Should bioethics play football?

Monash Bioethics Review Vol. 19 No.4 46 October 2000

Should bioethics play football?PAUL MMCNEU"L

Associate Profeuor, Community Medicine, University of New South Wales andPresident of the Australian Bioethics Auociation

Tim Smyth's paper is an exhortation for Bioethics (with a capital'B1 to get amongst it in the political fray. Smyth is kindly coach to thisweak-kneed gormless nerd who does not seem to understand which endof the field is the goal line or, indeed, that he is on a football paddock atall. 'Come on Bioethicsl Get out there and muscle into the action!'The football guernsey could carry a few advertising logos like 'resourceallocation' and 'power'to alert other players, and the spectators, to hissponsors. Smyth acknowledges that there are some topics otherplayers see as ethical. The examples he gives are transplantation,embryo experimentation and euthanasia, but, for the most part,Bioethics is sidelined and never included in the real game.

Smyth's challenge to Bioethics is well intentioned and appearsto come from a respect for the aptitude of this nerd Bioethics. Hencethese kindly words from one who is skilled and experienced in the fray.Methinks however, he is a poor judge of potential. My worry is: 'whatwill happen to young Bio when he does his weight training, builds uphis muscles, and shoulders it with all the other heavies.' I am worriedbecause I don't see him as a football hero. He is not in their league.Whilst some of the great league heroes might carry his poems in theirpockets (not too many as Smyth points out) it would be silly to invitehim on to the field. Bio would either be pummelled to death or becomea pummeller himself. Whichever the outcome, our sweet Bio would belost to us. Much better he writes poems, or sits on the sidelinequestioning the game itself and pointing out its ridiculousness.

This is churlish of me. I admit there is a political dimension tobioethics. Ethics is political in that it deals with different perspectivesand means for resolving the differences. This however, is politics in avery ·broad sense of the word. Bioethics is not a character who is wellsuited to narrow party politics, governmental infighting, vested interestgroup warfare and departmental policy-making bodies. It may have aninfluence, and to this extent I agree with Tim Smyth. That influencemight be even more persuasive if it were applied with more savvy.However bioethics is not well suited to this arena. At best the playersare those who have bunkered down with bioethics at some stage intheir training and can apply their own conclusions in the hurly burly ofguerilla warfare. .

To give a pertinent anecdote: the Australasian BioethicsAssociation has debated whether it should take a political stand onparticular issues. Each time this proposition has been raised, it hasbeen rejected by the members on the ground that the Associationincludes people with many different views on most issues. The ABA isnot a political lobby group in the same way that many environmental


groups are. Its goals are essentially to further bioethics by providing avenue through which different voices can be heard. Bioethics is anarena of ferment, not a political platform. It is this ferment, and thediscussion and thinking that it generates, that is important. Differentindividuals within the Association seek to persuade others to theirstandpoint. In the process all of us have an opportunity to examineour own understandings and positions in the light of those of others.From this - practical consequences flow. Individuals are strengthenedin their resolve to tackle injustices and armed with the support ofperspectives which may help them in these struggles.

A basic difficulty is created by Smyth's treatment of his subjectas a single entity. There is no such thing as bioethics nor is there onevoice that could be raised with political effect. Smyth comes closest torecognising the flaw in his approach in saying 'By its very nature,bioethics has many voices.' However he then lapses into discussingbioethics as if it has but one voice. At many points in his essay Smythwrites, 'bioethics needs to . . .' For example 'bioethics needs to create.. .', 'bioethics needs to target ...', 'bioethics needs to work on .. .','bioethics has to acquire .. .'. Yet if bioethics does not exist as a singleobject, it is hard to know who it is that should take his advice andwhere and how they should apply it. I agree with Smyth that bioethics'helps in analysis and guides approaches in some areas.' He indicatesthat it is of greatest help in areas before they are well developed andbefore there is a consensus. Perhaps this is its best role: primarilybecause there are many approaches and an ethical focus can allow aclearer recognition of conflicting values. Yet I question whether there isa 'bioethics' as such that can take it further than that.

Given that bioethics has a low profile Smyth wonders whetherbioethics should be 'rebadged' as 'efficiency' or 'quality' or 'outcomes'.Here the flaw in his argument is completely clear. If bioethics was toaccept the challenge - then I fear this is exactly what would happen.'Bioethics' would become just another word and suffer the same fate aswords like 'care' and 'quality' and, perish the thought, be dispatched tothe 'Quality Care Committee'.

Another difficulty with Smyth's representation of bioethics as asingle voice on a stage of politics and policy formation, is that it divertsattention away from the enterprise of politics as it is played andequates bioethics as one of many players. Like other well-intentionedpolitical movements, bioethics, as a player on the political stage, wouldprepare for its own demise. Worse still - it may become its opposite:just another vested interest. Smyth seems unaware of this irony insuggesting the marketing of bioethics with give-away mousepads andmugs - just like the pharmaceutical industry and other enterprisestrying to make a buck out of the health industry.

