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Abstract

Communitarian bioethics aims to balance concerns for individual rights and interests that are central to liberal and libertarian bioethics with the common good that is the primary concern of authoritarian approaches to bioethics. Communitarian bioethics is founded on four principles, which are here illustrated through comparative case studies of varying global practices relating to bioethical dilemmas. These principles are preference for moral rather than ﬁnancial appeals to convert attitudes into action on the individual level, the use of informal rather formal social controls to engender voluntary compliance with public policy on the community level, the promotion of moral dialogues rather than purely rational deliberation as means of discovering shared values to guide social change, and the balance of the common good with individual rights.

Introduction

The following discussion aims to illustrate communitarian principles by applying the approach to various bioethical dilemmas and by comparing their application with how liberals or libertarians and authoritarians would approach these dilemmas. This entry ﬁrst examines how moral appeals can increase organ donations. It then shows how informal social controls can help curb epidemics. Both illustrate the role of a third dimension in addition to the individual and the state, the societal one, which ﬁgures prominently in the communitarian approach to bioethics. The entry then presents communitarian criteria used to determine whether bioethics, as applied to particular policy or decision-making categories, should accord more weight to autonomy or to the common good. To this end, mandatory vaccination policies are examined as a case where individual rights should yield to the common good because the gain to the common good is very substantial and the intrusion is quite limited. Next, in vitro fertilization is presented as a case where individual rights should be privileged because the harm to the common good, if any, seems small and the personal rights involved are particularly powerful ones. Then, the entry examines the bioethical implications of treating the patient as a member of small communities (e.g., the family) and more extensive ones – in contrast to an autonomous person – which is an application of the communitarian view of the socially embedded self. Finally, the entry examines the communal processes, namely, moral dialogues, which may be used to change moral understandings of people in accordance with changes in medical technologies and procedures as well as sociological conditions.

History And Development

Communitarianism is a social philosophy that holds that there are and ought to be shared formulations of the good. It is often contrasted with the liberal thesis that the good should be formulated by each person. Early mainstream bioethics focused on the individual and strongly privileged liberal principles, especially autonomy, over non-maleﬁcence, benevolence, and justice. Communitarian bioethics has developed in response to growing concerns that mainstream bioethics focused too heavily on individual rights, built on an impoverished view of the self, and did not accord sufﬁcient attention to the responsibilities that members of communities have to one another pertaining to common goods such as public health.

Conceptual Clarification

Communitarianism differs from liberalism with regard to how the self is viewed. Communitarians challenge the notion of the self that is associated with libertarianism, as well as major segments of liberal political philosophy, a challenge that has signiﬁcant implications for communitarian bioethics. There are two parts to the communitarian challenge. One holds that the libertarian notion of the self is ontologically misguided because it assumes that the self can shed its social identity and exist as an atomized rights-bearing individual, but according to communitarians, peoples’ identities are constituted by their social ties with one another and the communities in which they are embedded.

The other part of the challenge holds that the libertarian view of the self is normatively misguided because even if persons could shed their social identity and deliberate as abstract individuals, such deliberations lead to normatively deﬁcient conclusions because individuals need to draw on their social identities, bonds, and commitments to help discover the shared values that people ﬁnd normatively compelling. Hence, communitarianism rejects the liberal Rawlsian decision procedure whereby free-standing, rational agents who are behind a veil of ignorance decide principles of justice upon which to build their social and political institutions.

Communitarians seek to promote shared values ﬁrst and foremost through informal social controls rather than state coercion. Studies show that these controls, which draw on people’s deepseated need to gain the approval of others, are highly effective in promoting prosocial behavior (e.g., attending to one’s children, providing a day’s work for a day’s pay, voting, and volunteering) and curbing antisocial behavior (especially criminality). The communitarian approach stresses that the public discourse – which tends to focus on contrasting the role of the government to that of the private sector (and that of free-standing individuals) – greatly underestimates the importance of the “third sector” composed of many hundreds of millions of families, many millions of social groupings (e.g., ethnic, racial, professional), religious institutions, residential communities, and hundreds of thousands of not-for-proﬁt corporations. The term community (or society) is often used to refer to these third sector entities.

