The primacy of the public: in support of bioethics commissions as deliberative forums

In a 2004 article, we argued that bioethics commissions should be assessed in terms of their usefulness as public forums. A 2006 article by Summer Johnson argued that our perspective was not supported by the existing literature on presidential commissions, which had not previously identified commissions as public forums and that we did not properly account for the political functions of commissions as instruments of presidential power. Johnson also argued that there was nothing sufficiently unique about bioethics commissions to make the public forum perspective particularly applicable. We respond by arguing that analysis of commissions' work as public forums fits well within the literature on commissions, especially on their agenda-setting functions, and that the political functions of commissions are often compatible with their functioning as public forums. We also demonstrate how the origins and concerns of bioethics make public forum analysis particularly applicable to bioethics commissions.     

The "nation's conscience:" assessing bioethics commissions as public forums

As the fifth national bioethics commission has concluded its work and a sixth is currently underway, it is time to step back and consider appropriate measures of success. This paper argues that standard measures of commissions' influence fail to fully assess their role as public forums. From the perspective of democratic theory, a critical dimension of this role is public engagement: the ability of a commission to address the concerns of the general public, to learn how average citizens resolve moral issues in healthcare, and to monitor public opinion on the topics addressed in the commission. Such a public forum role is supported by the critical literature within bioethics, which has deemed some commissions successful, supported more generally by the history of bioethics as a reform discourse that has brought socially important values into the medical domain, and supported more generally still by the example of the great social issues commissions of the 1960s.     

Promises and perils of public deliberation: contrasting two national bioethics commissions on embryonic stem cell research

National bioethics commissions have struggled to develop ethically warranted methods for conducting their deliberations. The National Bioethics Advisory Commission in its report on stem cell research adopted an approach to public deliberation indebted to Rawls in that it sought common ground consistent with shared values and beliefs at the foundation of a well-ordered democracy. In contrast, although the research cloning and stem cell reports of the President's Council on Bioethics reveal that it broached two different methods of public deliberation--balancing goods and following an overarching moral principle--it adopted neither. Thereupon its primer mover, Leon Kass, influenced particularly by the approach of Leo Strauss, sought to develop a method of public deliberation guided by tradition and practical wisdom. When this failed, the Council fell back on a method that took account of shared fundamental values of a free democracy--a method remarkable akin to that employed by the National Bioethics Advisory Commission. Respect for diverse reasonable conceptions of the good in a democratic polity requires national bioethics commissions to seek and incorporate that which is valuable in opposing positions.     

Diversity and deliberation: bioethics commissions and moral reasoning

This article considers the sort of diversity in perspective appropriate for a presidential commission on bioethics, and by implication, high-level governmental commissions on ethics more generally. It takes as its point of comparison the respective reports on human cloning produced by the National Bioethics Advisory Commission, appointed by President Bill Clinton, and George W. Bush's President's Council on Bioethics, under the leadership of its original chair, Leon Kass. I argue that the Clinton Commission Report exemplifies forensic diversity (the type of diversity between contesting parties in a legal case), while the Kass Council Report exemplifies academic diversity (the diversity found in a medieval disputatio). Drawing upon Thomas Aquinas, I argue that the type of diversity most appropriate for such advisory bodies is deliberative diversity, which facilitates the President's process of taking counsel. After considering their respective charges, I suggest that neither the Clinton Commission nor the Kass Council possessed an adequate degree of deliberative diversity for their respective tasks.     

Reflections on public bioethics: a view from the trenches

For many reasons, and more than its predecessors, the President's Council on Bioethics has been the subject of much public attention and heated controversy. But little of that attention and controversy has been informed by knowledge of the Council's mission, its ways of working, and, most importantly, its actual work. This essay describes the Council's mission, discusses its public ways of working, and reviews the five major works produced during the Council's first term. In all its activities, the Council has sought to develop a richer bioethics, one that recognizes and tries to do justice to the deep issues of our humanity raised by the age of biotechnology. Believing that these issues are properly matters to be discussed and governed by the polity as a whole, the Council also has sought to contribute to a genuinely public or political bioethics, beyond the rule of "experts," scientific and bioethical.     

