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...toward sociology is not without cause. Sociologists have been quite critical of what they call (with not-so-subtle pejorative overtones) the "bioethical project."
Two decades ago--when bioethics was just getting up on its organizational feet--Renee Fox and Judith Swazey leveled the charge of "cultural myopia" against bioethics, noting that this myopia "generally manifests itself in the form of systematic inattention to the social and cultural sources and implications of its own thought. They go on to say "if [bioethics] is an indicator of the general state of American ideas, values, and beliefs, of our collective self-knowledge, and our understanding of other societies and cultures--then there is every reason to be worried about who we are, what we have become, and where we are going ..." (3)
Bioethics began to address its cultural myopia in the late 1980s, but this did not silence the sociological critique: sociologists continue to find bioethics wanting. Jeanne Guillemin attributes the "phenomenal success of bioethics" to its presentation of "a legitimate, essentially conservative rationale for physician autonomy." (4) Daniel Chambliss describes how bioethics exerts this conservative influence:
Talk of "ethical dilemmas" diverts attention from the structural conditions that have produced the problem in the first place ... This is why so many hospitals can readily accept an "ethics committee" and its debates about ethical issues ... [threats to powerful hospital staff are] contained by framing issues as difficult dilemmas rather than seeing them as symptoms of structural flaws in the health care system.... If ethical problems are not dilemmas, then what are they? ... they are the symptoms of occupational group conflicts in the hospital, in which moral arguments are weapons in the fight ... Ethics committees ... are useful ... allies in those fights. (5)
Jonathan Imber asserts that "bioethics is the public relations division of modern medicine, whether physicians (or bioethicists) like it or not." (6)
Along with these less than flattering depictions of bioethics, sociologists have brought the unwelcome news that bioethicists are paying insufficient attention to the way the organization of their profession affects their ability to influence medicine and the biological sciences. Charles Bosk points out that bioethics programs are training far too many students: using data collected by the American Society for Bioethics and the Humanities (ASBH), he estimates that in ten years time, "close to 2500 bioethicists will be chasing 600 jobs." He goes on to note that "a buyer's market does not encourage fledgling bioethicists to take positions that go against the grain, to do work that ruffles feathers, or to take positions that challenge the conventional wisdom." (7)
Bioethicists, who view" themselves as advocates for patients and research subjects facing the power of medicine and the medical-industrial complex, have been less than happy with these sociological assessments of their work. (8) Samuel Gorovitz takes on those critics who, in his eyes, are "baiting bioethics;" he asserts that Fox and Swazey "offer no evidence to support their perceptions [of bioethics], except for smattering of brief quotations ..." He then goes on to offer his own collection (smattering?) of citations that shows their sociological characterization of bioethics to be false. (9) In his review of the anthology that includes the essays by Guillemin and Imber mentioned above, Maurice de Wachter accuses the editors of an "aggressive show of irritation with bioethics" marked by "undertones of resentment." Ethicist de Wachter has no use for authors of contributions he deems most critical of bioethics: Imber is accused of "rambling on ... without supporting his thesis credibly;" others are accused of "ax grinding," "reinventing the wheel," and of being "arrogant." Not exactly scholarly discourse. (10)
This is not to say that all sociological work on bioethics is offensive to bioethicists. Many sociologists are gainfully employed in centers of bioethics and their skills have been well used to help bioethicists solve the problems they face in ascertaining public opinion, understanding how organizations work, and in sorting out different cultural approaches to moral questions. And yet sociology remains a fly in the bioethical ointment. Why? Bioethics is famously interdisciplined--its practitioners are drawn from a collection of professions and academic fields including law, medicine, philosophy, theology, nursing, sociology, social work, anthropology, literature, history, and political science. And while members of each of these disciplines would like to see their concepts define the debates in bioethics, (11) rarely do they raise the hackles of bioethicists as sociologists have. (12)
Interestingly, anthropology has a less troubled relationship with bioethics than does sociology. This is curious because these two disciplines share some intellectual ancestors and their work often "looks" alike; however, there are important differences in how each approaches the study of bioethics, differences that help us understand how sociological and anthropological accounts of bioethics are received.