Communitarianism also differs from authoritarianism, which holds that the common good takes precedence over the rights and preferences of the individual. By contrast, communitarianism holds that the common good must be balanced with individual rights and preferences . Moreover, the authoritarian view typically draws on state coercion to further the common good, whereas communitarianism favors the use of informal mechanisms of social control combined with normative appeals to engender support for the common good and to secure voluntary acceptance of one’s social responsibilities. It should be noted though that although communitarianism seeks to minimize the role of coercive elements, we shall see that coercion cannot be fully avoided – when the threats to the common good are high. In those situations, communitarianism urges seeking ways to limit the scope of coercion, and indeed of other intrusions, as much as possible.

Ethical Dimension

Organ Donations: Moral Appeals

Organ transplantation is a successful treatment for organ failure, cost-effective, and a routine rather than experimental procedure with respect to several primary organs. There is, however, a great shortage of organs for transplantation. In the year 2000, more than 5,500 Americans died while awaiting transplants (Lovern 2001). In 2012, 95,000 Americans were on the waiting list for kidney transplants, the most commonly transplanted organ, but only roughly 16,500 kidney transplants were actually performed in 2012 (Becker and Elias 2014). Middle-aged persons (aged 45–49) who have damaged kidneys live, on average, an additional 8 years on dialysis, but an additional 23 years with a successful kidney transplant (ibid). With a wait of roughly 4.5 years for a kidney transplant, and 14 people dying each day in the USA alone while waiting for a kidney transplant, the question hence arises: what might be done to increase organ donations?

An authoritarian approach to organ scarcity is illustrated by the policy in China, where the government procures healthy organs from newly executed prisoners on the basis of “presumed consent,” that is, on the basis of assuming individuals consented to donating their organs, without asking for such consent. The Chinese government states that it will terminate its current practice of organ procurement by August 2015.

A much less coercive but nevertheless still state-driven strategy is the use of an opt-out system, which is followed by European countries such as Austria, Belgium, France, and Spain. In these countries, the government announces that unless persons opt out, their organs may be taken after they die. Opt-out systems achieve high donation rates; in Austria, for example, 99 % of the population has not opted out.

Libertarians hold that persons have rights to their bodies and the right to determine the uses to which their bodies are put, which is consistent with organ donation policies requiring explicit consent. Explicit a priori consent is required in most US states. In 2006, the Anatomical Gift Act was revised to make it easier to document donation (i.e., on drivers’ licenses), to authorize persons to donate on behalf of an incapacitated person before he or she dies, and to expand who may donate on behalf of a deceased person if the person did not express preferences before death. Despite these changes, the USA continues to follow a libertarian approach, leaving it to each person (or those who represent the person) to choose whether to donate, or even whether they wish to consider the matter at all, and leaves health-care personnel to decide whether to raise the question with the dying person or his family.

While many Americans report their acceptance and willingness to become organ donors, many do not take the concrete steps to opt in. Hence, some libertarians propose that people should be able to sell their organs to incentivize people to opt in into organ donation programs. In India, for example, it is a proﬁtable, albeit illegal, enterprise for living persons to sell their kidneys, skin, and eyes. As of 2007, the only legal market for organ sale could be found in Iran. Currently, federal law in the USA prohibits the sale of organs, though it allows for ﬁnancial reimbursement for expenditures made by living donors, and more than a dozen states offer the ﬁnancial incentive of up to a $10,000 tax deduction to help defray expenses (e.g., travel, lodging) to living donors. A leading libertarian Virginia Postrel, former editor of Reason, initiated a campaign to promote the idea that people willing to give others their organs should be compensated for it. In 2003, the American Medical Association partnered with the United Network for Organ Sharing to support legislation that would allow for pilot studies of an organ sale program under which families would be paid for donating a family member’s organs after he or she died.

The communitarianism approach to organ donation in the USA builds on the ﬁndings of a national survey conducted in 2012 that shows that while 94.9 % of surveyed Americans support or strongly support organ donation, only 60.1 % report to consenting to organ donation on their driver’s licenses (National Survey of Organ Donation Attitudes and Behaviors 2013). Hence, communitarians hold that the USA should not turn to an opt-out system or an open market for organs, but rather seek to convert these predispositions into active preferences through moral appeals and social recognition.