Respecting difference and moving beyond regulation: tasks for U.S. bioethics commissions in the twenty-first century

This article focuses on two possible missions for a national bioethics commission. The first is handling differences of worldview, political orientation, and discipline. Recent work in political philosophy emphasizes regard for the dignity of difference manifested in "conversation" that seeks understanding rather than agreement. The President's Council on Bioethics gets a mixed review in this area. The second is experimenting with prophetic bioethics. "Prophetic bioethics" is a term coined by Daniel Callahan to describe an alternative to compromise-seeking "regulatory bioethics." It involves a critique of modern medicine. In the contemporary context, the areas of biotechnology and access to health care cry out for prophetic attention. The Council has addressed biotechnology; unfortunately, that experience suggests that the kind of prophecy that it practices poses risks to conversation. With regard to access issues, the article proposes an effort that unites themes of human dignity, solidarity, and limits in support of reform, while highlighting, rather than papering over, differences.     

"Show me" bioethics and politics

Missouri, the "Show Me State," has become the epicenter of several important national public policy debates, including abortion rights, the right to choose and refuse medical treatment, and, most recently, early stem cell research. In this environment, the Center for Practical Bioethics (formerly, Midwest Bioethics Center) emerged and grew. The Center's role in these "cultural wars" is not to advocate for a particular position but to provide well researched and objective information, perspective, and advocacy for the ethical justification of policy positions; and to serve as a neutral convener and provider of a public forum for discussion. In this article, the Center's work on early stem cell research is a case study through which to argue that not only the Center, but also the field of bioethics has a critical role in the politics of public health policy.     

Examining the suitability of the principle of subsidiarity for bioethics

The political and social principle of subsidiarity can be useful as a general principle of bioethics. The principle states that only those decisions and tasks that cannot be effectively decided upon or performed by a supported or subsidized lower level authority ought to be relegated to a more central or higher authority. The concept of subsidiarity has been embedded tacitly in Western political thought for two millennia, but it has been articulated expressly only in the twentieth century. The principle has unique strengths: it is the only principle that addresses the issue of locus of decision making; it is strongly linked to human dignity, democracy, and solidarity; and it can assist in reaching agreements on the common good. There are also potential drawbacks that need to be taken into account when developing rules and guidelines for the principle's application in bioethics. The principle is particularly helpful in public health ethics, but it is also of use in the ethics of personal care and human research ethics.     

The Baroness's Comittee and the President's Council: ambition and alienation in public bioethics

The President's Council on Bioethics has tried to make a distinctive contribution to the methodology of such public bodies in developing what it has styled a "richer bioethics." The Council's procedure contrasts with more modest methods of public bioethical deliberation employed by the United Kingdom's Warnock Committee. The practices of both bodies are held up against the backdrop of concerns about moral and political alienation, prompted by the limitations of moral reasoning and by moral dissent from state policy under even the most democratic of governments. Although the President's Council's rhetoric is often scrupulously conciliatory, recurring features of its argumentative practice are regrettably divisive. They order these things better in Britain.     

探析美国国家生命伦理学委员会--历史沿革及启示

在一个没有单一国教或价值权威能全盘解决科技政策与价值问题的多元社会中,由政府设置公共论坛性质的政策咨询委员会,是一项值得采纳的作法.美国先后设立过6个国家生命伦理学委员会,探析它们的建立与变迁,可以为我国类似组织提供参考.     

Public Voices in Pharmaceutical Deliberations: Negotiating “Clinical Benefit” in the FDA’s Avastin Hearing

This article offers a hybrid rhetorical-qualitative discourse analysis of the FDA’s 2011 Avastin Hearing, which considered the revocation of the breast cancer indication for the popular cancer drug Avastin. We explore the multiplicity of stakeholders, the questions that motivated deliberations, and the kinds of evidence presented during the hearing. Pairing our findings with contemporary scholarship in rhetorical stasis theory, Mol’s (2002) construct of multiple ontologies, and Callon, Lascoumes, and Barthe’s (2011) “hybrid forums,” we demonstrate that the FDA’s deliberative procedures elides various sources of evidence and the potential multiplicity of definitions for “clinical benefit.” Our findings suggest that while the FDA invited multiple stakeholders to offer testimony, there are ways that the FDA might have more meaningfully incorporated public voices in the deliberative process. We conclude with suggestions for how a true hybrid forum might be deployed.     

