Society and the balance of professional dominance and patient autonomy in medical care.

Through "Bioethics with a Human Face" Carl Schneider crafts a lens to view in sharp and clear focus the nature of the bioethics' debate, the central linchpin of patient autonomy in these discussions, and the limits encountered when intellectual debates confront empirical reality in the world of medical decision-making.' As the end point to his arguments, Professor Schneider asserts that social, institutions inevitably shape the nature of future medical decisions; the fascination lies in exploring how particular social institutions will influence their specific character.2 This ending point presents my starting point, for it raises a paradox. How could the same set of social institutions, or perhaps better said, the same socio-historical context, produce two paradigms-biomedicine and bioethics-that so clearly oppose one another? The simple answer is an historical one. The rise of American modem medicine at the turn of the last century heralded a professionally dominant class of medical practitioners never before seen and so set the stage for the later appearance of the new discipline of bioethics which stands as a counterpoint to this incredible power over health, illness, and healing.' The more complex but more accurate and useful answer lies in taking a sociology of knowledge approach to understanding the modem medical profession, the bioethics discipline, the interaction of the individual and society, and the general nature of intellectual debates. Both biomedicine and bioethics developed as a response to social problems. The development marked, reflected, and addressed inherent societal tensions, particularly regarding the balance of expertise and individualism. Both were set within the larger paradigm of modem society which shaped the range of possibilities for the terms of a modem, science-based medicine and the discourse surrounding the problems that bioethics addresses. Further, both reflect the rhetoric of innovation through exaggeration, particularly in intellectual debates that promote and accompany the development bf paradigms and the adoption of social policy that follow from them. I will pull the lens back even further than Professor Schneider does, back beyond an overview of bioethical literature and its connection to modem medicine and patient preference. I argue that biomedicine and bioethics