Communitarians favor activating and mobilizing the moral voice of the community in favor of organ donation, by asking people when they enter clinics, hospitals, and doctors’ ofﬁces – all places they regularly complete several health-related forms – to ﬁll out a consent form that includes a strong moral appeal. The forms might also be available at places of worships and community centers. The following provides an example of what such a consent form might say:

First, thank you for considering a matter of great importance and value: giving the gift of life by donating your organs once they are no longer of any use to you. Each year, thousands of children and adults suffer needlessly and many die because not enough organs are available. Others remain or go blind or stay fettered to machines at great suffering and public cost, merely because too few organs are donated. Saving a life is of the highest moral order; there is no greater moral duty than helping to avert a death or great human suffering when one can do so readily and without costs or risk to self. We are sure you agree that the decent, upstanding thing to do is to reach out to others when less is asked of you than making a donation of money or time, which many-surely including you-so generously give when they are able to. If you have religious reasons not to proceed, we respect these commitments. Otherwise, please join us by signing this statement, and having it properly witnessed by anyone who is over the age of 18. We plan to let one and all know of your good act by posting it on a special website; however, if you wish to remain anonymous please mark the box below provided for this purpose. Kindly tell your relatives and friends of your good deed today and encourage them to do likewise.

Those who indicate that they are willing to make an organ donation following their death should be listed on honor rolls, on a web page, community by community, unless they prefer to remain anonymous. The public listing of consenting individuals would allow medical staff facing dying patients to readily determine what the patient’s preferences are in this matter and for society to reward those who made the commitment by social recognition. The same rolls would also ipso facto reveal who has not yet signed up.

If enhanced moral appeals and social promotion are insufﬁcient to raise donation rates, only then would communitarian principles support a policy of organ sale – but only as long as the sale proceeds through a foundation that buys the organs but sells them to persons according to their respective needs, rather than to those who are able to pay more. The foundation’s costs are to be covered by a sliding scale fee tailored to the economic circumstances of organ recipients as well as from donations.

In short, the communitarian approach is ﬁrst to try to activate the moral voice of the community by appealing to values and providing social recognition to those who contribute to the well-being of others in an effort to alleviate the organ shortage. Financial incentives should be introduced only if moral appeals and social recognitions are insufﬁcient and only if they are formatted so that need rather than wealth will determine the beneﬁciaries of these incentives. Organ donation, thus, illustrates a category of bioethical decisions in which a much greater role can be played by communal processes before market forces are introduced.

HIV: Preference For Informal Social Controls

Epidemics pose serious health risks to the general public. During the seventeenth and eighteenth centuries, tuberculosis (TB) caused up to 25 % of all deaths in Europe. When the disease spread to North America in the nineteenth century, it infected roughly 70–90 % of the European and North American urban population (Contagion: Harvard University Library Open Collections Program 2014). Improved living conditions reduced the incidence of TB in the early 1900s, but once HIV spread in the 1980s, TB infections again began to rise, as HIV weakens the immune system, making people more vulnerable to contracting TB. Both TB and HIV continue to be major health problems worldwide. By 2011, 34 million people contracted HIV, with an increase of about 2.5 million per year, and of those cases, 1.7 million die from AIDS caused by HIV each year (AVERT 2014).

In response to epidemics, authoritarians support the isolation or quarantine of infected persons or persons exposed to disease. To contain the outbreak of TB in the USA in the late nineteenth century, infected persons were separated from their families and isolated for extended periods in sanatoria. Cuba responded to the HIV outbreak in the 1980s by instituting a policy of forcible isolation. In 1994, Cuba relaxed its compulsory quarantine program, but even today, all new persons who test positive for HIV remain legally bound to participate in an 8-week education program on the disease at a sanatorium. In contrast, libertarians argue that each person is responsible for their own health and have a strong right to privacy. Hence, libertarians argue that there is no need for a requirement (legal or moral) for one person to disclose to a prospective or past sexual partner that he or she is HIV positive because everyone should engage in safe sex anyhow, and if they choose otherwise, they should live with the consequences. Some libertarians even reject mandatory HIV testing for rapists and the disclosure of test results to victims.

The communitarian approach favors appealing to people’s prosocial values and sense of responsibility for others and to the common good to (a) be regularly tested for HIV and (b), if tested positive, to disclose their condition to prospective partners, and (c) to agree to contact tracing, especially of the kind used by third parties to inform previous partners. Contact tracing is a technique used to stop the spread of disease by identifying individuals who have come into contact with an HIV-positive person and who may have contracted the virus – in order for them to be treated and to prevent them from passing the virus to others. One way this is accomplished is by urging those who found out that they are HIV positive to disclose this information to previous (and prospective) sexual partners. Another is for them to provide contact information to health-care personnel who will notify those who have been in contact with the said person – without identifying the source of the information.

