Do we all have to agree on bioethics policies for them to be legitimate?
Several eminent ethicists and political philosophers say “yes”. Over the last three decades, there have been multiple expositions of a view that legitimacy comes from democratic deliberation and agreement between reasonable agents. If a policy is to have normative and political force, it has to be the product of the rights sorts of procedures, and it must be sufficiently “public” so that all reasonable persons can accept it. Proponents of this general view include well-known names like Amy Gutmann, Dennis Thompson, Norman Daniels and James Sabin.
Yet a new article in the Journal of Medical Ethics challenges this “orthodox” view. Philosopher and medical doctor William R Smith argues that legitimate medical policy need not be generated through processes of democratic deliberation; rather, we should be looking towards “extra-procedural considerations” and embracing “the possibility that we have the epistemic resources to do so”.
The key exemplar in Smith’s argument is the Affordable Care Act. According to Smith, the ACA is an example of a legitimate healthcare policy; yet it was not legislated in accord with the requirements of liberal procedural justice. The ACA was passed through “backroom dealing, inaccurate campaign promises and political misdirection”:
In passing the ACA, President Obama was not always forthright. His stump speech attacks on Hillary Clinton’s proposal for an insurance mandate seem disingenuous since, shortly after winning the primary, he privately told an internal advisor that such a mandate would be needed. Likewise, he ‘promise[d]’ that Americans could ‘keep [their]' doctor, period’ when his reform team surely knew that insurance changes could jeopardise choice of doctors…Smith suggests that our political theory should match up with the real-world processes involved in lawmaking: “As debates about healthcare reform and resource distribution continue to arise, we should take stock of lessons that we should have already learnt”.
Sunday, May 27, 2018
Ireland, which was once Europe’s most socially conservative nation, has voted to repeal the Eighth Amendment to its constitution in order to permit abortion. The vote was roughly 2 to 1 in favour of change, with nearly the whole country supporting it. Taoiseach (prime minister) Leo Varadkar reassured No voters. “Ireland will still be the same country today as it was before, just a little more tolerant, open and respectful.”
The legalisation of abortion comes hard on the heels of the legalisation of same-sex marriage in 2015. Together they suggest that Ireland is not the same country, at least not compared to 1983, when the Eighth Amendment was passed by a 2 to 1 margin. It is obvious that the country has “changed, changed utterly” in a single generation – although people will differ on whether this signals a “terrible beauty” or a terrible shame.
What is responsible for the turnabout? The decline in the prestige and power of the Catholic Church, which once was synonymous with Irish culture, surely has something to do with it. But there must be other reasons as well, as Ireland is simply treading the well-worn path towards secularisation which has swept across Western Europe. It’s worthwhile trying to understand the dynamics of the change, as the rise of bioethics itself is part of that secularisation. Otherwise we – Ireland and the rest of us – will fail to understand ourselves.
One example of the narrative which is being used to explain the referendum result is the image of Savita Halappanavar, an Indian migrant who died after asking for an abortion in 2012. It was used to show what happens to women who are denied their reproductive rights. However, abortion had nothing to do with her tragic death, a government investigation concluded in 2014. Instead, it was a perfect storm of medical negligence.
“We have voted to look reality in the eye and we did not blink," says Mr Varadkar about the referendum result. If he meant by these self-congratulatory words that Ireland is no longer living in a world of delusion and lies, he has obviously spoken too soon.
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