Book Review

Freedom and Community: The Ethics of Interdependence

N Engl J Med 1994; 330:871March 24, 1994

Article

Freedom and Community: The Ethics of Interdependence
By Erich Loewy. 261 pp. Albany, N.Y., State University of New York Press, 1993. $17.95. ISBN: 0-7914-1513-9

A series of recent books and journal articles have argued that community must be considered in deciding questions ranging from individual clinical cases of futile treatment to the allocation of resources and health care reform. Freedom and Community contributes to this discussion, but it does not address specific issues in bioethics. Instead, it develops a framework for rethinking a wider range of public-policy and ethical issues.

The thesis of this work is that individual autonomy and freedom are best understood within a naturalistic framework that gives primacy to the nurturing function of community. Ethical obligation originates neither in freedom nor in the shell of rights that many thinkers habitually ascribe to individual persons, but rather in the phenomenon of suffering, a view articulated in Loewy's earlier book Suffering and the Beneficent Community (Albany, N.Y.: State University of New York Press, 1991). Ethics is thus less a matter of the rights of isolated individuals, in his view, than a matter of interpersonal relations within the surrounding community.

Loewy argues that moral worth is grounded in suffering. Entities, including animals, are said to have moral worth insofar as they are capable of suffering. (The implications of this view for the use of animals in research are, unfortunately, not developed.) The capacity to suffer constitutes the prima facie basis of obligation. Loewy does not describe in detail a system of obligation, however. For example, it is not clear how he believes one should assign priorities among not causing suffering, ameliorating suffering, and preventing suffering. With scarce resources, one might not be able to do all three, as Loewy himself recognizes. Rather than address these kinds of questions directly, Loewy argues that such questions are tractable only if we properly understand the relation of obligation and community.

Key to this relation is the view that an ethics predicated on suffering confers survival value on individuals and communities. This rather bold claim involves difficult empirical and normative questions that are only partially explored in the present work. The relation between the individual and the community and the relation between communities at various levels are explained in terms of the notion of homeostasis. Loewy stresses that the term defines a dynamic rather than a static relation. It is a process in which adjustment is constant. Such a concept is juxtaposed to a dialectical understanding of the relation between individuals and communities (or among communities) that assumes or implies conflict. There is no compelling logical reason why communities and individuals need be regarded in adversarial terms, although the tradition of liberal thought seems fixed on such a juxtaposition. Arguing against the mainstream, Loewy contends that communities are not adequately understood in terms of social-contract theory. Rather than regard communities as created by associations of free contractors, Loewy sees communities as primal entities into which individuals are born and by which they are nurtured and supported. This concept lends moral standing to community as the necessary condition of all value, but it does not necessarily confer an authoritative status on community.

Although more needs to be said about the practical implications of this view of community and its ethics founded on suffering, especially for a range of issues in bioethics, the author does touch on a variety of such subjects in laying out his overall position. Loewy has succeeded in showing that the importance of an ethics based on suffering is the way it uniquely provides a basis for understanding the central role of the community in ethics. Most other communitarian approaches rely on political thought, which Loewy trenchantly shows is the wrong arena for building a true ethics of interdependence.

George J. Agich, M.D.
Southern Illinois University School of Medicine, Springfield, IL 62704