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JME Online First, published on October 28, 2010 as 10.1136/jme.2010.037846
Ethics

Authoritarian versus responsive
communitarian bioethics
Amitai Etzioni

Correspondence to ABSTRACT fruitful ways to work out these differ-
Dr Amitai Etzioni, The Institute A communitarian approach to bioethics adds a core encesdwithout making all other values subordi-
for Communitarian Policy nate to one.
Studies, The George value to a field that is often more concerned with
Washington University, 1922 considerations of individual autonomy. Some This methodological approach is embodied in
F St NW, Suite 413, interpretations of liberalism put the needs of the patient another branch of communitarianism: responsive
Washington, DC 20037, USA; over those of the community; authoritarian (or liberal) communitarianism.i This communitari-
etzioni@gwu.edu communitarianism privileges the needs of society over anism seeks to balance autonomy with concern for
Received 19 May 2010 those of the patient. Responsive communitarianism’s main the common good, without a priori privileging
Revised 25 August 2010 starting point is that we face two conflicting core values, either of these two core values. And it seeks to rely
Accepted 2 September 2010 autonomy and the common good, and that neither should on society (informal social controls, persuasion and
be a priori privileged and that we have principles and education) to the greatest extent possible and
procedure that can be used to work out this conflict but minimise the role of the state (law enforcement) in
not to eliminate it. Additionally, it favours changing promoting compliance with the norms that flow
behaviour mainly through the creation of norms and by from these values. Thus, preference should be given
drawing on informal social control rather than by coercion. to programmes that encourage people to have their
HIV status tested, ensuring that the test results
remain confidential, and readily available to the
patientsdrather than requiring such tests or
Communitarianism is often viewed as the polar conducting them without knowledge of the
opposite of liberalism, as seeking to pre-empt indi- patients. Responsive communitarianism is often
vidual choices by relying on communal normative confused, or treated as part and parcel, with
criteria and authorities. Common good consider- authoritarian communitarianism, though the two
ations are to replace respect for autonomy.1 differ as much as social democratic socialism differs
Accordingly, for example, people with infectious from Soviet socialism.
diseases are to be incarcerated, the way Cuba deals I should note in passing that this essay does not
with those who contract HIV.2 Organs of those who lay out the communitarian position why a thick
have died or have been executed can be harvested, concept of the good is justified, because this posi-
because doing so serves a compelling public interest. tion has been spelt out repeatedly, subjected to
I refer to this way of thinking as authoritarian critical examinations, and these criticisms have
communitarianism. (A less radical version of this been responded to. Rather than rehashing these
kind of communitarianism strongly privileges the arguments, this essay builds on the points previ-
community even if does not fully dismiss consider- ously made, that the case for a thick concept of the
ations of autonomy or liberty.) Authoritarian common good can be entertained. Those whose
communitarianism has been championed by the views differ may nevertheless find some interest in
leaders and some public intellectuals of East Asian the following discussion because it shows the value
nations, especially Singapore and Malaysia.3 4 of making the said assumption for bioethics.
One major reason many, especially in the West, Although responsive communitarianism’s
reject this kind of communitarianism on normative starting point is the recognition that the tense
grounds is that they hold autonomy in high regard. relationship between autonomy and the common
Another reason is methodological, a reason that good must be worked out rather than assuming
deserves to be briefly discussed because it points to a priori that one of these core values trumps the
a rather different kind of communitarianism. The other, the treatment should be expected to differ
methodological point draws on the precept that from one society to another and among different
sound normative positions cannot be derived from
one overarching value. Societies are complex beings, i
The responsive communitarian position was first articulated by
composed of people who hold different values and a group of scholars and activists in the early 1990s, including
have different needs and interests. It follows that William A Galston, Mary Ann Glendon, Philip Selznik, Jean Bethke
one is much more likely to reach a normatively Elshtain, and Amitai Etzioni. They issued a platform that found many
defensible position if one draws on multiple values, endorsers across much of the political spectrum; the platform text
can be found at http://www.gwu.edu/wicps/RCP%20text.html.
rather than presumes that one value pre-empts or See also: Amitai Etzioni, The New Golden Rule: Community and
trumps all the others. Moreover, one should not be Morality in a Democratic Society (New York: Basic Books, 1997);
unduly troubled by the resulting tensions and and Amitai Etzioni, Genetic Fix: The Next Technological Revolution
contradictions that result from drawing on (New York: Macmillan Publishing Co, Inc, 1973);
multiple values, such as liberty and equality, or, in ‘Communitarianism,’ The Oxford Companion to Politics of the World
(London: Oxford University Press, 2001): 158. For a critical
the case at hand, autonomy and the common good, treatment see Elizabeth Frazer, The Problems of Communitarian
among other core values. We shall see that there are Politics (Oxford: Oxford University Press, 1999).

