommunication with the author 2009; Mark Kuczewski,personal communication with the author, 2009).

Indeed, the few early communitarian examinations of bioethics focused on the observation that American bioethiciststend to err on the side of considering the patient as an individ-ualistic being and view autonomy as the supreme value,according to which the patient’s right to personal choice isparamount. Daniel Callahan quotes Joseph Fletcher, stating thatbioethics is based on ‘the idea of personal choice as the highestmoral value and the struggle against nature as medicine’s mostliberating mission’.8 Ezekiel Emanuel, in his essay on the care of incompetent patients, points out that the understanding of the‘best interests’ of a patient allowed in this individualist vision of healthcare is based upon the degree of pain a procedure wouldinflict on that person.9 Jeffrey Blustein explains this conception

of autonomy in healthcare, stating,‘It rests on a picture of theperson as a separate being, with a distinctive personal point of

view and an interest in being able securely to pursue his or herown conception of the good’.10

Communitarianism in this context is often viewed as thepolar opposite position of the focus on autonomy. Thus, forinstance, Tom Beauchamp writes that communitarianism ‘holdsthat public policies should be derived primarily from communalvalues, the common good, social goals, traditional practices, andthe cooperative virtues’.11 Lawrence O Gostin defines commu-

nitarianism as a tradition that‘views individuals as part of social

and political networks, with each individual reliant on others forhealth and security. Individuals, according to this tradition, gainvalue from being a part of a well-regulated society that seeks toprevent common risks.’12

Similarly, Veena Das looks to a communitarian conception of bioethics to allow bioethicists to ‘find alternative anchoringconcepts to those of patient autonomy ’.13 Gboyega A Ogun-banjo and Donna Knapp van Bogaert define communitarianismas ‘a model of political organisation that stresses ties of affec-tion, kinship, and a sense of common purpose and tradition’.14

Finally, Michael Gross points to Israel as a communitarian state,which means it is ‘a society imbued with a high degree of collective consciousness, mutual concern and interdepen-dence’.15

In the terms used here, these precepts of communitarianbioethics lean in the direction of authoritarian communitari-anism, or at least leave the door open to such interpretationbecause they are not explicitly anchored in recognition of thecardinal normative standing of autonomy e as well as that of thecommon good.

To briefl y illustrate the generalisations introduced so far:a liberal bioethics may stress that patients should be free toinstruct their physicians not to disclose their conditions toothers (although exceptions may be recognised, such as whenwe deal with minors, infectious diseases or attempts to commithomicide). The patient should also be free to sign a do-not-

resuscitate statement or refuse other treatments, disregardingthe values and feelings of the patient’s family and surely of hiscommunity. Communitarianism is then depicted as the oppositeposition, in which the family can instruct the physician not todisclose to the patient that his condition is terminal, candemand continued healthcare services, and so on. However, inthe terms here employed, this second position is a form of authoritarian communitarianism, because it is centred aroundthe values of the community and disregards the value of autonomy. A responsive communitarian would favour seekingto work out the conflict between the patient and the family without a priori privileging either, examine the mechanism forsuch treatment of conflict and determine what is to be done if the conflict cannot be resolved by the parties directly involved.

Some of the early writings by bioethicists about communi-tarianism do reveal recognition of the two, sometimesconflicting, core valueseautonomy and the common goodealthough they do not necessarily employ these two terms.Thus, Callahan defines communitarian bioethics as seeking to‘blend cultural judgement and personal judgement’.8 Thomas HMurray writes that many theorists believe ‘the solution is not toabandon autonomy . But autonomy can only be a part of thestory about how we are to live together, how we are to makefamilies and communities that support the growth of love,enduring loyalties, and compassion’.16

Gilbert Meilaender too seeks not to give up the language of rights in bioethics but believes that alongside the ‘rights talk’, we

also need to have a‘morals talk

’.

