COMMUNITARIANISM AND BIOETHICS

In the 1990s, communitarian approaches to bioethics became increasingly common and explicit in the literature. This evolution was the result of the prominence of the communitarian philosophical critiques of liberalism that occurred in the 1980s, particularly works by Alasdair MacIntyre, Michael Sandel, Charles Taylor, and Michael Walzer.

Communitarianism is a neo-Aristotelian philosophy that focuses on the common good and is concerned with the relationship between the good person or good citizen and the good of the community or society. As would be expected, it has much in common with other neo-Aristotelian approaches, such as casuistry and virtue ethics. Communitarianism is both a critique of the dominant Western ideology of liberal individualism and an orientation to ethical problem solving.

Communitarians often argue that the notion of human nature and the concept of the self behind liberalism are insufficient to make possible a shared common understanding of values among members of society. Similarly, communitarians sometimes argue that liberal society is committed to neutrality toward all notions of the good life, and thereby cannot adequately address ethical issues. As a result, communitarians often stress an orientation toward ethical questions that relies on the establishment, or re-establishment, of a shared common understanding, a shared notion of the good life, or a shared notion of the self.

Only a few bioethicists have openly embraced the communitarian label in their writings (Emanuel; Brennan; Loewy; Nelson; Callahan, 1996; Kuczewski, 1997). However, much work in bioethics shares community-oriented assumptions—that healthcare is special and different from market commodities, for example (Daniels), and may be seen as a good that is part of the common good (even by those who do not embrace communitarianism in other spheres of distributive justice) (Jecker and Jonsen). Similarly, many writers take relationships as the starting point of their ethic, rather than the individual (Murray).

Furthermore, even if society tries to remain neutral toward visions of the good life, ethical issues arise within the context of healthcare and require that the public institutions that provide medical treatment and conduct biomedical research somehow address such ethical dilemmas. As a result, pragmatists such as Jonathan Moreno embrace communitarian strands of thought in an effort to resolve such questions through the production of consensus (e.g., the creation of shared common understandings) (Moreno).

Communitarian Critiques of Liberalism

Communitarian critiques of liberalism have an intuitive appeal, and the nature of the critiques determine the kind of solutions that communitarians seek. It is again important to note that these critiques were developed mainly in the philosophical and political-theory literature and then imported to bioethics, often in a compressed fashion. Two different, but related, starting points form the basis of the communitarian criticisms.

LOSS OF SHARED COMMON UNDERSTANDING. Some communitarians, most notably the philosopher Alasdair MacIntyre, claim that liberalism will always fail to settle ethical disagreements because of the loss of a shared common understanding, or of a shared view of the good life (MacIntyre, 1981). According to this view, ethical and moral concepts are only understandable within the framework of the traditions within which the concepts developed. Such traditions are marked by a shared vision of the good life. This vision is thought to contain a shared hierarchy of goods, and ethical disagreements are supposed to be resolved by reference to this hierarchy.

Such communitarians see the contemporary moral situation as dire. Because there is no shared vision of the good life within a liberal democratic society, they claim, there is no such thing as moral discourse. Although there may be the appearance of moral debate, such arguments tend to have a back-and-forth nature, mostly between rival conceptions that share few common assumptions. MacIntyre characterizes such discussions within our society as "shrill" and "interminable" (MacIntyre, 1981, pp. 8–12) The debates are shrill because, lacking the rational basis of a shared hierarchy of goods, rival conceptions can only advance their conclusions by the force of emotion. The debates are interminable because the force of emotion can produce no enduring consensus.

Societal discussion regarding bioethical issues is characterized as essentially being in bad faith. That is, bioethics must put forth public policy and some point to the developing of widespread consensus on several issues, but such consenses are said to be forced and sociological in nature (MacIntyre, 1984; 1990, pp. 226–227). For MacIntyre, the solution to the contemporary moral fragmentation is to build up from particular communities that share a vision of the good life, perhaps through sectarian universities, to the restoration of a shared common understanding of the good life (MacIntyre, pp. 220–223).