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Ethics

historical periods. Thus, in totalitarian societies and theocracies, view and an interest in being able securely to pursue his or her
such as those in Singapore and Iran, those who advocate the own conception of the good’.10
balance that responsive communitarianism favours would need Communitarianism in this context is often viewed as the
to promote autonomy, while in societies in which individualism polar opposite position of the focus on autonomy. Thus, for
is rampant such as the United States was in the 1980s, the instance, Tom Beauchamp writes that communitarianism ‘holds
advocates of responsive communitarianism would need to that public policies should be derived primarily from communal
promote more attention to the common good. That is, societies values, the common good, social goals, traditional practices, and
often need to move in opposite directions from one another to the cooperative virtues’.11 Lawrence O Gostin defines commu-
achieve the same balance. nitarianism as a tradition that ‘views individuals as part of social
In effect, responsive communitarianism, which arose in the and political networks, with each individual reliant on others for
USA in 1990, was a direct response to the Reaganism and health and security. Individuals, according to this tradition, gain
Thatcherism of the 1980s, and the findings of Robert Bellah and value from being a part of a well-regulated society that seeks to
his associates (later echoed by Francis Fukuyama and reinforced prevent common risks.’12
by Robert Putnam) that the USA had become excessively indi- Similarly, Veena Das looks to a communitarian conception of
vidualistic.4e7 That is, it sought to move the US and the UK bioethics to allow bioethicists to ‘find alternative anchoring
(and other relatively liberal societies) towards a more balanced concepts to those of patient autonomy’.13 Gboyega A Ogun-
position, one that pays more mind to the common good. banjo and Donna Knapp van Bogaert define communitarianism
Responsive communitarianism in Southeast Asia calls for more as ‘a model of political organisation that stresses ties of affec-
liberalism. tion, kinship, and a sense of common purpose and tradition’.14
It is might be a mistake to refer to this position as valuing Finally, Michael Gross points to Israel as a communitarian state,
pluralism, because it does not suggest that different values hold which means it is ‘a society imbued with a high degree of
for different societies in different historical periods. The core collective consciousness, mutual concern and interdepen-
values are the same. Only the direction societies need to modify dence’.15
their normative profile in order to move towards the ideal one, In the terms used here, these precepts of communitarian
one of a carefully crafted balance between autonomy and the bioethics lean in the direction of authoritarian communitari-
common good, is contextual. anism, or at least leave the door open to such interpretation
To put it in different terms, strong rights presume strong because they are not explicitly anchored in recognition of the
responsibilities. The right to be tried by a jury of one’s peers cardinal normative standing of autonomye as well as that of the
assumes that the peers will agree to serve on a jury. The right to common good.
healthcare assumes that people will realise they have to vote for To briefly illustrate the generalisations introduced so far:
taxes to be imposed to pay for such services, and so on. There are a liberal bioethics may stress that patients should be free to
also common goods that are morally compelling, for instance, instruct their physicians not to disclose their conditions to
our stewardship of the environment. To discharge our obliga- others (although exceptions may be recognised, such as when
tions to these goods entails assuming social (and interpersonal) we deal with minors, infectious diseases or attempts to commit
responsibilities. I turn next to explore the implications of these homicide). The patient should also be free to sign a do-not-
communitarian precepts for bioethics. resuscitate statement or refuse other treatments, disregarding
the values and feelings of the patient’s family and surely of his
community. Communitarianism is then depicted as the opposite
EARLIER TREATMENTS OF COMMUNITARIAN BIOETHICS position, in which the family can instruct the physician not to
Medicine is overwhelmingly non-communitarian in the sense disclose to the patient that his condition is terminal, can
that it rarely concerns itself with the common good. The indi- demand continued healthcare services, and so on. However, in
vidual patient’s good is at the centre of nearly every discussion. the terms here employed, this second position is a form of
Moreover, one is hard put to find a bioethicist who considers authoritarian communitarianism, because it is centred around
him/herself a communitarian. Those who do draw on commu- the values of the community and disregards the value of
nitarian deliberations do so mainly to criticise the excessive autonomy. A responsive communitarian would favour seeking
reliance on the value of autonomy but typically not to embrace to work out the conflict between the patient and the family
concerns for the common good (Michael Gross, personal without a priori privileging either, examine the mechanism for
communication with the author 2009; Mark Kuczewski, such treatment of conflict and determine what is to be done if
personal communication with the author, 2009). the conflict cannot be resolved by the parties directly involved.