17

(The term‘rights talk

’wasintroduced by responsive communitarian Mary Ann Glendon to

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stress the excessive tendency to frame normative claims in rightsterms).18

Mark Kuczewski recognises explicitly that we are dealing herewith two rather different kinds of communitarianism. Hecompares ‘whole tradition communitarians’ and ‘liberalcommunitarians’: the former requires an acceptance of the fullcloth of a single tradition and does not allow for compromise oreven significant communication across the borders of commu-

nities, while the latter stresses‘respectful moral deliberation

’as

a way to communicate and coordinate moral expectations acrosstraditional boundaries.19

Tom Beauchamp and James Childress’ sixth edition of theirinfluential text holds that communitarianism rejects a universalstandard of justice, that of rights, and views moral principles asparticularistic to each community.ii However, one can reconcileliberalism and communitarianism by respecting universal prin-ciples: by recognising the validity of universal individual rightsdbut also holding that, in addition, people have particularisticsocial responsibilities that they ought to discharge their obliga-tions to the common good. I turn below to discuss the stepsavailable when these two principles conflict.

Before I proceed, I must digress to explicate the term ‘thecommon good’. It refers to those goods that serve shared assetsof a given community. Examples include preserving nationalmonuments, supporting ‘basic’ scientific research, advancingnational security, protecting the environment and promotingpublic health. Contributions to the common good often offer noimmediate benefits to any one individual, and it’s often impos-sible to predict who will gain from them, or to what extent, inthe longer run. Often, investment in the common good is carriedout because we considered such investment the right thing todo, not because we expect we personally dor even ouroffspringdwill benefit from it.iii (I do not provide such anexplication for autonomy, because its meanings are so oftendiscussed in Western literature and are included in the discussion

of bioethics already cited.)

SOCIETY (COMMUNITY) VERSUS STATEResponsive communitarianism holds that the more one can rely on norms rather than laws, and on public education, moralpersuasion and informal social controls, rather than on lawenforcementdthe better the society. (Better in the normativesense of the term, in that it is ethically preferred, rather than,say, on the basis of cost-benefit analysis, although such analysiscan have ethical implications that should be taken into account.)The main reason is that societal processes can change prefer-ences and lead to truly voluntary compliance, while coercionleaves opposing preferences intact. It hence invites attempts to

circumvent the law and tends to generate a sense of alienation.

20

A telling example is the way Prohibition was introducedversus the ban on public smoking. The enactment of Prohibitionwas not preceded by the building of a normative consensus andinstead relied heavily on law enforcement. It failed to suppressthe use of alcohol and greatly increased the corruption of the American legal and political system. Moreover, it is the only constitutional amendment that was ever repealed. In contrast,

although it took some 25 years to build wide societal support toban smoking in public spaces, once these laws were introduced,they served to lock in an already very well established norm,which is almost completely self-enforcing.

Similarly, responsive communitarianism urges that longbefore one considers mandatory HIV testing, let alone forcefully isolating people who have contracted HIV, one is obligated toengage in public educational campaigns that encourage such

testing and to work with the communities of those most at riskto encourage their members to be tested. And rather than opena market in human organs to incentivise more people to donateorgans, which are in short supply, one should appeal to people tomake the gift of life.21 22 A colleague who read a previous draft of this essay introduced here the debate between those who see theworld through the eyes of rational choice and seek to reduce allconduct to self interest, and those who holddas I dodthatpeople are indeed influenced by incentives and disincentives, butalso by moral considerations, which change their preferences. Itis not possible to deal with this debate here, and I have treated itextensively elsewhere.23

At the same time, responsive communitarianism does recog-nise that there are conditions under which the state must beinvolved, although it is best used as the last, rather than the first,resort. For instance, when people infected with a highly communicable disease that has fatal consequences do not heedcalls to remain at home until they cease to be infectious, thestate has an obligation to enforce their quarantine. Historically,this issue has arisen with regard to the treatment of people withleprosy, tuberculosis and, more recently, SARS and H1N1.

Gostin provides a powerful study of this communitarian issuewith regard to a bioterrorist attack or a severe medical emer-gency.12 He points out that excessive concern for autonomy andneglect of the common good have led to a focus on individu-alised achievements in healthcare at the cost of severely under-funding public health infrastructure and ignoring the needed

adaptations of public health laws.12

As a result, public healthagencies do not have the capacity to ‘conduct essential publichealth services at a level of performance that matches theconstantly evolving threats to the health of the public’.12 At thesame time, public health law has fallen off the radar and is now‘highly antiquated, after many decades of neglect’.12 Finally, thedebate about the role of the government in providing healthcare,reignited in the USA by the Obama administration, has somestrong communitarian dimensions, as does the reliance oncommunity rating versus ‘cherry picking’.