Similarly, a number of communitarians echo MacIntyre's criticism by highlighting the fact that liberal political theory embraces the neutrality thesis toward views of the good life. It is not that visions of the good life have mysteriously been lost from moral discourse. Rather they are, in principle, not allowed to form the basis of ethical quandaries or social policies (Larmore, 1987, pp. 42–55). The neutrality thesis can be illustrated by the suspicion with which religion is treated in the public sphere. Policy positions that are seen to emanate mainly from religious sentiments, sentiments that are expressions of a particular vision of the good life, are generally not considered viable options within public policy debates. Similarly, such positions, should they become the law of the land, can and are sometimes struck down by courts if they infringe on the liberty interests of the nonreligious.

Communitarians note that the state cannot remain neutral toward all elements of the good life. It is the role of the state to protect the life and liberty of its citizens and to foster opportunity among them (i.e., to foster the "pursuit of happiness"). Although safeguarding life, liberty, and the pursuit of happiness does not logically entail a vision of the good life, questions of what kind of life a society wishes to foster can be unavoidable in practice. Simply providing and mandating a specific minimum amount of such a value neutral commodity as education can be more conducive to some visions of the good life than to others. Given the inevitability of impacting on visions of the good life, communitarians often seek ways to produce consensus regarding the values to be fostered, or to create policy solutions that balance widely shared values.

LIBERALISM'S IMPOVERISHED VIEW OF THE PERSON. Communitarians can also begin by showing that liberal democracy is based on a certain view of human nature, and that this view is inadequate even for the purpose of establishing the moral aspirations that liberal democratic theorists hold dear.

Liberal theorists do not wish to set forth a vision of the good life. Nevertheless, thinkers such as John Rawls posit a view of what is essential to human nature. Rawls puts forward such a vision in order to provide support for the rationality of the choice of certain principles of justice to govern the basic institutions of society (Rawls, 1971, pp. 54–60). In other words, although no vision of the good life is essential to humans, choosing a vision of the good is what is essential to human beings. This self that is defined by choice and will, i.e., this volitional self is the justification for a view of society as fostering opportunity to pursue one's vision of the good life.

The communitarian critique of the volitional self points to the fact that this concept fails on its own terms. The political theorist Michael Sandel argues that this vision of human beings is too thin to actually justify the kind of contractarian liberalism that rests upon it. Liberalism typically includes a distributive or redistributive role for government to assist the least advantaged, an aspiration that is viewed as not justifiable when based on such a thin concept of the self. Justifying such an aspiration requires a view of human beings as deliberative and interrelational, not merely volitional and contractual. People are not static and fixed entities who mysteriously have a set vision of the good life that they pursue; they develop and refine values and preferences in social processes. As a result, political processes should be arranged to foster the deliberative capacities of citizens, not to count the preferences in a voting procedure (Emanuel, p. 232).

Liberalism includes a principle of sharing. John Rawls expresses this as the "difference principle" (Rawls, 1971, pp. 75–83). According to this principle, inequalities are allowed as long as they work to benefit the least advantaged. Because liberal theorists wish for a sharing principle to follow from the description of the volitional self, Rawls argues that citizens would choose this principle if they did not know which arbitrary advantages or disadvantages they would have by accident of birth or luck. This derivation of the difference principle follows deductively only if we assume that persons are highly risk-averse creatures and will go to great lengths to avoid being in the worst position, even if such an outcome would be unlikely. This is the position Rawls took in his early development of the "maximin principle" (Rawls, 1971, pp. 152–157).

One could also say that that the choice of the difference principle reflects the kind of choice that persons in a certain kind of historical community would make in virtue of their self-understanding. This is the position toward which Rawls moved in his later work. But, if reflection on the ideals of a community's self-understanding can be the basis for ethics, ethics can be based on more contentful concepts of the self, such as the communitarian's ideal of the self as deliberative and rational.