Indeed, the few early communitarian examinations of Some of the early writings by bioethicists about communi-
bioethics focused on the observation that American bioethicists tarianism do reveal recognition of the two, sometimes
tend to err on the side of considering the patient as an individ- conflicting, core valueseautonomy and the common goode
ualistic being and view autonomy as the supreme value, although they do not necessarily employ these two terms.
according to which the patient’s right to personal choice is Thus, Callahan defines communitarian bioethics as seeking to
paramount. Daniel Callahan quotes Joseph Fletcher, stating that ‘blend cultural judgement and personal judgement’.8 Thomas H
bioethics is based on ‘the idea of personal choice as the highest Murray writes that many theorists believe ‘the solution is not to
moral value and the struggle against nature as medicine’s most abandon autonomy. But autonomy can only be a part of the
liberating mission’.8 Ezekiel Emanuel, in his essay on the care of story about how we are to live together, how we are to make
incompetent patients, points out that the understanding of the families and communities that support the growth of love,
‘best interests’ of a patient allowed in this individualist vision of enduring loyalties, and compassion’.16
healthcare is based upon the degree of pain a procedure would Gilbert Meilaender too seeks not to give up the language of
inflict on that person.9 Jeffrey Blustein explains this conception rights in bioethics but believes that alongside the ‘rights talk’, we
of autonomy in healthcare, stating, ‘It rests on a picture of the also need to have a ‘morals talk’.17 (The term ‘rights talk’ was
person as a separate being, with a distinctive personal point of introduced by responsive communitarian Mary Ann Glendon to

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stress the excessive tendency to frame normative claims in rights although it took some 25 years to build wide societal support to
terms).18 ban smoking in public spaces, once these laws were introduced,
Mark Kuczewski recognises explicitly that we are dealing here they served to lock in an already very well established norm,
with two rather different kinds of communitarianism. He which is almost completely self-enforcing.
compares ‘whole tradition communitarians’ and ‘liberal Similarly, responsive communitarianism urges that long
communitarians’: the former requires an acceptance of the full before one considers mandatory HIV testing, let alone forcefully
cloth of a single tradition and does not allow for compromise or isolating people who have contracted HIV, one is obligated to
even significant communication across the borders of commu- engage in public educational campaigns that encourage such
nities, while the latter stresses ‘respectful moral deliberation’ as testing and to work with the communities of those most at risk
a way to communicate and coordinate moral expectations across to encourage their members to be tested. And rather than open
traditional boundaries.19 a market in human organs to incentivise more people to donate
Tom Beauchamp and James Childress’ sixth edition of their organs, which are in short supply, one should appeal to people to
influential text holds that communitarianism rejects a universal make the gift of life.21 22 A colleague who read a previous draft of
standard of justice, that of rights, and views moral principles as this essay introduced here the debate between those who see the
particularistic to each community.ii However, one can reconcile world through the eyes of rational choice and seek to reduce all
liberalism and communitarianism by respecting universal prin- conduct to self interest, and those who holddas I dodthat
ciples: by recognising the validity of universal individual rightsd people are indeed influenced by incentives and disincentives, but
but also holding that, in addition, people have particularistic also by moral considerations, which change their preferences. It
social responsibilities that they ought to discharge their obliga- is not possible to deal with this debate here, and I have treated it
tions to the common good. I turn below to discuss the steps extensively elsewhere.23
available when these two principles conflict. At the same time, responsive communitarianism does recog-
Before I proceed, I must digress to explicate the term ‘the nise that there are conditions under which the state must be
common good’. It refers to those goods that serve shared assets involved, although it is best used as the last, rather than the first,
of a given community. Examples include preserving national resort. For instance, when people infected with a highly
monuments, supporting ‘basic’ scientific research, advancing communicable disease that has fatal consequences do not heed
national security, protecting the environment and promoting calls to remain at home until they cease to be infectious, the
public health. Contributions to the common good often offer no state has an obligation to enforce their quarantine. Historically,
immediate benefits to any one individual, and it’s often impos- this issue has arisen with regard to the treatment of people with
sible to predict who will gain from them, or to what extent, in leprosy, tuberculosis and, more recently, SARS and H1N1.
