This editorial can be found in the September 2024 issue of the American Journal of Bioethics
In “Bioethicists Today: Results of the Views in Bioethics Survey (VIBeS),” Pierson and colleagues describe the results of a survey inquiring into bioethicists’ views on normative issues. As the President of the American Society for Bioethics and Humanities (ASBH), I was largely unsurprised by the findings of the inquiry. I will explain why by using ASBH’s Strategic Priorities to guide the discussion.
But first things first: the VIBeS survey. The authors found consistency among normative commitments and views of bioethics issues from the respondents, high levels of agreement among bioethicists on substantive areas, and some differences when data were compared with reports of public views. Pierson et al. claim that this “point in time” survey is useful as a way of describing the current state of bioethics and can guide the field in making decisions—about equity and inclusion initiatives, about representation, and about appropriate paths for continuing discourse.
To understand why these results made sense to me, it is important to know something about ASBH as an organization. The purpose of ASBH is to promote the exchange of ideas and foster multi-disciplinary, inter-disciplinary, and inter-professional scholarship, research, teaching, policy development, professional development, and collegiality among people engaged in endeavors related to clinical and academic bioethics and the health-related humanities. It was formed in 1998 from a combination of three organizations: the American Association for Bioethics, the Society for Health and Human Values, and the Society for Bioethics Consultation.
ASBH has grown not just in numbers but also in breadth and depth over the past 25 years. This organizational development has enabled us to harness our strengths and create a series of strategic priorities: (1) to continue a strong annual meeting; (2) to support the goals of health care ethics consultation and the development of health care ethics consultants’ capabilities; (3) to develop a credible, defensible process to measure the knowledge and skills of entry-level healthcare ethics consultants; (4) to ensure that health humanities will remain core to our mission and consider ways to better serve our members; (5) to ensure optimal structures and processes for the Nominating Committee that will support the election of the best-qualified candidates to serve on the board of directors; and (6) to define diversity, equity, and inclusion (DEI) goals for ASBH as an organization and how those values will be reflected through ASBH programs.
Connection to the ASBH Annual Meeting
The reason Pierson’s findings did not surprise me is that despite a membership well over 2000 and an average conference attendance of about 1000, every year some attendees insist that we talk about “the same old things” in “the same old ways.” Each year, the Program Committee, in consultation with ASBH leadership, develops robust themes to unify annual meeting programming. Yet no matter how many presentations we accept, or how we lump or split the presentations, members routinely assert that there is “nothing new” here. This is why I was not surprised by the consistency that Pierson et al. describe; I hear the concern every year.
Pierson et al.’s piece suggests that one explanation for this lack of diversity in programming reflects the homogeneity of the views of bioethicists. While there is no necessary connection between one’s professional or personal commitments and one’s scholarship (one might make strong ethical arguments about the right to “death with dignity” and yet not support that for oneself or one’s family), there is often a symmetry between them. And given the amount of consensus among bioethicists in the VIBeS survey about, for example, consent in capacitated patients and the permissibility of abortion in some circumstances, then it’s no wonder that annual meeting presentations about these issues makes us feel as though we have heard it all before.
Furthermore, it is this sense of (if not unanimity then at least) broad consistency that encourages members to suggest that we, as an organization, can and should make substantive position statements reflecting this consensus that some views are obviously “wrong.” Some have argued that there are moral truths inherent in bioethics and medical humanities, and ASBH’s commitment to “moral neutrality” is morally reprehensible. There are clear wrongs, supporters claim, in the criminalization of addiction, on issues of human rights, or on the (in)adequacies of health care for the uninsured. Failure to call out these wrongs is a collective failure of ASBH, they say.