A communitarian viewpoint favors voluntary contact tracing and working with various communities to encourage their members to be tested and enable contact tracing. However, given that diseases like HIV pose direct and serious threats to persons’ lives, when these measures fail, there are grounds for a more coercive approach as a last resort. This is especially the case when a person who is aware of his or her condition does not inform prospective partners. This approach has been taken in the USA, where as of April 2011, the government has prosecuted 345 persons who knowingly spread HIV to others without prior disclosure (Shrage 2014). In addition, the communitarian approach calls for adding measures to guard against discrimination by requiring that any information about a person’s HIV status is especially well protected to prevent people from losing their jobs, insurance, or housing as a result of their medical condition. This is advocated to minimize the side effects of the intrusion.

The discovery of antiviral medications, which not only greatly prolong the lives of those who take them as required but also greatly reduce transmission rates, has considerably changed the situation. Nonetheless, a recent report still ﬁnds that “Of the more than 1.1 million people living with HIV in the U.S., an estimated one in six do not know that they are infected, and only one in four has their virus under control with treatment” (NPR 2014). Here, communitarian factors enter mainly in helping to ensure that the medications are available at reasonable rates, especially to those in less afﬂuent communities in the USA and elsewhere, and to encourage people to take the medications as required – and to act responsibly when engaging in sex.

While the communitarian approach emphasizes ﬁrst drawing on informal social controls and normative appeals, when these do not sufﬁce in the face of a contagious disease that is spreading rapidly, the approach will support the use of more authoritarian, state-driven, coercive measures as a fallback. Thus, the approach is consistent with the strategy advanced by Lawrence O. Gostin, who argues that when there is a public health crisis, for instance, following a bioterrorism attack, the public health authority should be empowered to declare a public health emergency, conﬁscate or destroy infectious property or waste, occupy medical facilities, and require cooperation from individuals, as seen in the anthrax threat of 2001.

In short, informal social controls are preferable to coercion and are often highly effective; however, when the threats to the common good are high, they may serve as only the ﬁrst line of defense. If coercion must follow, it will be less alienating in light of the fact that prior attempts to protect the common good by voluntary means have carried part of the burden and coercion has been introduced only as a last resort.

Vaccinations: The Common Good To Take Precedent

Vaccines are a widely used method by which societies seek to prevent the spread of diseases, a major common good. Vaccination is identiﬁed by the Centers for Disease Control and Prevention (CDC) as the single greatest health achievement of the twentieth century. This method can be very effective at producing immunity among a population if enough people are vaccinated – called herd immunity – but individuals do have to absorb some risk. Most side effects are mild, such as soreness where the shot was administered, but some persons experience allergic reactions that cause excessive bleeding, shock, severe head pain, fatigue, and even paralysis.

If enough individuals forgo vaccinations, it threatens the development of herd immunity. This has taken place when a signiﬁcant number of persons exempt themselves from vaccinations on religious or philosophical grounds as happened recently with the Amish in the USA. Others think that vaccines are ineffective or fear that the vaccines will harm them and so free ride on the vaccination by others to maintain herd immunity. As a result, the community suffers. In April 2014, for example, British Columbia experienced an outbreak of measles, with 320 persons becoming infected, most from a religious group called the Netherlands Reformed Congregation that refused vaccinations on religious grounds. Earlier in the year, 9,120 cases of whooping cough, which resulted in 10 deaths, were documented in California, arising from clusters of unvaccinated children.

A libertarian approach would not require vaccinations, but may encourage individuals to get themselves and their children vaccinated. This has been adopted in Australia, where the government recommends and encourages persons to become vaccinated, but does not require it by law. Under the Maternity Immunisation Allowance and Child Care Beneﬁt program, parents receive nontaxable payments for each child aged 18–24 months and 4–5 years who meets immunization requirements. Children are not required to be vaccinated to attend school, but they are required to stay home in the event of a disease outbreak. Libertarians support this approach because it expands individual choice, but it opens the door for individuals to choose to forgo vaccinations and thereby threatens herd immunity.

Another approach has been adopted by many governments, which is to make certain vaccinations mandatory and sanction persons who do not get themselves or their children vaccinated. Early instances of mandatory vaccination policies were found in England and Wales in 1853, where the law required universal vaccination against smallpox for infants, and by 1867, noncompliance was met with a ﬁne (El Amin et al. 2012, p. 4). After public objection to this policy mounted, a Royal Commission was established to review the need for the mandatory vaccination policy but allowing for “conscientious exemption” (ibid, p. 5–6). Opposition persisted, however, and eventually the revised law mandating vaccination with the possibility for exemption was repealed in 1946.