the longer run. Often, investment in the common good is carried Gostin provides a powerful study of this communitarian issue
out because we considered such investment the right thing to with regard to a bioterrorist attack or a severe medical emer-
do, not because we expect we personallydor even our gency.12 He points out that excessive concern for autonomy and
offspringdwill benefit from it.iii (I do not provide such an neglect of the common good have led to a focus on individu-
explication for autonomy, because its meanings are so often alised achievements in healthcare at the cost of severely under-
discussed in Western literature and are included in the discussion funding public health infrastructure and ignoring the needed
of bioethics already cited.) adaptations of public health laws.12 As a result, public health
agencies do not have the capacity to ‘conduct essential public
SOCIETY (COMMUNITY) VERSUS STATE health services at a level of performance that matches the
Responsive communitarianism holds that the more one can rely constantly evolving threats to the health of the public’.12 At the
on norms rather than laws, and on public education, moral same time, public health law has fallen off the radar and is now
persuasion and informal social controls, rather than on law ‘highly antiquated, after many decades of neglect’.12 Finally, the
enforcementdthe better the society. (Better in the normative debate about the role of the government in providing healthcare,
sense of the term, in that it is ethically preferred, rather than, reignited in the USA by the Obama administration, has some
say, on the basis of cost-benefit analysis, although such analysis strong communitarian dimensions, as does the reliance on
can have ethical implications that should be taken into account.) community rating versus ‘cherry picking’.
The main reason is that societal processes can change prefer-
ences and lead to truly voluntary compliance, while coercion WHICH COMMUNITY?
leaves opposing preferences intact. It hence invites attempts to The term community is often associated with small, traditional,
circumvent the law and tends to generate a sense of alienation.20 residential communities, such as villages. However, in the
A telling example is the way Prohibition was introduced modern era, communities are often non-residential and based on
versus the ban on public smoking. The enactment of Prohibition ethnicity, race, religious background or shared sexual orientation.
was not preceded by the building of a normative consensus and Moreover, people are often members of more than one
instead relied heavily on law enforcement. It failed to suppress community. Finally, it is often productive to consider commu-
the use of alcohol and greatly increased the corruption of the nities as nesting within more encompassing communities, such
American legal and political system. Moreover, it is the only as local ones within the national one. People are hence subject
constitutional amendment that was ever repealed. In contrast, not merely to tension between their personal preferences and
the values and norms promoted by their community but are also
subject to conflicting normative indications from various
ii
James Childress is a founding endorser of the Responsive Communitarian Platform, communities.
which can be found at http://www.communitariannetwork.org/RCP%20text.html The family can be viewed as a small community. In bioethics,
iii
For additional discussion see Alex John London, ‘Threats to the Common Good: strong champions of autonomy, as well as some feminists,
Biochemical Weapons and Human Subjects Research,’ The Hastings Center Report
33, No. 5 (2003): 17e25; Mark G. Kuczewski, ‘The Common Morality in suggest that each adult member of the family should make her
Communitarian Thought: Reflective Consensus in Public Policy,’ Theoretical Medicine or his own choices, and that other members of the family should
and Bioethics 30, No. 1 (2009). have no status in these decisions.10 (The treatment of

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incompetent people is considered an exception.) In contrast, good particular to utilitarianism’.9 Emanuel favours allowing
discussions about severely ill neonates whose parents seek to each community to determine its own concept of the good life
allow the infant to die because it will benefit other siblings tend on the grounds that (a) it is impossible to answer this question
to attach considerable weight to the welfare of the family as on neutral grounds and (b) we are a pluralistic society and hence
a whole (Michael Gross, private communication with the should respect the values of various member groups such as
author, 2009). Orthodox Jews and the gay community. This position is very
John Hardwig’s argument moves us far towards a responsive much in line with a communitarian position; however, it raises
communitarian position. Hardwig holds that ‘the interests of the question of whether there is room for nationwide or even
patients and family members are morally to be weighed equal’ transnational communal criteria and policies.
and ‘to be part of a family is to be morally required to make As I see it, the answer is diversity within unity. On some
decisions on the basis of thinking about what is best for all issues, it is clear that the most extensive communitydoften the
concerned, not simply what is best for yourself ’.24 It is an issue nation, but increasingly also transnational communities such as
that arises often in matters that do not directly concern health: the EU, and in some cases even the United Nation’s Universal
for instance, the effect of divorce on the children of the couple. Declaration of Human Rightsdshould and does provide the
In a bioethical context, the issue is well illuminated by a popular normative criteria. On other matters, diversity of the kind
book, My Sister’s Keeper.25 It depicts a situation in which various Emanuel depicts is fully appropriate. And, in still other
members of a family, the family’s very existence and the quality instances, one should expect disagreement about what ‘belongs’
of the relationships among family members are all deeply to the community at large and what to smaller, member ones.
affected by the sacrifices called for by the medical condition of Examples of those that are best guided by the most encom-
one member. passing communities are issues that concern basic rights (few
Hardwig adds, ‘That the patient’s interests may often would leave it to local communities to rule whether gay patients
outweigh the conflicting interests of others in treatment deci- or members of a given racial minority should be denied service)
sions is no justification for failing to recognise that an attempt and the moral claims that urge people to donate organs, blood
to balance or harmonise different, conflicting interests is often and time. In contrast, allowing different groups to rely on faith
morally required’.24 He leans somewhat in the authoritarian healers up to a point is an example of local community values
direction when at one point he claims that ‘considerations of influencing biomedical decisions.