WHICH COMMUNITY?The term community is often associated with small, traditional,residential communities, such as villages. However, in the

modern era, communities are often non-residential and based onethnicity, race, religious background or shared sexual orientation.Moreover, people are often members of more than onecommunity. Finally, it is often productive to consider commu-nities as nesting within more encompassing communities, suchas local ones within the national one. People are hence subjectnot merely to tension between their personal preferences andthe values and norms promoted by their community but are alsosubject to conflicting normative indications from variouscommunities.

The family can be viewed as a small community. In bioethics,strong champions of autonomy, as well as some feminists,suggest that each adult member of the family should make her

or his own choices, and that other members of the family shouldhave no status in these decisions.10 (The treatment of

ii James Childress is a founding endorser of the Responsive Communitarian Platform,which can be found at http://www.communitariannetwork.org/RCP%20text.htmliii For additional discussion see Alex John London, ‘Threats to the Common Good:Biochemical Weapons and Human Subjects Research,’ The Hastings Center Report 33, No. 5 (2003): 17e25; Mark G. Kuczewski, ‘The Common Morality in

Communitarian Thought: Reflective Consensus in Public Policy,’ Theoretical Medicine and Bioethics 30, No. 1 (2009).


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incompetent people is considered an exception.) In contrast,discussions about severely ill neonates whose parents seek toallow the infant to die because it will benefit other siblings tendto attach considerable weight to the welfare of the family asa whole (Michael Gross, private communication with theauthor, 2009).

John Hardwig’s argument moves us far towards a responsivecommunitarian position. Hardwig holds that ‘the interests of

patients and family members are morally to be weighed equal’

and ‘to be part of a family is to be morally required to makedecisions on the basis of thinking about what is best for allconcerned, not simply what is best for yourself ’.24 It is an issuethat arises often in matters that do not directly concern health:for instance, the effect of divorce on the children of the couple.In a bioethical context, the issue is well illuminated by a popularbook, My Sister ’ s Keeper.25 It depicts a situation in which variousmembers of a family, the family ’s very existence and the quality of the relationships among family members are all deeply affected by the sacrifices called for by the medical condition of one member.

Hardwig adds, ‘That the patient’s interests may oftenoutweigh the conflicting interests of others in treatment deci-sions is no justification for failing to recognise that an attemptto balance or harmonise different, conflicting interests is oftenmorally required’.24 He leans somewhat in the authoritariandirection when at one point he claims that ‘considerations of fairness and, paradoxically, of autonomy therefore indicate thatthe family should make the treatment decision, with allcompetent family members whose lives will be affectedparticipating’.24 Thus, a less authoritarian position wouldsuggest that, for instance, if nine out of 10 family members agreethat treatment should be stopped for a given member, but thememberdwho is competentdrejects this conclusion, thefamily ’s wishes should not carry. However, the person does owethe family members a careful consideration of their values,

reasons and needs.Jeffrey Blustein also articulates a responsive communitarianposition. He holds that while final decision-making authority ought to remain with the patient, medical personnel and society ought to focus on integrating family members into the decision-making process to support the patient’s ability to determine thebest optiondtaking into consideration the interests of thosemost important to him or her.10

When bioethical communitarian considerations turn to moreencompassing communities, especially to transnational ones,a whole host of additional issues arise. They often centre aroundthe question of which community ’s values should prevail. Theseissues have been debated with regard to numerous topics,ranging from female circumcision to the testing of new drugs

overseas. Whether one can apply here the dual approach of combining respect for the cultural autonomy of various culturesand the concern for a global common good is a topic that mustbe left for another discussion. The same holds for the numerousinter-community issues that arise when national culture, valuesand laws conflict with the culture, values and habits of variousimmigrant groups or confessional groups that are members of the same broader society.

Ezekiel Emanuel points out that the various criteria for whatis in the best interest of the patient are affected by what a givencommunity considers ‘the good life’: ‘This solution derives fromcommunitarianism, a philosophy that incorporates the truths of utilitarianism and liberalism, but transcends both by arguing

that ethical problems can be resolved only by accepting a publicconception of the good life while rejecting the conception of the

good particular to utilitarianism’.9 Emanuel favours allowingeach community to determine its own concept of the good lifeon the grounds that (a) it is impossible to answer this questionon neutral grounds and (b) we are a pluralistic society and henceshould respect the values of various member groups such asOrthodox Jews and the gay community. This position is very much in line with a communitarian position; however, it raisesthe question of whether there is room for nationwide or even