In the USA, every state and the District of Columbia legally require parents to provide documentation that their children have met the vaccination requirements upon entering school, with some US states imposing sanctions for violating these rules; the Department of Health in New York State, for example, reserves the right to impose a civil penalty on persons who violate the mandatory vaccination policy. The USA does not have a policy of mandatory vaccines for adults, but the US Supreme Court has upheld laws requiring vaccinations in the interest of the common good. In the ﬁrst case of its kind, Jacobson v. Massachusetts (1905), the Court upheld a Massachusetts law that granted municipal boards of health the authority to mandate the smallpox vaccine for persons aged 21 and over in the interest of public health in the face of a clear and present danger.

From a communitarian approach, vaccination belongs to the category of social policies, one in which the intrusion into the individual is small, but the gain for the community is very considerable, and hence mandatory vaccination policies are warranted. At the same time, greater efforts should be made to rely on moral appeals and informal social controls to persuade parents to vaccinate their children and to encourage them to be vaccinated before penalties are imposed.

In Vitro Fertilization: Autonomy Takes Precedence

Some couples seek to have children but cannot because of infertility. It is estimated that infertility affects about 6.1 million people in the USA, or about 10 % of men and women of reproductive age. Technological advances made it possible by in vitro fertilization (IVF) to enable many infertile couples to have children. When the technology was ﬁrst made available in the early 1980s, opposition was grounded in concerns that IVF would create disﬁgured babies, that the so-called test tube babies would be socially ostracized, that they would suffer from poor psychosocial adjustment, that IVF was unnatural and hence inherently wrong, and that IVF would lead to the end of the nuclear family by allowing families to be created in laboratories. Antiabortion activists also oppose the technology as they consider it a form of abortion insofar as some embryos may be discarded in the process. Strong continuing opposition toward IVF comes from religious communities and antiabortion groups that argue that the practice is morally wrong and should be banned because it fails to show due respect for life.

Studies of IVF births show that the process can be successfully completed, producing healthy children, which basically ended the concerns regarding the safety of the technology. Other concerns about the serious adverse social implications of the technology on the common good have not been supported by the data.

Empirical evidence shows that children born through IVF do not develop differently than ordinary children. And, having been born through IVF does not appear to burden individuals’ self-conception or their normative views toward the practice as they grow older. A study of the ethical views of young adults born through IVF in Germany ﬁnds that, “For these adults, the most important factor inﬂuencing their personal attitudes towards IVF was the knowledge that they were deeply wanted children. The artiﬁciality of their conception seemed irrelevant for their ethical opinion” (Siegel et al. 2008, p. 236). The practice has become part of common medical practice throughout much of the world.

On the communitarian view, unless the concerns about signiﬁcant harm to the common good – or the individual involved – can be validated, there are insufﬁcient grounds to restrict the liberty of individuals from pursuing IVF. Having children is a great beneﬁt to many individuals. A considerable number of people have a very strong commitment to the ideal that they ought to be parents. In addition, studies show that infertility engenders major stresses in marriages including “increased marital conﬂict, decreased sexual self-esteem, and frequency of sexual intercourse,” and also, “Individuals attempting to deal with infertility often report feeling inadequate and less of a man or a woman” (Monga et al. 2004; Sydsjö et al. 2011).

In short, IVF belongs to the category of bioethical decisions in which there is very little evidence of harm to the common good or those involved when IVF is practiced, combined with the fact that a major sense of self for individuals who seek to procreate is violated when it is banned and harm to individual self for those who cannot procreate but wish to. Communitarianism thus favors allowing IVF.

The Embedded Self: Commitments To Disclosure And Share Decisions

Physicians in general see the individual as their client. They will follow the patient’s decisions regarding which interventions to undertake, whether or not family members agree or are even informed (as long as they deem the patient to be competent). They will not disclose information to other members of the family unless the patient consented (or is deemed incompetent). And, they will not disclose information to public authorities unless the law explicitly requires them to do. Thus, the default position for medical professions is a highly libertarian one.