fairness and, paradoxically, of autonomy therefore indicate that In the USA, an example of communities defining ethical care
the family should make the treatment decision, with all concerns the conditions under which parents can deny medical
competent family members whose lives will be affected care for their children. Some states mandate treatment when it
participating’.24 Thus, a less authoritarian position would is a question of life and death, regardless of the parent’s request
suggest that, for instance, if nine out of 10 family members agree to forego care, while others allow extreme latitude in the deci-
that treatment should be stopped for a given member, but the sion-making options of parents, including choices made about
memberdwho is competentdrejects this conclusion, the lifesaving interventions. In contrast to this state-by-state
family’s wishes should not carry. However, the person does owe determination of critical care decisions, there is a nationwide
the family members a careful consideration of their values, consensus that in matters less than life or death, parents should
reasons and needs. be allowed to refuse treatment for their children in order to
Jeffrey Blustein also articulates a responsive communitarian maintain their personal perception of ‘the good life’.
position. He holds that while final decision-making authority In short, diversity within unityiv provides a responsive
ought to remain with the patient, medical personnel and society communitarian model of granting some discretion to member
ought to focus on integrating family members into the decision- communities while also maintaining select values of the most
making process to support the patient’s ability to determine the encompassing conceptions of the common good. The fact that,
best optiondtaking into consideration the interests of those in some matters, it is unclear which community should prevail
most important to him or her.10 does not obviate the merit of this design, which stands out
When bioethical communitarian considerations turn to more when one compares the diversity within unity position to those
encompassing communities, especially to transnational ones, that favour the national statedor favour turning these matters
a whole host of additional issues arise. They often centre around into the domain of each member community.
the question of which community’s values should prevail. These
issues have been debated with regard to numerous topics, A CONTINUUM
ranging from female circumcision to the testing of new drugs So far I have treated the three positions as if they were separate
overseas. Whether one can apply here the dual approach of camps: the strong champions of autonomy (especially libertar-
combining respect for the cultural autonomy of various cultures ians, but also quite a few contemporary classical liberals),
and the concern for a global common good is a topic that must authoritarian communitarians and responsive communitarians.v
be left for another discussion. The same holds for the numerous However, in actuality, there are various gradations within each
inter-community issues that arise when national culture, values camp and among them.
and laws conflict with the culture, values and habits of various A volume of essays commissioned by the Bush Administration
immigrant groups or confessional groups that are members of Council on Bioethics contains various nuanced positions, though
the same broader society.
Ezekiel Emanuel points out that the various criteria for what iv
For more discussion see: Amitai Etzioni, ‘Diversity within Unity,’ 21st Century
is in the best interest of the patient are affected by what a given Opportunities and Challenges: An Age of Destruction or An Age or Transformation, ed.
community considers ‘the good life’: ‘This solution derives from Howard F Didsbury, Jr. (Bethesda, MD: World Future Society, 2003): 316e323.
v
communitarianism, a philosophy that incorporates the truths of In addition there are often cited works by academic communitarians, especially
Charles Taylor, Michael Sandel, and Michael Walzer. These authors oddly almost
utilitarianism and liberalism, but transcends both by arguing never use the term communitarianism, do not consider themselves communitarians,
that ethical problems can be resolved only by accepting a public and do not explain why they do not relate to a philosophy they are often associated
conception of the good life while rejecting the conception of the with.

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most tend to be written by social conservatives who lean in the that she be taken off the machine and be allowed to die. The
direction of authoritarian communitarianism.26 Thus, most hospital refused, so the parents sued. Although Quinlan’s case did
authors consider immoral those choices that they see as not meet the definition of brain death, her case brought the issue
conflicting with their views of human dignity, including to national attention.26 There followed extensive and widespread
women’s right to choose to have an abortion, termination of dialogues in various communities spurred by the media, out of
medical services for those dependent on mechanical intervention which gradually grew a consensus accepting brain death as
to stay alive, and stem cell research. Moreover, they favour using a morally acceptable definition of end of life and substituted this
the powers of the state to ban such choices. definition for the previous belief that one ought to do ‘all one
One main difference between these bioethical social conser- could’ to keep one’s loved ones alive.