Disability: an agenda for bioethics

Contemporary bioethics has been somewhat skewed by its focus on high-tech medicine and the resulting development of ethical frameworks based on an acute-care model of healthcare. Research and scholarship in bioethics have payed only cursory attention to ethical issues related to disability. I argue that bioethics should concern itself with the full range of theoretical and practical issues related to disability. This encounter with the disability community will enrich bioethics and, potentially, society as well. I suggest a number of items that the bioethics agenda should include, such as the development of a casuistry of the right to healthcare and to community integration and an advocacy role in fostering an understanding among the public and policy makers of the need to reform research and treatment related to disability.     

Christian bioethics and the Church's political worship.

Christian bioethics springs from the worship that is the response of the Church to the Gospel of Jesus Christ. Such worship is distinctively political in nature, in that it acknowledges Christ as Lord. Because it is a political worship, it can recognize no other lords and no other prior claims on its allegiance: these include the claims of an allegedly universal ethics and politics determined from outside the Church. However the Church is called not just to be a contrast society, but also to witness to the freeing of the world from salvific pretensions in order that it may embrace its proper temporality. The implications of this for the distinctiveness of Christian bioethics are brought out in three movements: first, the Church's itself learning how it is to conceive bioethics; second, the Church's role in unmasking the idols of secular bioethics; and third, the Church's witnessing to the freeing of medicine from idolatrous aspirations.     

Deliberative Democracy and Emotional Intelligence: An Internal Mechanism to Regulate the Emotions

Deliberative democracy, it is claimed, is essential for the legitimisation of public policy and law. It is built upon an assumption that citizens will be capable of constructing and defending reasons for their moral and political beliefs. However, critics of deliberative democracy suggest that citizens?? emotions are not properly considered in this process and, if left unconsidered, present a serious problem for this political framework. In response to this, deliberative theorists have increasingly begun to incorporate the emotions into their accounts. However, these accounts have tended to focus only upon the inclusion of emotions in the external-collective exchange of reason between citizens. Little work has been done on how the individual will actually cope with emotions internally within their own minds. There has been no consideration of the capacities that citizens will need to perceive, understand and regulate emotions as they formulate reasons both by themselves and with others. Moreover, there has been little consideration of how these capacities might be educated in children so that emotionally competent deliberative citizens can be created. In this paper, emotional intelligence is presented as an essential capacity that can fulfil this role for the deliberative citizen and deliberative democracy more generally. The ??deliberative school?? is suggested as a potential site for this transformation that can progress from generation to generation, cultivating citizens that are increasingly better equipped to handle emotionally-laden deliberative engagement.     

Encountering Dissimilar Views in Deliberation: Political Knowledge,Attitude Strength,and Opinion Change

Conversing with diverse points of view stands as the central tenet of deliberative democracy, yet empirical evidence has suggested mixed outcomes related to perspective change as a result of deliberative encounters. I propose a difference‐driven model that suggests individual predispositions moderate the processing of dissimilar views when changing policy preferences. My analysis is based on a random sample of over 400 voters at a California‐wide deliberative event, where participants discussed proposals for reforming the state politics. I find that encountering more and different arguments transforms policy attitudes. Yet it is more difficult for people to change their minds on issues about which they hold strong beliefs. Some evidence suggests that different psychologies are at play for people who enter deliberation with substantial or weak political knowledge and for those who deliberate while holding strong or moderate prior opinions. Well‐grounded strong opinions are resistant to change, while well‐grounded moderate opinions are persuadable in deliberative groups. Uninformed positions can become entrenched in like‐minded groups, yet they can be adjusted once participants deliberate with dissimilar views, especially opinions that are held strongly without good informational ground. The findings urge deliberative forums that introduce participants to diverse perspectives to foster a considered public opinion.     

Complexity and deliberative democracy

Communism may be dead, but a quasi‐Marxist critique of liberal democracy survives in the writings of a number of thinkers ‐ most notably, David Miller and John Dryzek ‐ who deplore the self‐centered apathy of their fellow citizens and defend the radical ideal of deliberative democracy. Inspired mainly by Rousseau and Habermas, this emergent school of thought argues for a more participatory system where the public interest takes precedence over private interest, and where rational argument replaces cynical manipulation. The paper questions whether the deliberative model can cope with the incalculable complexity of modern society. Deliberative democracy, it is contended, rests on doubtful metaphysical assumptions, a blinkered approach to empirical evidence, and a common misapprehension about the nature of political argument.     

