Moral Teachings from Unexpected Quarters

Abstract

Lessons for Bioethics from the Social Sciences and Managed Care Consider the following sketch of how bioethics relates to health care, its major object of study, and to the social sciences, one of its chief allies. Bioethics's job is to assess in what respects prevailing or proposed health care practices, policies, and institutions are morally defensible. To make these assessments, it draws on an interdisciplinary set of resources, crucial among which are those provided by the social sciences. Yet because it is a normative inquiry, its definitive tools are, broadly speaking, philosophical--theories of morality and of practical rationality, analyses of moral concepts, and so forth. These modules of bioethical analysis--the normative core, the empirical auxiliary, the practice that serves as the target--keep distinct characters, and the flow of thought among them is largely linear. Moral theories, informed by facts, judge practices. There's no lack of sniping at various aspects of this picture, but I want to explore here what might be gained by standing it more or less on its head. The social sciences, that is, will not merely be seen as sources of the facts that bioethics grinds fine in its normative mill, but of more or less distinctive and potentially unsettling values. Health care--and for my present purposes, managed health care will -- not be portrayed solely as an object of bioethics's judgmental gaze, but as a repository of moral understandings of its own. My belief is that inverting common wisdom about the relations between the normative and the descriptive, and between a study and its object, will yield interesting results both methodologically and substantially. To make this thought plausible, I will first smooth out the rough sketch of the orthodox model of the social sciences-bioethics relationship just given, provide some reasons for being dubious about it, and then describe a more heterodox model, one that sees the interaction among the elements in a more complicated way. From this second model I extract a lesson for how bioethics should go about its work, illustrated by a similarly heterodox discussion of the moral dimensions of managed care. These points suggest yet a third model for the role of social scientific inquiry in bioethical thinking, one that tries to resurrect some of bioethics's formative impulses. Some caveats: the point of this exercise is not exhaustively to delineate the possible jobs that social science methodologies, results, or sensibilities have performed or might perform in association with or as a part of bioethics. Nor do I discuss even a representative sample of views on this topic that already exist in the literature; the scholarly ambitions of this essay are modest. My hope, rather, is to press beyond what I think are fairly common and too simple notions of what the social sciences, and medical practice as well, hold out to bioethics, and to enter a brief for the attractiveness of some more complex ideas. The strategy is to highlight how those ideas make more accessible some promising yet underexplored directions for thinking about bioethics and about ethics tout court. Just the Facts, Ma'am The common picture of the relationship between bioethics and the social sciences assigns responsibility for accurately gathering the pertinent facts to epidemiologists, sociologists, anthropologists, and their kin, and for assessing those facts to bioethicists wielding explicitly normative techniques. We can track this image down to a standard lesson taught in many an undergraduate class in ethics, where good moral reasoning is said to involve the following components: (1) accurate empirical beliefs, (2) defensible moral values, (3) clarity about relevant concepts, and (4) formally valid argumentation. The first component is where the social sciences would most naturally operate; responsibility for the rest of these elements falls to the lot of other disciplines. …