The inclination of anthropology has been toward area studies, ethnographies of local cultures and the events that occur there. Anthropologists have done important and useful work on cultural notions of death and disease (13) and the culture(s) of clinical settings and ethics consultations. (14) Sociologists also do this kind of work--witness the studies of ethical issues in intensive care units, neonatal and otherwise (15)--but, for reasons having to do with the history of our profession, our inclination is to step back from the local setting and to ask historical and structural questions about the actors and events we are watching. Where anthropologists relativize the norms and values can-led into the "bioethical moment"--an approach bioethicists find useful in their work--sociologists relativize the bioethical moments themselves: why is it that the category of bioethics exists at all and how has one class of workers come to claim bioethics as their jurisdiction? (16) Reflecting on what social science can contribute to bioethics, Nora Jones, an anthropologist, says:
Ethnographic case studies offer the ability to generate interesting questions about the lived reality of issues related to bioethics. How can practitioners make the best decisions? What are the best means of applying and distributing genetic testing? How can ethics consultations work best in clinical settings? (17)
Contrast this with a sociological view of the study of bioethics:
... as sociologists we are not ... interested in helping bioethicists do their work better. Our intent is to use bioethics and bioethicists for our own social scientific ends: 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. (18)
This disciplinary difference is at least in part the result of different expectations bioethicists have for the two disciplines. To the extent that bioethicists distinguish sociology and anthropology, they expect anthropology--which they perceive as the study of "other," "exotic" people--to help them sort out the proper way to approach these people when they enter the health care system. Bioethicists do not expect to become the exotic subjects of ethnography, and they are sometimes upset by the characterizations of their profession offered by sociologists (and anthropologists) who remain outside of their (inter)discipline.
A SHORT HISTORY OF (BIO)ETHICS AND SOCIOLOGY
The relationship between sociology and ethics is a peculiar one. In spite of a long interest in ethics and morality on the part of sociologists--classical social theorists had an explicit concern with the moral foundations of society and, more to the point, pioneers in medical sociology often examined issues in health care with direct ethical import --contemporary sociologists are not all that interested in the study of bioethics.
The well known classical sociologists, Marx, Durkheim and Weber (often referred to by students of sociology as the "big three"), were deeply interested in the moral fibers that bind members of society together--a topic of special concern to those witnessing the shift from a rural and agrarian mode of life to an urban and industrial economy. In their efforts to understand how members of modern societies sorted out how to best live together and decided what was right and wrong, these social theorists studied and wrote about religion, law, politics, the economy, and science. In his Division of Labor in Modern Society, for example, Emile Durkheim presented his vision of forces that hold society together. Durkheim responded to Toennies' gloomy depiction of modern life--where small and friendly gemeinschaft societies were giving way to the larger and impersonal gessellschaft--with a more positive view of urbanization and industrialization as a transition from "mechanical" to "organic" solidarity. According to Durkheim, older societies were united in a mechanical, non-thinking way: evidence of this was found in their legal systems, which responded to the violation of norms by lashing out with repressive sanctions. In modern societies people are connected organically--each dependent on the other in a complex division of labor. This type of society is characterized by a system of restitutive law: when a norm is violated the conscience collectif responds by addressing the imbalance created. The goal is to restore the status quo ante, not to punish the offender. (19)
Working in this tradition, Talcott Parsons--one of the mid-twentieth century sociologists whose work would help define the new field of medical sociology--saw medicine as an important system of social control. For Parsons, illness was a type of deviance, a threat to the stability of society. Those guilty of deviating from legal norms were sent to legal institutions (courts, prisons, parole offices) intended to rehabilitate them and integrate them back into society; the sick--violators of the norms of health--were treated and rehabilitated by the institutions of the medical system (doctors' offices and hospitals). (20)
Other pioneers in medical sociology showed a similar emphasis on the moral questions that permeate illness and its treatment (even though they rarely mentioned an explicit interest in ethics): studies of medical education describe the "fate of idealism" and explore how students "negotiate" the demands of coursework and examinations; (21) ethnographies of work in the hospital reveal how death is thought about, managed, discussed, and revealed to next-of-kin and others; (22) research on the medical profession shows an unfavorable balance between the self-interest of professionals and the interest of patients; (23) studies of stigma and "total institutions" expose the underside of the treatment given those not seen as "normal;" (24) analyses of the medicalization of deviance describe how the control of certain behaviors has moved from legal to medical institutions. (25)
Implicit interest in the morality of medicine became explicit in the 1970s. During this decade, sociologists made a turn toward a more conscious study of ethical issues in health care, looking at medical experiments, organ transplantation and medical errors. In the first half of the decade Bernard Barber and his colleagues (26) and Bradford Gray (27) were involved in sociological studies of the treatment of human subjects of medical research. Their work was important to the conduct of science and relevant to the social sciences but it failed to capture...
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More articles from Journal of Law, Medicine & Ethics
Law & bioethics: from values to violence.(Symposium on Bioethics), June 22, 2004
Passing on the right: conservative bioethics is closer than it appears..., June 22, 2004
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