The Communitarian Concept of the Self

For the communitarian self, the pursuit and choice of the good life is a process that is interpretive and deliberative. Persons are born into, or thrown into, situations that contain fragments of traditions, values, customs, norms, and habits. However, these raw materials are continuously reinterpreted and reappropriated as circumstances evolve and change. Similarly, persons make choices, accumulate experience, and receive a variety of kinds of feedback. They modify, refine, or change their ends, or the means to those ends, based upon these life processes. In so doing, they come to know who they are. Being a "self" is therefore a process of self-discovery.

Being a person is also a process of mutual self-discovery (Kuczewski, 1997, pp. 51–56, 108–112). That is, a person not only makes his or her own plans and gathers feedback, but is also shaped by his or her response to, and participation in, the process of self-discovery of others. A person's identity is thereby inseparable from the life of the communities and societies in which the person participates. Of course, this is not the mere alignment of the projects and values of the person with the community. The person's identity is partially constituted by his or her community, even in the person's rejection of the community's values.

The essence of a person comes from the person's participation in the process of mutual self-discovery. Thus, for the communitarian, the ultimate question is always how to foster the development of a person's deliberative powers and create appropriate opportunities for exercising meaningful participation in communal deliberation. This heuristic applies to deliberation on levels of interpersonal encounters such as clinical decision making as well as societal decisions regarding the use of common resources.

Communitarian thought is obviously closely related to another neo-Aristotelian ethic, virtue theory. Communitarians hold that the concept of the person includes the notion of capacities that need to be developed to be a good citizen and good person. Virtue ethics takes the development of excellence of character as its end-point, its telos. That is, the virtuous person is what the community and social practices should aim to produce. There are few obvious points of tension between communitarianism and virtue ethics, and disputes would seem to be a matter of emphasis and tone. Communitarians are generally oriented to process, virtue theorists to outcome (i.e., character). But both emphasize the relationship and interdependence of the community and the deliberative capacities of its members.

The Methods of Communitarianism: Consensus from Fragmentation

Communitarianism is probably best characterized as a philosophy of public deliberation that tries to produce consensus on public matters—matters that include the topics typically considered in the field of bioethics. Of course, the important question is how to actually produce that consensus. Three general approaches predominate: the whole tradition method, liberal communitarianism, and consensus in public judgment.

THE "WHOLE-TRADITION" METHOD: REVIVAL AND REVITALIZATION OF PARTICULAR TRADITIONS. The "whole tradition" method of communitarianism sees the fragmentation of values and traditions as an almost insurmountable problem. Communitarians such as the philosopher Alasdair MacIntyre and the Christian theologian Stanley Hauerwas view moral concepts as only intelligible within the traditions in which they originated. Moral traditions, therefore, contain concepts that are incommensurable with those of other traditions, and that are untranslatable because they only make sense within their respective traditions. As a result, moral method must take the form of reviving particular traditions.

MacIntyre proposes that moral discourse take the form of a competition among revitalized traditions. Each tradition would express itself through a university in which the tradition would express and develop its worldview across the disciplines. The ultimate test of a tradition is the degree to which it can create a comprehensive worldview that accounts for the facts of the contemporary world and can respond to new challenges and crises that arise. MacIntyre also holds open the possibility that one worldview may simply be developed that is comprehensive enough to encompass the truths and strengths of other traditions. He clearly believes that the Aristotelian-Thomistic tradition is the most promising in this regard (MacIntyre, 1990, p. 81).

The whole-tradition movement in communitarianism is the most radical and pessimistic form of communitarianism. It holds that there is (and can be) no genuine moral discourse in a pluralistic liberal society—and that the revival of whole traditions in toto is the only possible solution. Once such traditions are developed, people can choose among the views of the good life that are contained therein. The work required to bring this about is described by MacIntyre as being akin to the service that Saint Benedict and the monastic orders provided in keeping civilization alive during the medieval period.