transnational communal criteria and policies. As I see it, the answer is diversity within unity. On some

issues, it is clear that the most extensive community doften thenation, but increasingly also transnational communities such asthe EU, and in some cases even the United Nation’s UniversalDeclaration of Human Rightsdshould and does provide thenormative criteria. On other matters, diversity of the kindEmanuel depicts is fully appropriate. And, in still otherinstances, one should expect disagreement about what ‘belongs’to the community at large and what to smaller, member ones.Examples of those that are best guided by the most encom-passing communities are issues that concern basic rights (fewwould leave it to local communities to rule whether gay patientsor members of a given racial minority should be denied service)and the moral claims that urge people to donate organs, bloodand time. In contrast, allowing different groups to rely on faithhealers up to a point is an example of local community valuesinfluencing biomedical decisions.

In the USA, an example of communities defining ethical careconcerns the conditions under which parents can deny medicalcare for their children. Some states mandate treatment when itis a question of life and death, regardless of the parent’s requestto forego care, while others allow extreme latitude in the deci-sion-making options of parents, including choices made aboutlifesaving interventions. In contrast to this state-by-statedetermination of critical care decisions, there is a nationwideconsensus that in matters less than life or death, parents should

be allowed to refuse treatment for their children in order tomaintain their personal perception of ‘the good life’.In short, diversity within unity iv provides a responsive

communitarian model of granting some discretion to membercommunities while also maintaining select values of the mostencompassing conceptions of the common good. The fact that,in some matters, it is unclear which community should prevaildoes not obviate the merit of this design, which stands outwhen one compares the diversity within unity position to thosethat favour the national statedor favour turning these mattersinto the domain of each member community.

A CONTINUUM

So far I have treated the three positions as if they were separatecamps: the strong champions of autonomy (especially libertar-ians, but also quite a few contemporary classical liberals),authoritarian communitarians and responsive communitarians.v

However, in actuality, there are various gradations within eachcamp and among them.

A volume of essays commissioned by the Bush AdministrationCouncil on Bioethics contains various nuanced positions, though

iv For more discussion see: Amitai Etzioni, ‘Diversity within Unity,’ 21st Century Opportunities and Challenges: An Age of Destruction or An Age or Transformation, ed.Howard F Didsbury, Jr. (Bethesda, MD: World Future Society, 2003): 316e323.v In addition there are often cited works by academic communitarians, especiallyCharles Taylor, Michael Sandel, and Michael Walzer. These authors oddly almostnever use the term communitarianism, do not consider themselves communitarians,

and do not explain why they do not relate to a philosophy they are often associatedwith.


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most tend to be written by social conservatives who lean in thedirection of authoritarian communitarianism.26 Thus, mostauthors consider immoral those choices that they see asconflicting with their views of human dignity, includingwomen’s right to choose to have an abortion, termination of medical services for those dependent on mechanical interventionto stay alive, and stem cell research. Moreover, they favour usingthe powers of the state to ban such choices.

One main difference between these bioethical social conser-vative positions and the outright authoritarian ones is that thescope of decisions these conservatives seek to curb by relying onthe law is much narrower than the range of choices countriessuch as Iran, Singapore and China, seek to ban, at least in theirstrongest ideological periods. Furthermore, one must note thateven liberals and responsive communitarians justify banningsome choicesdfor instance, those involving marketing foodsthat contain carcinogenic ingredients or acts that poison theenvironment. All this serves to illustrate that we are actually dealing with a continuum composed of both the scope of choicesand the main means used to foster them. Moreover, as already indicated, the historical context must be taken into account insearching for the responsive communitarian balance. Thus, if there is a major pandemic, the point of balance will shift to morerestrictions than when there is no such threat. The underlyingrationale is that while there are some matters on which thecircumstances should have no effect (eg, rejecting eugenics), formost issues, relative harm is relevant, determined both in utili-tarian and deontological terms. Thus, if a given measure limitsautonomy to a minor extent but provides great public value,these attributes favour this measure. HIV testing of newbornshas limited adverse effect on privacy, and it saves lives. Incontrast, allowing employers to purchase the medical records of potential employees has major privacy implications and very little, if any, public benefit.

PROCEDURES AND CRITERIAResponsive communitarians must concern themselves withprocedures and criteria that allow one to work out personaldecisions and public policies in the face of conflicting values.(This is less of a challenge for those who take the position thatone value, such as autonomy or the common good, trumps allothers. They can put the onus of finding exceptions on thosewho feel differently.)

