Book Review

The Future of Bioethics

N Engl J Med 2009; 361:542-543July 30, 2009

Article

The Future of Bioethics
By Howard Brody. 261 pp. New York, Oxford University Press, 2009. $49.95. ISBN: 978-0-19-537794-1

Since the inception of bioethics as a discipline almost 40 years ago, its scholars and practitioners have devoted much of their time and attention to two sets of issues — namely, ethical quandaries posed by medical treatment, particularly end-of-life care, and the protection of human subjects in the conduct of biomedical research. The reasons for the focus of bioethics are readily apparent to any historian of medicine. The first set of issues flourished in the wake of new technologies that have enabled physicians to prolong life; the second set grew out of infamous cases of abusive “research” at home and abroad — most notably in Tuskegee, Alabama, and in Nazi Germany.

In The Future of Bioethics, Howard Brody — a veteran bioethics scholar with a medical degree and a Ph.D. in philosophy — offers an articulate and compassionate plea for an expanded and enriched discipline of bioethics. Drawing on feminist scholarship, Brody accuses bioethics of “wishing to appear macho” by focusing on life-and-death decisions. He argues that bioethics has neglected other important issues — not the least of which is whether patients' pain, anxieties, and information needs are being addressed — because they seem, by comparison, to be “housekeeping” or “women's work.” Brody is similarly critical of the field for its neglect of the ethical implications of evidence-based medicine and physician incentives such as pay-for-performance programs.

The author argues for a “patient-centered bioethics” that pays attention to these problems and maintains a strong alliance with primary care medicine. This is, he contends, “the side of medicine most concerned about talking with and listening to patients and forging long-term relationships” with them. Brody also argues that bioethicists should talk with and listen to communities (not just patients), and in an insightful chapter, he compares and critiques several models of community dialogue.

More broadly, Brody calls for a revolution in “future bioethics.” He argues persuasively that “we need to understand how certain facts, issues, and questions turn invisible to us, depending on where we happen to be placed in a hierarchy of power” (italics in the original). According to Brody, “feminism teaches bioethics that it must `learn to see' what the dominant power structure may be actively, even if unconsciously, discounting.” As far as inequalities between the sexes are concerned, Brody acknowledges that bioethics has been a relatively good student. It has learned that such inequalities are not resolved “merely by appeal to autonomy” and that “much of human ethical life exists outside of the sphere of rules and principles.” But, the author contends, these insights should also be applied to power disparities that arise from cultural, racial, and ethnic differences; to disparities that are experienced by people with disabilities; and to disparities that are experienced by inhabitants of the developing world.

Not surprisingly, Brody's “future bioethics” has practical as well as theoretical dimensions. He exhorts bioethicists to speak up for the powerless — or, better still, to help the powerless find ways to speak for themselves — and he concludes with a plea for more activism in bioethics. Recognizing the challenges that this vision presents, he counsels bioethicists to “act as people of thought, and think as people of action.”

This provocative critique of bioethics and the accompanying prescription for the future, from one of the discipline's most respected scholars, are welcome. Although neither the critique nor the prescription will be met with unanimous agreement, they should trigger a vociferous debate about the path that bioethics has taken and the way ahead. Brody's discussion is also timely, given the recent proliferation of graduate programs in bioethics. Students in these programs deserve the education and mentorship they will need to become the next generation of multidisciplinary bioethics scholars. Taking stock of bioethics is the best way to ensure that they receive both.

Jonathan H. Marks, M.A., B.C.L.
Pennsylvania State University, University Park, PA 16802
marks@psu.edu