T. Patrick Hill

This is a book that promises much but delivers relatively little, at least if we are to take the authors declared intentions at their face value. We are told unambiguously in the preface that Recreating Medicine is intended to be on the cutting edge of the new medical ethics issues of our time. Urging this intention is the authors belief that both the discourse and practice of bioethics in the United States have been controlled by an inner circle for too long, have become stale and are in need of a major overhaul. At the same time, he points to a range of new ethical issues confronting medicine and maintains that the goal is to re-create medicine by recreating medical ethics. Nothing will do short of overcoming a backward-looking, overly cautious medical ethics that reduces complex issues to simplistic oppositions of black and white, that insists on perfect standards for technologically based interventions and that distrusts the basic choices of ordinary people.

The feeling that our bioethics, as institutionalized in the four principles of patient autonomy, benevolence, non-maleficence and justice, is seriously limited has been acknowledged long ago. One concern has been with their undue orientation toward the individual to the exclusion of the community. A second has been their reliance on a framework of rights that is rooted in the notion of property, predisposing the rights-holder to an absolutist exercise of his or her rights, and fostering adversarial attitudes between patients and health care professionals. Positive alternatives to counteract such concerns have included, for example, theories of virtue ethics, narrative ethics and feminist ethics, each of which has been seen as only partially satisfactory in addressing unprecedented ethical issues emerging from techno-science-based medicine.

It is curious that the author of this book, Gregory E. Pence, professor in the School of Medicine and the department of philosophy at the University of Alabama, makes no reference, even in passing, to what is at least a widespread recognition of the need for a systematic rethinking. In contrast, he has merely addressed the symptoms of the problem. In the process, he is guilty of the very thing for which he criticizes the bioethics establishmentnamely, discussing complex matters simplistically. In his case, issues like cloning, the genetic enhancement of offspring and technologically assisted reproduction are analyzed in terms that would suggest that market forces alone should determine their availability.

Regarding tissue donation, for example, the author argues that if creating wanted human life is a primary good, and if that is a matter best left to human choice, then knowing that such choices are conditioned by the amount offered for the tissue means that payment for services of this kind should go unregulated. Not only is the logic questionable here, but the argument trades on a number of unexamined assumptions, not the least of which is that one can equate the donation of human tissue with a service, like being a nanny or an assembly-line worker, for which remuneration is justified.

That the author would make that equation is revealing. On careful examination, it can be traced to his extremely conventional understanding of technology and its implications for human agency, particularly in medicine. In the effort to be at the cutting edge of the new ethical issue in medicine, his proclaimed strategy is to recreate medicine by recreating ethics. In fact what he has consistently done is the inversehe allows techno-scientific medicine to recreate ethics.

Now if it is possible to think that technology refers to nothing more than some instrument and as such is to be considered morally neutral, taking on moral quality only in relation to the purposes human beings set for its use, there may be some merit to the authors assumption that technology merely occasions new moral possibilities.

But we may have reached a point in the history of technology when it is critical to think of it in ways that discern a dialectic occurring when human beings develop and use modern technology. Hans Jonas, for example, thought so and characterized the dialectic as one of power, by means of which humans have sought to control the external world around them. But what began as an expression of human power over physical nature now threatens human nature itself either by destroying it or radically refashioning it. For this reason, Jonas sought to recreate ethics on the grounds that the fundamental assumptions of traditional ethics had come under question.

In the presence of modern technology, it is no longer possible to assume that human nature is an unalterable given. Nor is it possible, as a consequence, to think of human nature as normative for what is morally good for human beings. Moreover, it would be naïve to think that the scope of human agency, with its corresponding degrees of moral responsibility, continues to be contained by an unalterable human nature.

If all of this is true, then we can no longer consider technology as a morally neutral instrument, a mere means, subject to human goals, that humans use in their dealings with one another and their physical environment. On the contrary, under the conditions envisaged by Jonas, technology would have human beings relating to the physical world not as an immutable order above and beyond common things, but merely as another of those common things. Martin Heidegger and a number of other philosophers, to whom there is no reference in this book, saw the same possibility.

While not everyone, including this reviewer, might agree entirely with Jonass formulation of the basic moral challenge occasioned by technology for human beings, his insights regarding the nature of technology as a dialectic process provide at least one vantage point from which to assess the depth and range of this challenge. That cannot be said of our author. By failing to provide any philosophical account of technology itself, he falls considerably short of what he thought he was doing and what actually needs to be done if the real task is to recreate the practice of medicine by recreating ethics. As this book unfortunately demonstrates, the fact that one raises cutting-edge issues does not automatically mean that one discusses them in cutting-edge fashion.

 

T. Patrick Hill, an ethics consultant, is completing his doctoral dissertation on ethics, technology and genetics at the University of Chicago.

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