A major way to proceed is through moral dialogues. Exami-nations of actual processes of consensus building, especially whenthey concern normative matters, show that individual preferencesand judgements are largely shaped through interactive commu-nications about valuesdthat is, through moral dialogues thatcombine passion with normative arguments and rely on processes

of persuasion, education and leadership. Moral dialogues focusmore on values than on facts. Although passionate and withouta clear starting and ending point, they often lead to new sharedmoral understandings. Such dialogues led to the formation of a new sense of duty to protect the environment, to reject racismand sexism, to oppose the war in Vietnam and many other suchsociety-wide shared understandings.

The redefinition of death that took place in the USA illustratesthe ways moral dialogues work. In 1968, an ad hoc committee atthe Harvard Medical School published a report that defined anirreversible coma as ‘brain death’da new definition of death. Thereport, put together by academics and medical professionals, didlittle to redefine the public perception of death. However, in 1972,

a young woman named Karen Ann Quinlan fell into a persistentvegetative state. After weeks of life support, her parents asked

that she be taken off the machine and be allowed to die. Thehospital refused, so the parents sued. Although Quinlan’s case didnot meet the definition of brain death, her case brought the issueto national attention.26 There followed extensive and widespreaddialogues in various communities spurred by the media, out of which gradually grew a consensus accepting brain death asa morally acceptable definition of end of life and substituted thisdefinition for the previous belief that one ought to do ‘all one

could’

to keep one’s loved ones alive.

The communitarian moral dialogues differ significantly fromthe ‘rational democratic deliberations’ discussed and favoured by Leonard M Fleck among others.27 The term ‘rational’ impliesthat the deliberations are based on empirical findings and logicalconclusions, and the term ‘democratic’ implies that the resultsreflect the preferences of the electorate. They are also expectedto be ‘cold’ and rather impassionate. In contrast the moraldialogues under discussion here concern values and help shaperather than reflect people’s preferences. Above all, they concernwhat has been called ‘otherworldly ’ matters, for which there areno rational statements but are matters of belief, are non-rational.For example, the argument over whether the death penalty isjustified would be rational if it were driven by the considerationof whether or not the data show that this penalty reducesviolent crime. It is subject to non-rational, moral dialogue to theextent it is driven by considerations of whether it is ever morally acceptable for the state to deliberately take a person’s life.vi A prime example of such a moral dialogue is the dialogue aboutwhat is implied by our commitment to human dignity, a majorsubject of a report by the President’s Council on Bioethicspublished under the title Human Dignity and Bioethics.

The difference between rational deliberations and moraldialogues is further illustrated by the following examples. Thedeliberations about the effects of smoking were affected consid-erably by data, especially about the effects of second-hand smoke. At the same time, other dialogues that seemed to be data-driven

were largely about moral positions. For instance, whatever thedata show about the effects on promiscuity of the availability of condoms in nurses’ of fices in high schools (and about the effectson drug addition of the distribution of clean needles) seems not toaffect much the opinions of those opposed to these policies. They mainly retreat to a different line of argumentation, namely thatsuch actions send the wrong message to the rest of society. (Itshould be further noted, most deliberations are not purely of onekind or the other, but many seem to be mainly empirical andlogical, and many others largely moral dialogues).

A reviewer of a previous draft of this essay posed here a very worthy challenge. He wrote: ‘I may, for example, fully recognisethat US$ 250000 for a bone-marrow transplant for me (at age70) is far too expensive to be in the common good. But if it’s my

only chance of survival, how can my values and priorities berearranged so that I not only accept with resignation . butembrace the conclusion that I should not have a transplant inorder better to utilise the pooled resources in my insurance plan(public or private) to serve other anonymous ‘covered lives?’ Theexample implies that the way to bring to bear considerations of the common good is to change the preferences of the patients.This is indeed a major way. Some older patients are made to feelguilty because they are reminded that they spend a greatamount of scarce medical resources in the last year of their life,and often to little benefit. Some are made to feel that they are ‘aburden’ on their families, another communitarian consideration.

vi

For more discussion, see Ch 8 in Amitai Etzioni, The New Golden Rule (New York:Basic Books, 1996).