A communitarian, although respecting the individual right to privacy and autonomy, holds that people do not exist in isolation, but are members of social communities, as small as the family and as large as the nation, and they have bonds and obligations to each other that should be taken into account. Some psychologists now suggest that this view of the socially embedded self needs to have a more prominent place in contemporary psychoanalysis for married couples. The dominant approach to psychoanalysis and psychotherapy is highly individualistic. Communitarians are concerned about the effects of this approach on people’s bonds to the immediate community (especially to the family, nuclear or extended) and to more encompassing communities as well as the effect this approach has on people’s sense of their moral responsibilities to the common good.

A communitarian psychoanalytic and psychotherapeutic approach would treat people as members of communities rather than as isolated individuals. This can be achieved by couples counseling rather than individual counseling, especially for married people, or a combination of individual and couples counseling, or by group sessions. Secondly, psychologists can view their role as not merely enhancing the personal growth and contentment of the individual but also as ﬁnding ways to achieve these goals in ways that strengthen rather than undermine individuals’ sense of moral obligations to others and to the common good.

The importance of treating the person as socially embedded also stands out in examining both the legal and social standing of DNR (or “do not resuscitate”) orders. Although the term sounds as if it refers only to refusing CPR (or cardiopulmonary resuscitation), in effect, it is used to refer to a list of interventions that a patient may refuse. It is sometimes referred to as an end-of-life medical directive. Libertarians approach the ethics of DNR as a matter of individual autonomy. Some argue that even patients who are not close to death should be free to end their lives if they so choose and even be assisted if this is desired. Some go as far as to embrace the libertarian view that “the taking of one’s own life is the highest expression of our autonomy” and should be respected (Joe 2013). In the USA, all 50 states and DC recognize the right of the patient to refuse life-sustaining treatment by submitting a DNR order, and none afford any legal role for the patient’s family and all greatly limit the legal role of the wider communities, beyond the family, to interfere or limit these decisions.

From a communitarian viewpoint, two issues arise with the libertarian approach. First, a person’s suffering and ending of life deeply affects not just him or her but also those with whom he or she bonded, especially his or her family; hence, the family’s feelings and preferences should be granted a voice. Secondly, as we are socially embedded selves, the community and its values should be taken into consideration in the end-of-life decisions of individuals.

With respect to the family, if a person chooses a DNR order but the family strongly objects, physicians should not ignore these objections, and indeed few do. Health-care personnel (sometimes those specially trained for these situations) should help the patient communicate with his or her family to reach a shared understanding. Even if the patient elects for the DNR order in the end, these consultations will help the family come to terms with the loss they are about to face, alleviate any guilt that they might harbor in thinking they could have done more for their loved one, and ensure that the patient is thinking about the matter seriously with attention to the irrevocability of his or her decision. However, if after careful and extended deliberations and consultation with the family and some reasonable passage of time, still no agreement is reached, then the patient’s last wishes should trump the family’s preferences because the harm to the family (from having to cope with what may be considered a premature ending of treatment) is unlikely to be as strong as that to the patient who must undergo suffering beyond what he or she seeks to tolerate.

A contrasting case, where the family plays too prominent of a role and the individual plays too limited of a role, is found in the practice in Pakistan. There, terminally ill individual patients are often not notiﬁed that they are dying and hence are not given a say over their end-of-life care. This practice is based on the idea that competent but dying persons should not have to deal with the anxiety and distress associated with the fact that they are dying. Another contrasting case is where physicians are afforded nearly exclusive discretion for end-of-life care decisions. In the Philippines, for example, “physicians are held in high esteem and are given extensive authority, so questioning the physician’s treatment decision or being asked to make a decision about one’s own health care is not expected” (Coolen 2012). Both of these practices are at odds with communitarian principles in that they afford no role to individual autonomy and nearly exclusive jurisdiction over end-of-life decisions to the individual patient’s family or the physician. On the communitarian view, the physician’s knowledge should be used to help the patient make informed decisions regarding his or her end-of-life care, and, moreover, the family’s wishes are a relevant concern, but they are not the only or the most important concern in such decisions.

Beyond the family, the community also ought to be granted a voice in the matter. All communities have shared values that are essential for providing moral guidelines for the shared life that communities provide. These values set some limits on the conditions under which various kinds of DNR can be allowed. Thus, Christian groups express concerns of allowing patients to exercise their right to stop life-prolonging technology or treatment. According to communitarianism, physicians should be sensitive to the ways in which “cultural [i.e. communal] inﬂuences can signiﬁcantly impact the patient’s reaction to the dying process and the decisions the patient and family make” (Coolen 2012). Adaptations include providing an opportunity for a clergy to consult patients and for allowing individuals to select among different medical or hospice facilities that follow different cultural norms.

