Bioethics in a Liberal Society

There are many books on bioethics.  Yet few books offer a comprehensive analysis of the political framework within which bioethical decision-making occurs in a liberal constitutional democracy.  While written from within a US background this book is nevertheless applicable to readers from any Western democracy.

Thomas May is Associate Professor and Director of Graduate Studies in Bioethics at the Center for the Study of Bioethics at the Medical College of Wisconsin, Milwaukee. He develops his argument over a series of seven chapters.  May notes how a person’s right to make independent decisions is a key feature of a liberal society and this has significant impact upon patient autonomy and constraints to the actions of health care professionals.  However, this right rests upon an assumption - what some would call a norm - of an individual being competent.  As readers of Metapsychology will aware significant challenges exist when people do not have the competence to make adequately informed decisions.  Hence, William May explores the importance of healthcare ethics committees and ethics consultants to inform and assist decision-making within modern health care facilities.

Chapter 1, appropriately entitled, “The Liberal Framework”, sets itself clearly within a US context.  It makes a very interesting contrast between the individual rights focus of the USA and Japanese cultural history with emphasis on a family authority.  In so doing he points out that:

Healthcare, as a social practice, is bounded by the fundamental political context within which it exists.  In short, the role that moral beliefs play in bioethics will be limited, in a social context, by the political rights of individuals. (Page 5).

As May notes, respecting patient autonomy in a liberal society often involves recognizing negative requirements as being less intrusive than positive ones.  For example the emphasis on a patient’s right to refuse treatment.

In Chapter 2, May discusses “patient autonomy and informed consent” utilizing the first of many case studies which are of great assistance in making the point being discussed.  An important dimension to informed consent is the emphasis upon adequate disclosure, recognizing the role of the notion of what a “reasonable person” would require.  Yet he also recognizes the five general bases for potential exceptions to informed consent:  threats to public health, medical emergency, therapeutic privilege, waver of informed consent by the patient and lack of competence. These are discussed in a critical and accessible way. 

As May notes in the next chapter, perhaps one of the most important developments in health care has been an increased emphasis on patient autonomy.  This is discussed in a chapter entitled “Patient Responsibility for Decision-making”.  In my experience as a consultant in the area, May offers an important insight about the fact that:

… the “standards for competency” offered in the biomedical ethics literature often “smuggle” concerns about the merit of a patient’s decision into the idea of competency preempting the patient’s judgment by assessing that the patient lacks the capacity to make decisions because the patient’s decision is not a “good” decision. (Page 33)

While May focuses his discussion on individual cases, I couldn’t help reflecting that other examples were to be found when cultures clash with regard to contested notions of the “right” decision.  May also goes on to identify the challenges associated with “the incompetent patient" and the way in which a liberal framework, based upon the notion of a competent adult independent decision-maker, does not adequately provide a “correct” mechanism.  This insight is an important contribution to the literature in itself.  Too often we can take for granted the social and political context within which decisions are made.  This book makes clear that this can be problematic for some of the most disadvantaged people – those that don’t fit the norms of competence.

In Chapter 4, May discusses the role of “advanced directives” as extending autonomy for patients.  He also notes how this has been addressed at a federal level in the US through the Patient Self-determination Act 1990.  It is worth noting here that some other Western countries with differing political ethos have not tended to pursue this within the health care system to the same extent as the USA.  May’s critical exploration of advanced directives, including incorporating work that is critical of his own, is to be applauded.

An understanding of the role of the history of paternalism, and yet the liberal obligation of tolerance, informs Chapter 5 “Beneficence, Abandonment, and the Duty to Treat” which argues that the negative rights granted to patients in a liberal society impose claims requiring healthcare professionals to respect the autonomous decision of the person.  May establishes beneficence as a core feature of the physician-patient relationship.  Strangely he does not discuss other healthcare professionals but certainly this could also be seen to obtain.  He also suggests that a liberal society can establish a minimal duty to treat, though he restricts this to the special circumstances of a physician-patient relationship and where there is insignificant or even no cost imposed on the person required to provide aid.  Readers from other Western countries will find that their own social and political context will provide them with an alternative perspective with regard to this discussion, which is dominated by a US conception of healthcare. Chapter 6 discusses the “Rights of Conscience in the Physician-Patient Relationship” with the situation of a Jehovah’s Witness being an excellent example with which to start the chapter. 

May concludes in Chapter 7 in making the case for healthcare ethics committees and consultants within the liberal framework.  This is in itself an important contribution to the literature and will be of particular interest to readers from some non-US countries with little experience of ethics committees having a role regarding treatment decisions. 

Hence, May’s book is a helpful overview and introduction to the political framework of bioethics decision-making within a liberal society.  I did however find myself raising a couple of questions.  Firstly, there is uncritical use of the terminology “patient” and yet little justification for that terminology.  Certainly there is a leap from the discussion of individuals or people in the political literature to its application within the healthcare system.  The terminology “patient” is hardly agreed upon and has its own power relations worthy of exploration.  Secondly, the book also would have benefited from some cross-cultural analysis.  Written from within a US context about largely US notions of a liberal framework some noticeably different readings of liberalism are to be found in a variety of Western societies.  The incorporation of these within the book would have strengthened not only the analysis but also the critical reflection that this book seeks to foster. 

However, there is no doubt that this book marks an important contribution to the literature.  It will be of particular interest to readers of Metapsychology because it touches explicitly on the issues of perceived and actual lack of competence, substituted decision-making, advanced directives and the important roles of ethics committees and consultants.  It also shows how some of the dominant norms utilized within notions of the liberal society inherently disadvantage people who do not fit criteria for autonomy. May’s book will be of interest to a wide scale of readers, from philosophers to politicians, including bioethicists, patient advocates and indeed healthcare professionals. Undergraduate and postgraduate students alike in bioethics, public policy, politics and a variety of health care disciplines will find it worthwhile. Well worth the investment of time and money.

© 2002 Christopher Newell

Dr. Christopher Newell is Senior Lecturer in Medical Ethics, School of Medicine, University of Tasmania, Australia.