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Moreover, while some families discourage these sentiments,others enforce them for of self-serving reasons. Also peopleinfected with SARS stayed home, under voluntary self-confine-ment, in order not to infect othersdalthough it limited theirfreedoms. And at least according to one authoritative source,physicians in the UK convince patients, after a certain age, thatthey should not seek kidney dialysis or chemotherapy.28

Above all, the balance between autonomy and the common

good is often not subject to free choice by the patients. Thus,some ethicists, most notably Daniel Callahan, called forproviding only ameliorative care after a certain age.29 And of course which services are reimbursed versus which are not, havemajor effects on the said balance.

Another way to work out the balance between autonomy andthe common good as it applies to specific matters is to leavethese issues to courts or to legislatures. Should people berequired by law to vaccinate their children? Under whatconditions may people be subjects of research? Can one requirepeople who have been arresteddbut not yet convicteddto yieldtheir DNA, the way their fingerprints are collected? These andmany other bioethical considerations are best first subject tomoral dialogues, assisted by bodies such as ethics committees inhospitals or the President’s Council on Bioethics, but

despecially

given the growing volume of such policy mattersdsome may have to be worked out by courts and legislatures.

Finally, responsive communitarian bioethics leads one tosuggest criteria that moral dialogues, judges, and lawmakers may draw upon. One is the relative adverse impact on the two coreconflicting values that flow from the adoption of a given policy.That is, when autonomy must be much curbed for minor gains tothe common good, responsive communitarianism suggestsautonomy should be given the right of way, while public policy should lean in the opposite direction if the gains to the commongood are substantial and the sacrifice of autonomy is minimal.vii

These criteria would help explain the position articulated by

Tom L Beauchamp, who argues that society should switch itsconceptions of the public and private good in terms of eutha-nasia and organ donation. Euthanasia, currently considered anissue where the public determines its application, ought to bea private matter, according to Beauchamp, because that is thelogical conclusion of a culture that allows patients extremelatitude to determine their treatment up to (but currently notincluding) death, with the assumption that personal care choiceshave more impact on personal autonomy than they do onsociety at large.11 At the same time, organ donation, with itswidespread implications for the wellbeing of the community,ought to be moved out of the realm of personal decision-makingand into the public arena, putting the focus on the public good,which is more impacted by organ-donation decisions than is

individual autonomy.11

Other criteria indicate that one ought to find ways to absorbthe side effects. For instance, if one introduces a policy that callsfor testing newborn infants for HIV, special care must be takento keep the results confidential, lest the mother lose her job,housing or insurance.viii

THIRD VALUESSo far I have limited the discussion to two core values becausethese are the ones that define the main differences among

liberals, authoritarian communitarians and responsive commu-nitarians. However, bioethical judgements obviously can and dodraw on additional values, and the ways these can be treated inthis context remain to be discussed. Much of this discussionmust be deferred to a future publication because it requiresrather extensive deliberations. However, the main issue at handcan be illustrated by pointing to the four values often quoted by bioethicists, drawing on the influential work of Tom L Beau-

champ and James F Childress, Principles of Biomedical Ethics.1

These are respect for autonomy, non-maleficence, beneficenceand justice.30

The meaning of autonomy in a bioethical context has already been covered by the quotations in the first parts of this essay.Non-maleficence also focuses on the wellbeing of the individualpatient: do no intentional harm. Beneficence, the third principle,is defined as an obligation to advance the healthcare interestsand welfare of othersdbecause we have ourselves receivedbenefits.31 Again, the focus is on the individual. Justice, thefourth principle, raises a host of complicated issues that so farhave not been addressed by communitarians of either kind.

In the context at hand it is important to note that even thenuanced and enriched set of normative principles developed by Beauchamp and Childress does not include a concept of thecommon good, above and beyond the concept of justicedforinstance, conditions under which individuals have to acceptvarious sacrifices for the good of all. A thicker definitionwould include common goods that command our moral respect,such as the protection of the environment, basic research,homeland security and public health.ix These kinds of concernsthat Gostindand communitarians more generally dhave aboutpreventing the spread of infectious diseases, responding tobioterrorist attacks, protecting the environment, balancingpreventive and acute medical treatments, and determining theextent to which one can foster or force limits on individualchoices for the public good, do not find a comfortable home in

the most widely followed bioethical texts. Hence, concern forthe common good, responsive communitarians would argue,should be added to the already existing core values on whichbioethics draws.