vative positions and the outright authoritarian ones is that the The communitarian moral dialogues differ significantly from
scope of decisions these conservatives seek to curb by relying on the ‘rational democratic deliberations’ discussed and favoured by
the law is much narrower than the range of choices countries Leonard M Fleck among others.27 The term ‘rational’ implies
such as Iran, Singapore and China, seek to ban, at least in their that the deliberations are based on empirical findings and logical
strongest ideological periods. Furthermore, one must note that conclusions, and the term ‘democratic’ implies that the results
even liberals and responsive communitarians justify banning reflect the preferences of the electorate. They are also expected
some choicesdfor instance, those involving marketing foods to be ‘cold’ and rather impassionate. In contrast the moral
that contain carcinogenic ingredients or acts that poison the dialogues under discussion here concern values and help shape
environment. All this serves to illustrate that we are actually rather than reflect people’s preferences. Above all, they concern
dealing with a continuum composed of both the scope of choices what has been called ‘otherworldly’ matters, for which there are
and the main means used to foster them. Moreover, as already no rational statements but are matters of belief, are non-rational.
indicated, the historical context must be taken into account in For example, the argument over whether the death penalty is
searching for the responsive communitarian balance. Thus, if justified would be rational if it were driven by the consideration
there is a major pandemic, the point of balance will shift to more of whether or not the data show that this penalty reduces
restrictions than when there is no such threat. The underlying violent crime. It is subject to non-rational, moral dialogue to the
rationale is that while there are some matters on which the extent it is driven by considerations of whether it is ever morally
circumstances should have no effect (eg, rejecting eugenics), for acceptable for the state to deliberately take a person’s life.vi A
most issues, relative harm is relevant, determined both in utili- prime example of such a moral dialogue is the dialogue about
tarian and deontological terms. Thus, if a given measure limits what is implied by our commitment to human dignity, a major
autonomy to a minor extent but provides great public value, subject of a report by the President’s Council on Bioethics
these attributes favour this measure. HIV testing of newborns published under the title Human Dignity and Bioethics.
has limited adverse effect on privacy, and it saves lives. In The difference between rational deliberations and moral
contrast, allowing employers to purchase the medical records of dialogues is further illustrated by the following examples. The
potential employees has major privacy implications and very deliberations about the effects of smoking were affected consid-
little, if any, public benefit. erably by data, especially about the effects of second-hand smoke.
At the same time, other dialogues that seemed to be data-driven
PROCEDURES AND CRITERIA were largely about moral positions. For instance, whatever the
Responsive communitarians must concern themselves with data show about the effects on promiscuity of the availability of
procedures and criteria that allow one to work out personal condoms in nurses’ offices in high schools (and about the effects
decisions and public policies in the face of conflicting values. on drug addition of the distribution of clean needles) seems not to
(This is less of a challenge for those who take the position that affect much the opinions of those opposed to these policies. They
one value, such as autonomy or the common good, trumps all mainly retreat to a different line of argumentation, namely that
others. They can put the onus of finding exceptions on those such actions send the wrong message to the rest of society. (It
who feel differently.) should be further noted, most deliberations are not purely of one
A major way to proceed is through moral dialogues. Exami- kind or the other, but many seem to be mainly empirical and
nations of actual processes of consensus building, especially when logical, and many others largely moral dialogues).
they concern normative matters, show that individual preferences A reviewer of a previous draft of this essay posed here a very
and judgements are largely shaped through interactive commu- worthy challenge. He wrote: ‘I may, for example, fully recognise
nications about valuesdthat is, through moral dialogues that that US$ 250000 for a bone-marrow transplant for me (at age
combine passion with normative arguments and rely on processes 70) is far too expensive to be in the common good. But if it’s my
of persuasion, education and leadership. Moral dialogues focus only chance of survival, how can my values and priorities be
more on values than on facts. Although passionate and without rearranged so that I not only accept with resignation . but
a clear starting and ending point, they often lead to new shared embrace the conclusion that I should not have a transplant in
moral understandings. Such dialogues led to the formation of order better to utilise the pooled resources in my insurance plan
a new sense of duty to protect the environment, to reject racism (public or private) to serve other anonymous ‘covered lives?’ The
and sexism, to oppose the war in Vietnam and many other such example implies that the way to bring to bear considerations of
society-wide shared understandings. the common good is to change the preferences of the patients.
The redefinition of death that took place in the USA illustrates This is indeed a major way. Some older patients are made to feel
the ways moral dialogues work. In 1968, an ad hoc committee at guilty because they are reminded that they spend a great
the Harvard Medical School published a report that defined an amount of scarce medical resources in the last year of their life,
irreversible coma as ‘brain death’da new definition of death. The and often to little benefit. Some are made to feel that they are ‘a
report, put together by academics and medical professionals, did burden’ on their families, another communitarian consideration.
little to redefine the public perception of death. However, in 1972,
a young woman named Karen Ann Quinlan fell into a persistent vi
For more discussion, see Ch 8 in Amitai Etzioni, The New Golden Rule (New York:
vegetative state. After weeks of life support, her parents asked Basic Books, 1996).