LIBERAL COMMUNITARIANISM. Communal deliberation is intrinsic to communitarianism. So it is natural that some communitarians should propose that community members gather and deliberate to develop consensus. In bioethics, this approach is notably associated with the early work of Ezekiel J. Emanuel.

In his highly regarded book, The Ends of Human Life: Medical Ethics in a Liberal Polity (1991), Emanuel suggests that ethical decisions regarding medical care are best handled by the members of small cooperatives called Community Health Plans (CHPs). Members would have a choice of a variety of CHPs in their geographic area. In the early stages of the founding of the plan, members would articulate the fundamental value assumptions behind the plan. For instance, some CHPs could have a philosophy that is strongly geared toward preservation of biological life, while others might maximize palliative care options. Similarly, some might strongly favor choice in reproductive and contraceptive options, while others would promote religious approaches to family life. By organizing the CHPs according to nonnegotiable value choices, the CHP progresses easily beyond the shrill and interminable debates to the more subtle choices involved in developing a health plan.

In Emanuel's plan, each person would have a voucher that would be brought to the plan. As a result, the deliberation about values and coverage of treatments is also a resource-allocation process. Each member must think not only about his or her values in the abstract, but must consider how to balance the fiscal implications of those commitments against other values and potential needs. This discussion takes place within a communal dialogue among the approximately 10, 000 members of the plan. In such a dialogue, a person comes to develop his or her deliberative capacities and refine and clarify his or her values.

The strength of such a proposal is that it embodies the virtues of a genuine deliberative democracy. Such a plan brings together the rights and responsibilities of each person, granting each the right to be true to his or her most fundamental value commitments, and to be self-determining in devising a health plan to meet those commitments. But, more importantly, it demands personal responsibility in accepting the allocation consequences of one's choices. One may choose to be part of a plan that explicitly provides a maximum amount of some services and minimizes other services, and one must live with the minimal services provided should he or she develop an illness that might benefit from a higher level of services. Because the plan respects the rights of each within a communal framework, it is sometimes called liberal communitarianism.

Of course, the proposal for CHPs suffers from the practical difficulties of any community-based initiative. Although our best selves may develop in a context of dialogue and deliberation, many persons will simply not wish to devote the time and energy needed to participate meaningfully. Emanuel acknowledges that the model of the New England town meeting (the model on which the CHP is based) usually becomes dominated by a small, highly participatory group in whom the silent majority comes to have confidence (Emanuel, pp. 231–232). However, if stable communal consensus can be developed in ways that do not require the direct participation of most citizens, such approaches may recommend themselves to communitarians.

CONSENSUS IN PUBLIC JUDGMENT. Proxy dialogue and balancing values. One of the striking facts concerning bioethics is that public debate has produced areas of stable consensus, most notably in the United States, concerning informed consent to treatment and the principles concerning end-of-life decision making. Similarly, some studies have suggested that the American people may, in general, be less fragmented in reference to their values than is usually thought to be the case. Contrary to the radical communitarians such as MacIntyre, there may be empirical reason to be optimistic that a society can achieve stable consensus on moral problems that occur within public and quasi-public institutions.

The public debate concerning informed consent and end-of-life decisions has not been one with a clearly identifiable locus, but has taken a variety of forms, including court decisions, state referenda, and the policy deliberations of institutions such as professional societies and accreditation agencies. The public has been informed in a variety of ways, including media coverage of court decisions, public education efforts when referenda are introduced, and portrayal of these issues in entertainment programming such as television medical dramas. Somehow, over time, a consensus has taken shape.