Acknowledgements I am indebted to S Riane Harper and Julia Milton for researchassistance on this essay and two reviewers for very stimulating comments ona previous draft.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th edn. Oxford:

Oxford University Press, 2008.2. Hansen H, Groce N. Human immunodeficiency virus and quarantine in Cuba. JAMA

2003;290:2875.3. Jiang YH. Asian values and communitarian democracy. paper presented at the

International Workshop on Deliberating the Asian Value Debate: National Values,Chinese Values and Muslim Values in Southeast Asia, Taipei. 1998.

4. Bell DA. A communitarian critique of authoritarianism. Society 1995;32:38e43.5. Bellah R, Madsen R, Sullivan W, et al . Habits of the Heart . Berkeley, CA: University

of California Press, 1985.6. Fukuyama F. The Great Disruption: Human Nature and the Reconstitution of Social

Order . New York: The Free Press, 1999.

vii For more discussion, see: Amitai Etzioni, The Limits of Privacy (New York: BasicBooks, 1999).viii

For more discussion, see: Amitai Etzioni, Limits of Privacy (New York: Basic Books,1999).

ix Some authoritarian communitarians try to maintain that their privileging of thecommon good, even if it is enforced by the state and affects a wide array ofbehaviour, does not conflict with autonomydas long as the individuals voluntarily dowhat they are supposed to! Beauchamp and Childress carry out a similar manoeuvre

from the other side of the equation, arguing that one can readily accept obligations tothe common gooddas long as they have been ‘autonomously accepted’.


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7. Putnam R. Bowling Alone: The Collapse and Revival of American Community New York: Simon and Schuster, 2001.

8. Callahan D. Bioethics: private choice and common good. Hastings Cent Rep1994;24:28e31.

9. Emanuel EJ. A communal vision of care for incompetent patients. Hastings Cent Rep 1987;17:15e20.

10. Blustein J. The family in medical decisionmaking. Hastings Cent Rep1993;23:6e13.

11. Beauchamp TL. Reversing the protections. Hastings Cent Rep 1994;24:18e19.12. Gostin LO. Public health law in an age of terrorism: rethinking individual rights and

common goods. Health Aff 2002;21:71e93.13. Das V. Public good, ethics, and everyday life: beyond the boundaries of bioethics.

Daedalus 1999;128:99e133.14. Ogunbanjo GA, van Bogaert DC. Communitarianism and communitarian bioethics.

South African Family Practice Journal 2005;47:51e3.15. Gross ML. Autonomy and paternalism in communitarian society: patient rights in

Israel. Hastings Cent Rep 1999;29:13e20.16. Murray TA. Communities need more than autonomy. Hastings Cent Rep

1994;24:32e3.17. Meilaender G. Our vocabularies, our selves. Hastings Cent Rep 1994;24:13e14.18. Glendon MA. Rights talk: the impoverishment of political discourse . New York: The

Free Press, 1991.

19. Kuczewski MG. The epistemology of communitarian bioethics: traditions in thepublic debate. Theor Med Bioeth 2001;22:135e50.

20. Etzioni A. A Comparative Analysis of Complex Organizations. Revised edn. New York:The Free Press, 1975.

21. Etzioni A. Organ donation: a communitarian approach. Kennedy Inst Ethics J2003;13:1e18.

22. Erin CA, Harris J. An ethical market in human organs. J Med Ethics 2003;29:137e8.23. Etzioni A. The Moral Dimension: Toward a New Economics. New York: Free Press,

1988.24. Hardwig J. What about the Family? Hastings Cent Rep 1990;20:5e10.25. Picoult J. My Sister’s Keeper . New York: Atria 2004.26. Human Dignity and Bioethics: Essays Commissioned by the President’s Council on

Bioethics. Washington, DC: US Independent Agencies and Commissions, 2008.27. Fleck LM. Can we trust democratic deliberation? Hasting Cent Rep 2007;37:22e5.28. Aaron H, Schwartz WB, Cox M. Can We Say No: The Challenge of Rationing Health

Care. Washington DC: Brookings, 2005.29. Callahan D, Prager K. Medical care for the elderly: should limits be set? Virtual

Mentor 2008;10:404e10.30. Gillon R. Medical ethics: four principles plus attention to scope. BMJ

1994;309:184e8.31. The Nathaniel Centre for Bioethics. Bioethical principles. http://www.nathaniel.

org.nz/%3dsid¼27.


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