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Moreover, while some families discourage these sentiments, liberals, authoritarian communitarians and responsive commu-
others enforce them for of self-serving reasons. Also people nitarians. However, bioethical judgements obviously can and do
infected with SARS stayed home, under voluntary self-confine- draw on additional values, and the ways these can be treated in
ment, in order not to infect othersdalthough it limited their this context remain to be discussed. Much of this discussion
freedoms. And at least according to one authoritative source, must be deferred to a future publication because it requires
physicians in the UK convince patients, after a certain age, that rather extensive deliberations. However, the main issue at hand
they should not seek kidney dialysis or chemotherapy.28 can be illustrated by pointing to the four values often quoted by
Above all, the balance between autonomy and the common bioethicists, drawing on the influential work of Tom L Beau-
good is often not subject to free choice by the patients. Thus, champ and James F Childress, Principles of Biomedical Ethics.1
some ethicists, most notably Daniel Callahan, called for These are respect for autonomy, non-maleficence, beneficence
providing only ameliorative care after a certain age.29 And of and justice.30
course which services are reimbursed versus which are not, have The meaning of autonomy in a bioethical context has already
major effects on the said balance. been covered by the quotations in the first parts of this essay.
Another way to work out the balance between autonomy and Non-maleficence also focuses on the wellbeing of the individual
the common good as it applies to specific matters is to leave patient: do no intentional harm. Beneficence, the third principle,
these issues to courts or to legislatures. Should people be is defined as an obligation to advance the healthcare interests
required by law to vaccinate their children? Under what and welfare of othersdbecause we have ourselves received
conditions may people be subjects of research? Can one require benefits.31 Again, the focus is on the individual. Justice, the
people who have been arresteddbut not yet convicteddto yield fourth principle, raises a host of complicated issues that so far
their DNA, the way their fingerprints are collected? These and have not been addressed by communitarians of either kind.
many other bioethical considerations are best first subject to In the context at hand it is important to note that even the
moral dialogues, assisted by bodies such as ethics committees in nuanced and enriched set of normative principles developed by
hospitals or the President’s Council on Bioethics, butdespecially Beauchamp and Childress does not include a concept of the
given the growing volume of such policy mattersdsome may common good, above and beyond the concept of justicedfor
have to be worked out by courts and legislatures. instance, conditions under which individuals have to accept
Finally, responsive communitarian bioethics leads one to various sacrifices for the good of all. A thicker definition
suggest criteria that moral dialogues, judges, and lawmakers may would include common goods that command our moral respect,
draw upon. One is the relative adverse impact on the two core such as the protection of the environment, basic research,
conflicting values that flow from the adoption of a given policy. homeland security and public health.ix These kinds of concerns
That is, when autonomy must be much curbed for minor gains to that Gostindand communitarians more generallydhave about
the common good, responsive communitarianism suggests preventing the spread of infectious diseases, responding to
autonomy should be given the right of way, while public policy bioterrorist attacks, protecting the environment, balancing
should lean in the opposite direction if the gains to the common preventive and acute medical treatments, and determining the
good are substantial and the sacrifice of autonomy is minimal.vii extent to which one can foster or force limits on individual
These criteria would help explain the position articulated by choices for the public good, do not find a comfortable home in
Tom L Beauchamp, who argues that society should switch its the most widely followed bioethical texts. Hence, concern for
conceptions of the public and private good in terms of eutha- the common good, responsive communitarians would argue,
nasia and organ donation. Euthanasia, currently considered an should be added to the already existing core values on which
issue where the public determines its application, ought to be bioethics draws.
a private matter, according to Beauchamp, because that is the
logical conclusion of a culture that allows patients extreme Acknowledgements I am indebted to S Riane Harper and Julia Milton for research
latitude to determine their treatment up to (but currently not assistance on this essay and two reviewers for very stimulating comments on
a previous draft.
including) death, with the assumption that personal care choices
have more impact on personal autonomy than they do on Competing interests None.
society at large.11 At the same time, organ donation, with its Provenance and peer review Not commissioned; externally peer reviewed.
widespread implications for the wellbeing of the community,
ought to be moved out of the realm of personal decision-making
and into the public arena, putting the focus on the public good, REFERENCES
which is more impacted by organ-donation decisions than is 1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th edn. Oxford:
individual autonomy.11 Oxford University Press, 2008.