Consensus, in this context, has tended to mean a set of principles that are widely accepted. It does not mean unanimity, for a large pluralistic society will always include those who disagree. Similarly, the interpretation and application of the principles will constantly require refinement because of the wide variety of possible circumstances in which they may be needed. As a result, debate may seem to be ceaseless, but the object of the debates actually becomes more refined. For instance, the consensus on forgoing life sustaining treatment includes a distinction between forgoing treatment and assisted suicide (though the state of Oregon does not adhere to this distinction in a substantive way). The consensus also holds that patients who have lost their decision-making capacity (i.e., they have been deemed "in competent") have the same rights as other patients. While all U.S. states adhere to this general principle, the evidentiary standards regarding the incapacitated patient's prior wishes can differ substantially among states (Meisel, Snyder, and Quill). Although these are important disputes, they do not undermine the widely shared areas of agreement.

Of course, identifying that a society has achieved a stable consensus is not always a simple task. Public opinion polls can measure the public's views, but it is not always obvious when the data reflect a stable consensus. It is often the case that responses to poll questions reflect mere fleeting preferences. Although communitarianism is premised on the idea that people must come to discover their wishes, or how their values translate into preferences, how this happens on a grand scale is somewhat mysterious. However, some suggestions have been made.

First, a consensus is probably more stable if it is able to balance several competing values that are important to a society. For instance, the consensus on forgoing life-sustaining treatment has been relatively stable for more than a decade because it reflects the balancing of important values and considerations (Kuczewski, 2002). A patient's ability to participate in the decisions regarding his or her medical care, especially as one nears death, is fostered and balanced against the duty of society and the medical profession to protect patients, especially those who are vulnerable due to lack of decisional capacity. Policy proposals that tip the balance heavily in favor of patient self-determination, such as those for legalizing assisted suicide, have met with limited success. Similarly, proposals that eschew patient autonomy in favor of the physician's duty to do no harm, such as futility policies, continue to remain outside the consensus (Helft, Siegler, and Lantos).

Second, in situations in which the content of consensus gains widely shared acceptance without direct participation by the citizenry, some sort of "proxy dialogue" might have served as a substitute for direct participation (Yankelovich, 1999, p. 167). That is, representatives of various positions and interests might achieve recognition, and their interaction might forge a position that accommodates the major values at stake. By having the process play out publicly, the solution is internalized by much of the citizenry. Furthermore, consensus is semiperformative (Moreno, p. 52).

A consensus is furthered when an announcement is made that there is a consensus on certain points. People generally do not wish to overturn consensus for its own sake. Thus, when one announces consensus and proceeds to state the specific points, people will probably prefer to assent. This assent would seem more likely to be freely given if the citizens are able to recognize their values as being respected in the points of consensus. Dissent would seem more likely to follow if the consensus is ideological in the sense that it traces all its points to only one value or principle, rather than representing the array of values that are relevant to the issues under consideration. These values may be identified a priori by surveying the goods generally considered characteristic of a particular sphere of human activity (Walzer, pp. 6–10), or by empirical approaches that assess the values of the community involved.

Relationships, casuistry, and pragmatism. On the most pragmatic level, communitarians often approach ethical issues by beginning with the norms of the relationships involved, rather than the rights of the individual. In this way, communitarianism provides the foundational philosophical assumptions for the customary workings of popular methods in bioethics, such as casuistry, pragmatism, and the four principles method. Bioethics, especially clinical bioethics, has often proceeded as if a number of persons have a stake in the outcome of the case, and that dialogue and negotiation leading to consensus are better than a simple assertion of one person's rights. These practices are more easily justified within a communitarian conception of the person as being essentially related to those around him or her than on the liberal conception of the individual. However, this does not necessarily result in a tyranny of the interests of the majority, as there may be spheres of being in which individual rights are more authoritative, and irreconcilable conflicts may have to be resolved in favor of certain individuals no matter in which sphere of endeavor it takes place.

