‘Impact ethics’ is an ethics that does more than prescribe minimum standards of behavior for everyone or propose ideals to guide everyone. An impact ethics brings about substantial change for the better.
An ethics that produces only sporadic, perhaps serendipitous, notably good or worthy outcomes is not an impact ethics. An ethics that regularly generates and sustains notably good or worthy outcomes is an impact ethics. An ethics that prompts, at substantial risk, an exemplary good or worthy outcome, for example, exposing notorious, seriously harmful wrongdoing, is an impact ethics. Because an impact is an outcome, an impact ethics must actually produce, not just endorse or encourage morally significant outcomes in a systematically intelligible manner.
Is bioethics an impact ethics? The repudiation of paternalism and installation of patient autonomy was a radical—and quick—transformation of the ethics of medicine. With the recognition of respect for autonomy, patients became entitled and expected to make decisions on the basis of their own values, and nobody could presume that they knew the patient’s values better than the patient. But can that impact be credited to bioethics, or did bioethics ride on the coattails of the law?
Regardless, why is bioethics not now an impact ethics? Because bioethics is both confined by the abstractions of its underlying moral theory and distanced from the particularities and complexities of real moral problems by its theoretical orientation. And, because practicing bioethicists are beholden to their employers. When decision making about treatment becomes controversial and complicated in a hospital, for example, throughput is disrupted and slows down, and the bioethicist’s task is to remove that impediment to the efficient processing of patients. Given that time is the most precious and scarcest resource in a hospital or a doctor’s office, moral deliberation for the sake of moral deliberation is an inefficient luxury.
Bioethics could become an impact ethics by being more aggressive. Bioethicists need to take risks, name names, speak up, and speak out. The bioethicist should be an investigative journalist or an activist, whose job is to expose corruption, stamp out moral crimes and injustice, and instigate radical reform. These activities are not in the standard job descriptions of bioethicists, however, and bioethicists with limited or tenuous employment would have to be wary.
Bioethics also could become an impact ethics by fostering a morality of genuinely patient-centered care. Patient-centered care can be narrowly understood as patient-chosen care, with morality reduced to the individualism of respect for autonomy. But the autonomous choices of patients can be inconsistent with, and can undermine, established practices of recognized good care (Mol, 2008). Mol appreciates that “individual choice is a widely celebrated ideal,” but she separates the logic of choice from the logic of care and, in an illuminating study of people with diabetes, challenges “the generalization of choice” because “practices designed to foster ‘patient choice’ erode existing practices that were established to ensure ‘good care’” (p.1). “Continuing to emphasize patient choice will not,” in her view, “bring about the improvements hoped for” (p.2).
Severing choice from good care and subordinating choice to good care are bioethical heresies. These heresies proceed from empirical research of the sort that bioethics largely has shunned but badly needs. What Mol calls the “clash” between patient choice and good care does not exist in the rarefied theorizing of bioethics, but in the engagement of choice with the daily practices of providing care. To become an impact ethics, bioethics must not abandon criticism but must move beyond it by recognizing, learning from, and supporting good practices. Bad outcomes that result from disregarding good practices of delivering and receiving health care should be avoided, and patient choice should be attuned to the realities of good practices.
As well, bioethics could become an impact ethics by expanding its scope. Bioethicists are enticed and enchanted by controversial issues that attract public attention—often generated by new technologies—but affect relatively few people. Yet caring for the many people with mundane degenerative or chronic diseases, for example, gets virtually no bioethics attention until they want to end their lives. Caring for them—giving them good care—means helping them live with their illnesses and limitations. But being in the presence of suffering is discomforting, and, compared to organ transplants, neuro-enhancements, reproductive technologies, cloning, et cetera, suffering is a drearily banal, quotidian topic. Health care practitioners who confront suffering are more morally discerning than bioethicists. Bioethics could bring about substantial change for the better by recognizing the moral distress of suffering and prompting the relief of suffering for people who might not have much good left in their lives.
Barry Hoffmaster, Professor of Philosophy, University of Western Ontario