Communities can set legal limits on the decisions involved, for instance, by setting the conditions under which life support may or may not be ended, as was the case in the Karen Ann Quinlan case and in the Terry Schiavo case. (A related example of the community having a voice in a bioethical issue is shown by the Supreme Court’s 2014 ruling that some religious groups can be exempt from offering insurance that covers certain forms of contraception to employees.)

Some communitarians, like Michael Walzer, hold that the community should be the ultimate arbitrator of moral values involved. Other communitarians hold that communities should be free to affect such decisions but only as long as they do not violate basic, universal rights.

Moral Dialogues: A Source Of Changed Shared Moral Understanding

Medical innovations, such as the development of new technologies and new medications, often require reconsiderations of the values that communities seek to uphold through informal social controls and laws. This was the case when in vitro fertilization (IVF) ﬁrst became possible and is part of the ongoing debates about the ethics of cloning and of public reimbursement of the costs of very expensive medications from which millions could beneﬁt.

The communitarian approach stresses the importance of moral dialogues as a source of changes in shared moral understandings. These take place when members of the society at large focus on a moral issue and debate it, over dinner tables and during commutes, at water coolers and call-in shows, and in many other such venues. The debates are often passionate and prolonged and have no clear starting date or closing point. Nevertheless, the record shows they often result in a change in shared moral understanding and, most importantly, in the preferences and behaviors of the members of the community.

For example, until the 1950s, and for many years that followed, the point of death was understood to be when the heart and lungs ceased to function. Until that point, one had a moral obligation to do “all one could” for one’s loved ones, and to deny health-care services before that point was at least unethical if not a crime. Technological developments made it possible to keep the heart and lungs functioning long after a person lost any hope of becoming a person who could have a meaningful life. In 1968, a committee of scientists at the Harvard Medical School suggested that the point of death should be redeﬁned and set when the brain waves are “ﬂat,” which has since come to be known as “brain death” (Beecher et al. 1968). It took many years of public debate, but ultimately increasing parts of the community accepted this deﬁnition.

The communitarian moral dialogues differ signiﬁcantly from the “rational democratic deliberations” that have been favored by liberals. The term “rational” implies that the deliberations are based on empirical ﬁndings and logical conclusions, and the term “democratic” implies that the results reﬂect the preferences of the electorate. They are also expected to be impassionate. In contrast, moral dialogues concern values and help shape rather than reﬂect people’s preferences . Moreover, they concern what have been called “otherworldly” matters, for which there is no evidence but which are matters of belief, like the nature of the afterlife. For example, the argument over whether the death penalty is justiﬁed would be evidence driven if it was based on data that show whether or not this penalty reduces violent crime, but it is subject to moral dialogue to the extent it is driven by considerations of whether it is ever morally acceptable for the state to deliberately take a person’s life.

In 1972, the author suggested the formation of a Health-Ethics Commission to launch and focus moral dialogues on new key bioethical issues (Etzioni 1973). The idea was embraced by the Council for International Organizations of Medical Sciences (CIOMS), but no concrete steps were taken at the time (ibid, p. 15). Between 1974 and 2001, ﬁve commissions were established to address bioethical issues in the USA. In addition, several universities established centers and appointed professors to specialize in bioethics. Think tanks have also been established for the study of bioethics, most notably the Hastings Center, which was founded in 1969. The voices of these scholars and public intellectuals are often heard in the media, in congressional testimony, and in the courts when bioethical issues are discussed, thus enriching the moral dialogues.

Conclusion

In toto, the preceding discussion illustrates the communitarian approach by pointing to the importance of drawing on moral appeals and informal social controls to promote prosocial bioethical changes on the individual and community levels. Communitarians encourage individuals to see themselves as having a responsibility to maintain their own healthy behaviors and favor limited roles both for state coercion and ﬁnancial incentives. Communitarian strategies appeal to persons as members of small and more encompassing communities, rather than as isolated and autonomous agents. Communitarian criteria suggest when more weight should be accorded to the common good and when it should be afforded to individual autonomy. Finally, communitarianism assumes that there are shared conceptions of the good and that moral dialogues are the main processes through which these understandings can be modiﬁed by the community.

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