2. Hansen H, Groce N. Human immunodeficiency virus and quarantine in Cuba. JAMA
Other criteria indicate that one ought to find ways to absorb
2003;290:2875.
the side effects. For instance, if one introduces a policy that calls 3. Jiang YH. Asian values and communitarian democracy. paper presented at the
for testing newborn infants for HIV, special care must be taken International Workshop on Deliberating the Asian Value Debate: National Values,
to keep the results confidential, lest the mother lose her job, Chinese Values and Muslim Values in Southeast Asia, Taipei. 1998.
4. Bell DA. A communitarian critique of authoritarianism. Society 1995;32:38e43.
housing or insurance.viii 5. Bellah R, Madsen R, Sullivan W, et al. Habits of the Heart. Berkeley, CA: University
of California Press, 1985.
6. Fukuyama F. The Great Disruption: Human Nature and the Reconstitution of Social
THIRD VALUES Order. New York: The Free Press, 1999.
So far I have limited the discussion to two core values because
these are the ones that define the main differences among ix
Some authoritarian communitarians try to maintain that their privileging of the
common good, even if it is enforced by the state and affects a wide array of
vii
For more discussion, see: Amitai Etzioni, The Limits of Privacy (New York: Basic behaviour, does not conflict with autonomydas long as the individuals voluntarily do
Books, 1999). what they are supposed to! Beauchamp and Childress carry out a similar manoeuvre
viii
For more discussion, see: Amitai Etzioni, Limits of Privacy (New York: Basic Books, from the other side of the equation, arguing that one can readily accept obligations to
1999). the common gooddas long as they have been ‘autonomously accepted’.

6 of 7 Etzioni A. J Med Ethics (2010). doi:10.1136/jme.2010.037846
Downloaded from jme.bmj.com on November 10, 2010 - Published by group.bmj.com

Ethics

7. Putnam R. Bowling Alone: The Collapse and Revival of American Community New 19. Kuczewski MG. The epistemology of communitarian bioethics: traditions in the
York: Simon and Schuster, 2001. public debate. Theor Med Bioeth 2001;22:135e50.
8. Callahan D. Bioethics: private choice and common good. Hastings Cent Rep 20. Etzioni A. A Comparative Analysis of Complex Organizations. Revised edn. New York:
1994;24:28e31. The Free Press, 1975.
9. Emanuel EJ. A communal vision of care for incompetent patients. Hastings Cent 21. Etzioni A. Organ donation: a communitarian approach. Kennedy Inst Ethics J
Rep 1987;17:15e20. 2003;13:1e18.
10. Blustein J. The family in medical decisionmaking. Hastings Cent Rep 22. Erin CA, Harris J. An ethical market in human organs. J Med Ethics 2003;29:137e8.
1993;23:6e13. 23. Etzioni A. The Moral Dimension: Toward a New Economics. New York: Free Press,
11. Beauchamp TL. Reversing the protections. Hastings Cent Rep 1994;24:18e19. 1988.
12. Gostin LO. Public health law in an age of terrorism: rethinking individual rights and 24. Hardwig J. What about the Family? Hastings Cent Rep 1990;20:5e10.
common goods. Health Aff 2002;21:71e93. 25. Picoult J. My Sister’s Keeper. New York: Atria 2004.
13. Das V. Public good, ethics, and everyday life: beyond the boundaries of bioethics. 26. Human Dignity and Bioethics: Essays Commissioned by the President’s Council on
Daedalus 1999;128:99e133. Bioethics. Washington, DC: US Independent Agencies and Commissions, 2008.
14. Ogunbanjo GA, van Bogaert DC. Communitarianism and communitarian bioethics. 27. Fleck LM. Can we trust democratic deliberation? Hasting Cent Rep 2007;37:22e5.
South African Family Practice Journal 2005;47:51e3. 28. Aaron H, Schwartz WB, Cox M. Can We Say No: The Challenge of Rationing Health
15. Gross ML. Autonomy and paternalism in communitarian society: patient rights in Care. Washington DC: Brookings, 2005.
Israel. Hastings Cent Rep 1999;29:13e20. 29. Callahan D, Prager K. Medical care for the elderly: should limits be set? Virtual
16. Murray TA. Communities need more than autonomy. Hastings Cent Rep Mentor 2008;10:404e10.
1994;24:32e3. 30. Gillon R. Medical ethics: four principles plus attention to scope. BMJ
17. Meilaender G. Our vocabularies, our selves. Hastings Cent Rep 1994;24:13e14. 1994;309:184e8.
18. Glendon MA. Rights talk: the impoverishment of political discourse. New York: The 31. The Nathaniel Centre for Bioethics. Bioethical principles. http://www.nathaniel.
Free Press, 1991. org.nz/%3dsid¼27.

Etzioni A. J Med Ethics (2010). doi:10.1136/jme.2010.037846 7 of 7