Baiting bioethics

Various criticisms of bioethics are reported and evaluated in an effort to determine what it is reasonable to expect of this rapidly developing field and what should be its future directions. Specific charges by Renée Fox, Judith Swazey, and William Bennett are explored. Fox and Swazey contend that bioethics champions individualism and pays little attention to social relationships, that bioethicists distance themselves from the human settings where ethical issues are experienced, and that bioethics pretends to a false validity. Bennett indicts bioethics on the grounds that it promotes ethical relativism and moral indifference. Gorovitz argues the case against these contentions but urges ethicists systematically to assess their critics' statements.     

THE LIMITS TO PARTICIPATION IN DIS‐EQUILIBRIUM ECOLOGY: Maori involvement in habitat restoration within Te Urewera National Park

In this paper, we explore conceptualizations of ‘ordinary’ citizens common in public engagement forums on emerging technologies and assumptions from deliberative theory that ordinary people are more likely to be appropriately ‘changed’ through deliberative processes facilitated by experts. Looking at a large US public forum event [the National Citizens Technology Forum (NCTF)], we asked: What were the goals for this exercise and how did they shape conceptualizations of ordinariness and representativeness? Whose goals and conceptualizations were they? Were the engaged citizens ordinary and representative—and were they changed by the exercise? Our exploration revealed that exercise organizers conceived of ordinary citizens as people lacking science and technology backgrounds, without advocacy or business connections to the technologies at hand, and demographically reflecting the US population. Exercise materials also implied that ideal ordinary participants would lack strong opinions and emotions about these technologies. Actual NCTF participants, however, tended to be more educated, have higher incomes, and to be more liberal than the US public, and participants from all backgrounds had a range of relevant knowledge, experiences and opinions about science and technology. They were changed by the exercise in complex and conflicting ways—based as much on their own knowledge and reflections on relational dynamics as on exercise processes, interactions with experts, and information provided in the exercise. We argue that inadequately explored ideas about ordinary citizens are highly problematic. Further, invisible assumptions about what is ‘normal’ among experts and status quo institutions serve to reify the lay–expert divide that engagement exercises are intended to counteract.     

The Rhetoric of Deliberation: Some Problems in Kantian Theories of Deliberative Democracy

Deliberative or discursive models of democracy have recently enjoyed a revival in both political theory and policy practice. Against the picture of democracy as a procedure for aggregating and effectively meeting the given preference of individuals, deliberative theory offers a model of democracy as a forum through which judgements and preferences are formed and altered through reasoned dialogue between free and equal citizens. Much in the recent revival of deliberative democracy, especially that which comes through Habermas and Rawls, has Kantian roots. Deliberative institutions are embodiments of the free public use of reason that Kant takes to define the enlightenment project. Within the Kantian model the public use of reason is incompatible with the use of rhetoric. While this paper rejects strong rhetorical criticisms of deliberative democracy which render all communication strategic, it argues that rhetorical studies of deliberation have highlighted features of deliberation which point to significant weaknesses in Kantian approaches to it. Two features are of particular importance: the role of testimony and judgements of credibility in deliberation; and the role of appeal to emotions in public discourse. Both from the Kantian perspective are potential sources of heteronomy. However, the appeal to testimony and emotion are features of public deliberation that cannot and should not be eliminated. For those committed to the enlightenment values that underlie the deliberative model of democracy the question is whether these rhetorical features of deliberation are incompatible with those values. The paper argues that they are compatible. It does so by defending an Aristotelian account of rhetoric in public deliberation which denies the Platonic contrast between reasoned discourse and rhetoric which the Kantian model inherits. This revised version was published online in August 2006 with corrections to the Cover Date.     

On a communitarian approach to bioethics

A communitarian approach to bioethics adds a core value to a field that is often more concerned with considerations of individual autonomy. Some interpretations of liberalism put the needs of the patient over those of the community; authoritarian communitarianism privileges the needs of society over those of the patient. Responsive communitarianism’s main starting point is that we face two conflicting core values, autonomy and the common good, and that neither should be a priori privileged, and that we have principles and procedures that can be used to work out this conflict but not to eliminate it. This discussion uses the debate in the US over funding for entitlements as a case study to apply the values of communitarian bioethics.