Book Review

Society's Choices: Social and ethical decision making in biomedicine

N Engl J Med 1995; 333:886September 28, 1995

Article

Society's Choices: Social and ethical decision making in biomedicine
Edited by Ruth Ellen Bulger, Elizabeth Meyer Bobby, and Harvey V. Fineberg. 541 pp. Washington, D.C., National Academy Press, 1995. $59.95. ISBN: 0-309-05132-0

Since the demise of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in March of 1983, a strange fate has attended efforts to constitute a similar body. Congress, or the President, or both are continually on record expressing their desire for such institutions; legislation has been passed to create them; and yet nothing — or essentially nothing — ever seems to come of it. Currently there is talk of a new Ethics Advisory Board in the Department of Health and Human Services, as well as interest in a National Bioethics Advisory Commission, which has been favored by the President. But “interest” is apparently where it remains.

Society's Choices speaks, if a bit obliquely, to this curious situation. The book presents itself as a response to the lamentable lack of “systematic study of the various collective processes through which we subject . . . ethical and social issues to debate and analysis” — that is to say, hospital ethics committees and institutional review boards, the ethics activities of professional associations and ethics centers, and grass-roots organizations. The book is the precipitate of an Institute of Medicine committee charged with analyzing the nation's ability to respond to the ethical dimensions of developments in the life sciences and biotechnology and with issuing recommendations based on its findings.

Although all the “collective processes” for bioethical discussion are at least lightly touched on in this book of over 500 pages, its predominant concern is overwhelmingly with the prospects for further efforts at the national level. And the chief conclusion would seem to be that we should be bullish on bioethics: the book recommends that both a bioethics body at the level of the Department of Health and Human Services and a “supra-agency” group be established. Much of the analysis in this book is devoted to increasing the chances that any such new committees will be able to put together a record of achievement that will match or exceed that of the President's Commission.

Granted both this report's positive view about ethics commissions and that the likelihood that such a body will be constituted are realistic, this focus is surely reasonable, as are (typically) the arguments, analyses, and recommendations of the distinguished group that engaged in this study. The book might have been even more interesting had the inquiry into the social processes by which we configure, deliberate, and decide about bioethical problems been as general as the preamble might have led one to expect. What constitutes successful functioning in a hospital ethics committee, and whether such bodies ought to step beyond hospital walls to touch off grass-roots deliberation, might actually be more important issues in the long run. And it is at least arguable that organizations such as the Kennedy Institute of Ethics and the Hastings Center have had an impact on social discourse on these matters that rivals that of the President's Commission; what occurs in academic and private research settings might have a greater influence on the present and future character of public debate over ethical and political issues surrounding medicine than national commissions do.

Still, it is uncharitable to complain about what a book leaves undone, when it does well what it takes up. In addition to its careful discussion of the technical, historical, institutional, and cultural contexts that lead up to its own recommendations, Society's Choices includes 12 background papers by well-regarded scholars. These papers — extending from moral epistemology to a comparison of French and U.S. national commissions — do a nice job of conveying the rich range of issues involved in trying to get a better grasp on how a society like ours can grapple publicly and thoughtfully with the moral problems of health care and biotechnology. The papers are clear and authoritative and include some standout essays — such as those by Ron Bayer and Baruch Brody, to name only two.

What is most impressive about Society's Choices is that it represents a thoughtful effort by an increasingly important part of our intellectual culture — the bioethics community — to reflect on itself, particularly on its engagement with political culture. Self-scrutiny of this sort is important and too rare. The more it goes on, the more both bioethics and society will benefit.

James Lindemann Nelson, Ph.D.
University of Tennessee, Knoxville, TN 37996