Presidential Address: Bioethics and Social Responsibility

What is a bioethicist? We might suppose that we can define this role by describing the subject matter of the field. But this keeps changing. There have been, in my reckoning, three states thus far, with a fourth in the process of birth as we speak. I. The first consisted of codes of professional conduct. Bioethics (more precisely: medical ethics) in this sense consisted of rules against advertising, or speaking ill of another doctor; and against such practices as fee-splitting and kickbacks. II. The second phase, dubbed `The Birth of Bioethics' by Prof. Jonsen and his fellow-historians, turned tables on the doctors. Where Stage I bioethics involved doctors talking to peers in order to define what the medical profession stood for, Stage II set loose a swarm of critics, some of them doctors and many others not, who questioned virtually every medical tradition. Age-old patterns of paternalism and husbanding of the truth were successfully challenged. Bioethicists were the academic allies of the patients' rightsmovements, arguing for a renegotiation of the doctor-patient relationships. III. Daniel Callahan, in his 1980 Shattuck Lecture, pointed out that the doctor-patient relationship and all of the concerns of Stage II bioethics were shaped and controlled to a large (but scarcely visible) extent by the structure, financing, and management of the health care system. Callahan called on his colleagues to engage in these issues at the macro level, learning enough about these largerscale issues and choices to speak usefully to the ethical basis of the system as a whole. It was not easy to respond to Callahan's urging. Bioethicists needed, but did not possess, detailed knowledge of health economics and politics. New philosophical resources were needed, too: not the morality of individual action, nor the traditional ethical codes of defining the medical profession, but social and political philosophy, particularly theories of distributive justice. Bioethics in this new, third mode began as a trickle. Norman Daniels's Just Health Care was an early landmark. The flow of books Bioethics ISSN 0269-9702 Volume 11 Number 3&4 1997