Book Review

Bioethics in a Liberal Society

N Engl J Med 1994; 331:686-687September 8, 1994

Article

Bioethics in a Liberal Society
By Max Charlesworth. 172 pp. New York, Cambridge University Press, 1993. $39.95 (cloth); $12.95 (paper). ISBN: 0-521-44503-5 (cloth)

Max Charlesworth, the distinguished Australian philosopher and bioethicist, has written a lucid and instructive analysis of the concept of autonomy in medical ethics and health care. He unabashedly tackles three controversial areas: decisions at the end of life and assisted suicide, medically assisted reproduction, and the allocation of health care resources.

The book begins with a superb discussion of the moral ideal of liberty, autonomy, and -- in John Stuart Mill's apt phrase -- “self-sovereignty.” The freedom to choose our own way of life, to experiment in living, and to explore our own individuality is what makes us deserving of respect and capable of taking responsibility for our actions. There is a bright line between the law and morality and between the state and the private sphere. The state must secure the conditions of equal freedom and justice; it can properly restrict the liberty of an adult only to protect others from harm.

Autonomy arms individuals with the moral authority to make claims on society, not only negative claims to privacy and to be left alone, but also affirmative claims to the resources necessary for the exercise of freedom and the pursuit of one's own life (or death) in one's own way.

This principle is the key to Charlesworth's account of how autonomy applies to medical care and health policy issues. The state cannot justifiably outlaw rational suicide because it would thus illicitly impose the state's conception of the good on dissenting individuals. And if one's theoretical freedom to choose the nature and timing of one's death is to be a reality, a competent adult should have access to the most benign and effective assistance in suicide -- namely, that of a physician.

The author applies a similar line of reasoning to “procreative liberty” and access to medically assisted methods of reproduction such as in vitro fertilization. He also defends surrogate gestation. His arguments are careful, and he scrupulously considers opposing viewpoints, if only to reject them by testing them against the criterion of autonomy and the harm principle.

The book's least compelling discussion is of rationing and the allocation of resources in systemwide health policy. This is not surprising, because of all the issues in bioethics, these two have been the most resistant to the focus of liberalism on autonomy. The reason is that allocation involves scarcity and redistribution in a way that other civil-liberties issues do not. If, as Charlesworth convincingly demonstrates, utilitarianism and cost-benefit analysis do not solve this problem, neither does the ideal of autonomy.

The only solution is procedural. For Charlesworth, the allocation of resources should be based on open debate, social consensus, and incremental change. But can autonomy-minded people reach the necessary kind of consensus? For this task we may need citizens with a broader moral and civic sensibility than liberalism tends to provide. We may need to learn to value our social being and our interdependency as much as our self-sovereignty. And we may need to learn to cherish community, compassion, and mutuality as deeply as Charlesworth teaches us to honor autonomy before we can forge a new social contract for health care in a post-liberal society.

Bruce Jennings
The Hastings Center, Briarcliff Manor, NY 10510