T1?-e stuff of bioethics is value. It is an arena in which questionsof wellbeing and suffering can be asked and taken seriously. In thisarena equity and justice are prime concerns. These are political issuesbut this is politics in the broadest sense of the word. A necessaryingredient in this arena is the ability to step aside from vested


interests. It is a question of serving the interests of all, not myparticular interests. Ethics must have this universal aspect or it ceasesto be ethics. This disinterest is what politics lacks. I anticipate thatthis argument will seem idealist and not achievable in the real world. Ifso, my answer is two-fold: that ethics needs to retain an aspirationalquality; and secondly that we can do democracy better than we see itpractised at present.

An article in the Sydney Morning Herald (26 August 2000)features a New South Wales politician who was blatantly motivated bygreed. He is one of many that have been exposed. The popularperception is that most politicians are primarily motivated by selfinterest. Whilst some individual politicians apparently do care aboutother human beings, and put the interests of others ahead ofthemselves, the whole system of influence by large corporations makesa mockery out of democracy. Optus had sufficient political clout toover-ride the combined opposition of most of the municipal councilsthroughout Australia and was empowered by the federal government todrape its fat cables across the skyline everywhere. This is not ademocracy that gives citizens influence over important issues in theirlives. It is political power wielded in support of vested interests againstthe interests of the community.

The basic problem with ethics as a player in this political fray isthat ordinary people have been disenfranchised. The politicallyinfluential speak of markets, economic viability and growth. Theirdiscourse is part of a technological consciousness that valuesinstrumental approaches to achieving materialist and economic goals.Human welfare, the environment, the rights of indigenous peoples,equity and justice are all hinged on values that are out of vogue. Inthis political climate ethics has been sidelined. Ethical issues are nottreated as important. The reason for this is a fundamental divergencebetween the assumptions of ethics and the underpinnings of politics.Ethics is concerned for individual welfare and fairness between peoplefrom a perspective of non-vested interest. Conversely politics works bybalancing the forces of powerful vested lobbyists.

There is no simple Band-Aid solution that will alter this. Addingan 'ethicist' or two to policy-making bodies may have little effect. Insome situations, it may actually make the situation worse by offering atoken gesture that gives the appearance of ethical consideration whilstit allows the players to get on with the main game: profit making andprofit taking. Neither does resort to universal rules, maxims,principles, codes, or protocols deal with the problems created byindividuals and institutions acting in their own interests. The tendencyto issue 'national statements' and make global pronouncements aboutwhat constitutes ethical behaviour involves the same error as recourseto experts: it eliminates the active, dynamic, deliberative nature ofethical discourse and undermines a potential engagement with localconditions.

The German philosopher Jiirgen Habermas proposes that aregeneration of the public sphere is needed to address inequality and


the disenfranchisement of citizens. Within a reinvigorated democracy,it is reason that is the currency for exchange. He expands the notion ofreason to recognise its basis in language and its role in communicationbetween people. It is not simply an instrumental tool, but a means forthe exchange of views and for reaching understanding and agreement.Within this 'communication community' it is not force, or vestedinterest that predominates, but the 'unforced force' of the betterargument. This amounts to a radical overhaul of democracy itself.Perhaps in this kind of democracy, ethics could find its voice.

It is individuals who will contribute to these policy activities.Ideally, those individuals will have studied bioethics and have had theopportunity to develop their own approaches to questions of value, havethe skill to apply clarity in their analysis, and the determination andcommitment to resisting vested interests out of their concern for otherhuman beings and for the life of this planet. The particular issues DrSmyth raises are important and need to be critically examined from anethical perspective. These include priority setting in health, healtheconomics and equitable distribution of resources, Medicare coverage,power between professions in clinical decision making, and genetechnology. It is individuals however, and not bioethics as such, thatmust grapple with these issues.

The question that Smyth's paper raises is: 'Should bioethicsplay football?' My answer is 'No'. Individuals who are interested inbioethics may well play football but bioethics itself is another game.

AcknowledgementI am thankful to Paul Komesarolf for his reading of an earlier version ofthis paper and for his helpfUl suggestions.

The centrality of marginalizationSAMUEL GOROVITZ

Professor of Phllosophy and of Public Administration Syracuse University andFaculty Scholar, Center for Bioethics and Humanities Upstate Medical University,Syracuse, NY USA

Tim Smyth presents a cascade of questions and an assortmentof recommendations about the relationships, actual and possible,between bioethics and the formation of health policy in Australia.Residing as I do in the United States, I have no detailed familiarity withhow things work in the Australian context, but I have various reactionsto Smyth's remarks. I offer them aware that my American perspectivemay be of only limited relevance.

I agree with what seems to be Smyth's main point: thatbioethics can and should help in the setting of health policy. I havemisgivings about his sense of how that might best happen.

There is always an inherent tension between working inside asystem that has decisional authority and working on related issues

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Should bioethics play football?