Bioethics down under--medical ethics engages with political philosophy.

T he beginning of November last year was a busy time in the bioethics calendar with four conferences taking place in New Zealand and Australia. The Fifth International Conference on Priorities in Health Care took place in Wellington; the Fifth Feminist Approaches to Bioethics congress, the Seventh World Congress of Bioethics, and the meeting of the Australasian Bioethics Association were all in Sydney. One of the interesting features of these meetings was a move to a deeper exploration of the relations between ethics and political theory and political philosophy. The factors that drive this exploration are manifold but the four most important seem to be: 1) that ethicists often comment on, or propose political action and regulation; 2) that there is a growing awareness that the basic national and international societal and legal structures profoundly influences ethical issues; 3) the growing interest in global and third world issues, and 4) the move in many countries toward greater public participation in decision making concerning ethically contentious issues. All of these developments move the focus from the traditional subject matter of medical ethics— that is, the individual ethically charged action, to the question of how ethics should influence political action and regulation. To claim that this is a totally new development is obviously false. There has for a long time been great interest in public health ethics, the ethics of health systems, research ethics regulation, and many other systemic and regulatory issues, and some of these debates have drawn upon political philosophy. What is new, however, is the realisation that an engagement with political philosophy may be necessary across the whole field of medical ethics. What are the implications of an engagement with political philosophy? The first implication is that is becomes problematic to what extent and exactly how ethical analysis should influence policy making. A naı̈ve view would claim that public policy on ethically contentious issues should mirror the best ethical analysis, or at least not be in conflict with the best ethical analysis, but this naı̈ve view is rather problematic. It will come as no surprise to the readers of the Journal of Medical Ethics that there is great ethical and public disagreement on issues such as stem cell research and therapeutic cloning, a fact that was also evident in the presentations on stem cell issues at the conferences in Sydney. In the face of such disagreement, whose ethical analysis should influence the policy making? This is a central issue in the longstanding discussions of deliberative democracy in multicultural societies. This means that there is no reason for the ethics community to try to reinvent the wheel. There is a basic wheel blueprint out there. It may have to be tweaked somewhat to fit the ethics wagon, but it does not have to be reengineered from scratch. A second implication of an engagement with political philosophy is that it makes it clear that much of medical ethics activity is actually political activity, not party political, but political anyway because it tries to influence the direction in which society develops. The identification of the ethicist as a political actor has profound implications both for the role obligations of the ethicist, and for the skills needed by the ethicist. In order to be an effective political actor the skills of philosophical analysis and the knowledge of the ethical literature clearly have to be complemented with a much wider range of skills. This raises an interesting question. Is the standard model of medical ethics analysis compatible with public decision making in a deliberative democracy? By the standard model of bioethics analysis I mean the following process (this is clearly a simplification, but not excessively so): 1) A putative moral problem is identified; 2) it is analysed and sharpened in various ways, often to the point where it is stated that ‘‘... we can now see that the problem is essentially ...’’; 3) a number of solutions to this refined problem are canvassed, and counterarguments claimed to be decisive are marshalled against all but one of them (or in some cases against all of them); 4) positive arguments in support of the remaining solution (or a new solution brought in at this stage) are presented, and 5) a definitive conclusion is reached. Implicit in the standard model are a number of assumptions about the aims of philosophical analysis and the relationship between the view that is argued for, and the competing views. Most importantly in the present context is the assumption that most opposing views are not only wrong in some sense, but that this can also be shown decisively to be the case, because they are irrational, or at least unreasonable. When the ethicist using the standard model enters the public debate it is therefore with the firm conviction that most of the views being put forward by others have already been shown to be unreasonable. There is no reason to take account of them or to let them influence decision making. Discussing them is only worthwhile as a tactical manoeuvre to get your own arguments on the table, or in order to show them to be unreasonable. The standard model, and to an even greater extent the rhetoric of ethics, often imply that there is only one right solution to each policy making decision, and that it is possible to find this solution, and to know that it is the right decision. ‘‘Knowing that you are right’’ is in general a bar to a positive engagement with the views of others, but ‘‘Knowing that you are right after proper philosophical reflection’’ can be even more problematic. In contrast, theorising about deliberative democracy proceeds from the assumption that whereas there might be a right solution, it is often impossible to find this solution or to know that it is the right solution in any absolute sense. The best we can do is to outline the area of acceptable policies, and then choose a policy within this area through a deliberative, democratic process. If philosophers participate in the public discourse about contentious issues in the same way as they engage in philosophical discourse they are very likely to breach many of the requirements for an engagement in public reason. They will also, however, have engaged in a social category mistake. Attempting to reach a legitimate public policy in a morally pluralistic liberal democracy is not a social activity of the same kind as trying to win a philosophical argument.