Casuists such as Albert Jonsen and Stephen Toulmin assert that that the kinds of norms that predominate in various types of cases result from the nature of the relationships involved in the particular case under examination. Cases in which the relationships are intimate are more generally decided in favor of values such as beneficence and caring. In these kinds of cases the boundaries between persons are fluid, and looking out for the good of the other is often called for by the situation. In impersonal situations, in which persons are more likely to be strangers, solutions are more often found in the direction of autonomy and individual rights. Nevertheless, specific circumstances can render these generalizations inapplicable, and some spheres of interaction (e.g., healthcare) can embody elements of both an ethics of strangers and an ethics of intimacy. As a result, paradigm cases for each kind of bioethical issue must be sought and taxonomies of paradigms and variations established (Jonsen and Toulmin, pp. 291–292).

Similarly, the famed four principles approach, also known as principlism, takes the physician-patient relationship as the starting point of medical ethics (Beauchamp and Childress, pp. 12–13). Principlists argue that ethical problems arise when any of the four main obligations of physicians to patients (respect for autonomy, nonmaleficence, beneficence, and justice) come into conflict with another of the principles. The goal then becomes to resolve this conflict of principles. This method assumes that members of society share a common morality, and that it is interpretable within the confines of the healthcare system (Beauchamp and Childress, pp. 401–405). These same assumptions are shared by many communitarian bioethicists. However, communitarian philosophers have made advances on the static understanding of the moral principles of the principlists. For instance, Emanuel's communitarianism includes a theory of the physician-patient relationship. This relationship, in its highest expression, focuses on helping the patient to interpret and discover his or her health-related values and how they apply to the choices before the patient (Emanuel and Emanuel). In this framework, patient autonomy is an essential element, but in many situations it is seen as the outcome of an interpersonal process rather than as the starting point of the interaction. Others with communitarian leanings focus on familial relationships as the starting point of an ethic.

Thomas Murray, a sociologist by training, argues that bioethics will make more progress toward consensus on controversial issues by starting with a tapestry of relationships that are prized by persons in a society. He notes that familial relationships are often among those that give distinctiveness to life. By creating such a tapestry, and describing the goods fostered therein, he believes that some of the so-called unending debates in bioethics can be defused. For instance, Murray asserts that conclusions in the abortion debate often exceed the premises and are inconsistent with other practices of adherents of the conclusions. Murray believes that the strength of the conclusions is probably a derivative from perceived threats to valued relationships (Murray, pp.173–174).

James and Hilde Nelson have begun the work of developing an ethics of intimate relationships that takes familial relationships as the starting point. This kind of work exemplifies the nuances of contemporary communitarian bioethics in that it results in generalizations about specific spheres of relationships. Furthermore, the kinds of generalizations that are developed give moral weight to those whose interests are most affected by situations, rather than invoking individual rights.

Applications

Radical whole-tradition communitarianism results in the most radical prescriptions, since it nullifies all rights claims and counsels a return to separate communities to work out a shared ethic. As we have seen, most communitarians have far more subtle prescriptions for facilitating the kind of public deliberation that they seek.

There are few attempts in the literature by communitarians to directly deduce conclusions from communitarian premises. One might expect that communitarians will be more sympathetic to the common good in weighing solutions to ethical problems. It is true that some communitarians have favored aggressive approaches to organ procurement for transplantation (Nelson), mandatory rationing to resolve resource-allocation problems (Callahan, 1990), and public health concerns over individual privacy and choice (Etzioni). However, none of these positions are necessarily entailed by communitarian sympathies as one can easily argue that these same policies foster values the community should reject. As a result, communitarianism continues to be an approach to bioethics that is more about process than particular outcomes.

mark g. kuczewski

SEE ALSO: Consensus, Role and Authority of; Contractarianism and Bioethics; Feminism; Healthcare Resources, Allocation of; Human Nature; Justice; Law and Morality; Managed Care; Natural Law; Patients' Responsibilities; Public Health: Philosophy; Sustainable Development; Virtue and Character

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