Critical Theory in Bioethics: Challenging Assumptions Behind Beneficence and Justice

Critical theory seeks to challenge assumptions and constraining ideologies, both in a reflective, self-critical way and a normative way. It seeks to identify areas in need of change, identify who makes the change, and challenge prevailing views. Applying critical theory to bioethics would lead to questioning and changing prevailing assumptions as well as the actions stemming from them.

Beneficence in the doctor-patient relationship is a principle that makes sense only because of an assumption about the moral stake of the doctor, hospital, or state in medical care. When beneficence is used to justify paternalistic action (the doctor or state making a medical decision to achieve a “good” outcome against the will of the person who is seeking or refusing care), there is an underlying assumption that the doctor knows not just what is medically “best” but what is best for society or for the person or family. The doctor not only can be medically wrong, but also can be operating on assumptions when the decision is outside the realm of the doctor’s expertise. The doctor may be on an ethics committee adding to the appearance of moral authority.

Critical theory helps enlighten bioethicists about what assumptions and norms are at the root of beneficence and promote analysis of those assumptions. While, to me, beneficence should be eliminated from the bioethics vernacular, the concept of doing “good” is worthy of analysis. Conceptually, good is subjective, debatable, and not conducive to choosing one action and applying it to all people experiencing a certain medical condition. (For example, if the epilepsy patient wanting the keto diet chooses that and has success, a good is achieved. Some doctors seem to feel that the only good or the preferred good is a pharmaceutical option, even when the outcome turns out to be the same. This disconnect is at the heart of the beneficence-autonomy stalemate. The norm that is medicalized, the failure to define and limit the weight of the doctor’s stake, the undervaluing of the stake of the patient who lives with the day-to-day side effects, and the inability to value autonomy as a good in itself constrain bioethics. Critical theory may offer an approach that unleashes competing assumptions and helps ethics committees and doctors avoid both a medicalized norm and the assumption that their priorities should govern when there are other paths to the desired outcome.

Another bioethical theoretical assumption is that justice in the form of making certain things available, free, or accessible acts as a goal, is always a good, and once achieved, would indicate a problem is solved. I see justice as one factor of many affecting a bioethical dilemma. Justice is stretched in bioethics to cover vast subject matter. Justice is often presented as the worthy endgame, an assumption that I challenge. An inability to achieve justice often ends the dilemma prematurely. (Many bioethicists say if X cannot be offered fairly, it should not be offered.) Justice can crowd out other goals. Muddled language like access and divvying up scarce resources successfully can mask the bigger issues of whether the resource in question is the best solution, whether it makes sense to govern its allocation or allow market forces to do so, whether is should be scarce and is not really a “good”. (E.g., justice arguments about access to common antibiotics vary from justice arguments about cloning.) Most importantly when bioethics depends solely on justice to prohibit something that is potentially bad, then when that “bad” is available to all, it would be ethically valid, or an ethically or morally neutral option. Justice arguments can be similar to safety arguments in the implication that once the justice issue is solved, autonomy would justify availability.

When the power is off kilter, as in pharmaceutical advertising, justice fails to protect consumers despite the existence of fairness in the exposure to ads or even in the ability to access a doctor to ask for the pharmaceuticals seen advertised. Pharmaceutical advertising may tempt people into thinking a drug is a cure and contradicts calls for prevention. Organizational ethics tend to govern sales and marketing but justice is a prevailing theme. Rather than challenging the role a drug may play in a crisis of overmedication or in curing a person’s debilitating condition, truth-telling and reading the risks suffice as a way of making the advertising fair. The underlying assumptions in bioethical justice need challenge to highlight circumstances where fairness itself becomes unfair.