Except that the values that support “taking stands” are neither ubiquitous nor obvious. That is: ASBH strives to be the space for respectful, dynamic discourse even when—especially when—there is disagreement at the margins. We believe that this is what it means to meet the needs of annual meeting attendees in bioethics and the health humanities—ALL the attendees, not just those with the majority view. Members routinely advocate for those who may be silenced in more mainstream conversations. In recent years, we have consciously encouraged individuals to submit abstracts that challenge conventional wisdom—that is what integrating our DEI priority means. Our materials describe the annual meeting as a “platform for presenting new ideas, debate, discussion, learning.” We will not fulfill this goal if those more common stances Pierson et al. cite become official positions of the organization. If we did, those who want to challenge those positions will no longer have equal standing to express their perspectives. A commitment to pluralism and vigorous discourse means being open to views that are less common for many reasons, not the least of which is, as the authors describe, that these views may be quite disparate from the public that we serve. At the very least, being more conversant with those views would facilitate the advancement of bioethics and health humanities in ways that reflect the common morality. At most, this work could serve to expand our disciplines in ways that are productive and provide a much-needed constructive critique of the rhetoric of majority views.
Connection to Health Humanities and DEI
Pierson et al. admit several challenges to their research: that their definition of bioethicist was bounded in a particular way that likely oversampled academic bioethicists, that their analysis only represents results from 515 survey respondents, and that they oversimplified (deliberately) complex topics. Of course, researchers must start somewhere, but it can be argued that these methodological constraints inappropriately skewed the results such that using these data as a “starting point” for anything would be ill advised.
For example: the overfocus on academic bioethics, especially the requirement that someone spend at least 20% time on bioethics-related activities, excludes faculty or staff at under-resourced organizations who may engage in this work on collateral or personal time. At ASBH, we know this is a particular concern for our colleagues in the health humanities who may also engage in bioethics or clinical work. We are thinking carefully as an organization about how to integrate the discourse of these areas in ways that further the conversation; that is, we are thinking about ways the “and” of “…Bioethics AND Humanities” can produce more than either of the fields alone. Aiming at rich intersectionality will require a rethinking of both the who and the what of bioethics. If that is true, then the narrow focus of the VIBeS survey may not serve our interests as a discipline.
This intersectionality that characterizes ASBH’s approach to DEI is about both people and process. That is, we take a deliberately broad view of who we are precisely because we know that strict definitions are limiting—within bioethics, within the humanities, and across the two. This is my worry about the narrow nature of those included in the VIBeS survey: to the extent that those excluded by basis of position represent marginalized or minoritized individuals, one would be ill-advised to use the resulting survey data as a basis for decision-making for a wider and more diverse constituency.
The likely objection that “this is just a sample/snapshot” misses the mark: citing this study as the foundation of even broad understanding among bioethicists paradoxically reinforces the lack of inclusion in the field that the authors challenge. Making bioethics “braver, broader, and more just” is not simply a matter of recruiting new students from a more diverse cohort. Instead, it requires recognizing and confronting the racial and power hierarchy that characterizes not just the individuals in the field, but also the work in which the field engages. Answering that call to transform bioethics might have included asking different questions in this survey: instead of asking about views on embryo selection and medical aid in dying, Pierson et al. could have asked about bioethicsts’ views on health disparities or structural racism. The questions we ask and the ideas that we name change a conversation. Being committed to inclusion requires a fundamental change of perspective so that the central questions we formulate wrestle with the issues we see as the most dire and neglected. ASBH is trying to do just this through its DEI strategic priority. Such a fundamental shift will undermine the long-term value of the VIBeS survey since longitudinal data would be meaningless, and yet it is the direction in which many believe we ought to go.
Connection to Clinical Ethics
Even if we focus on what some consider the more common areas in clinical ethics, I worry about how much we can rely on the results presented here in guiding the future of the field. We know that the number of clinical ethicists who are members of ASBH is a microcosm of those who are engaged in this work in hospitals. Indeed, one estimate is that there are as many as 32,000 individuals engaged in the work of healthcare ethics at US hospitals. It is an open question how many of those individuals consider themselves bioethicists, but surely at least some of them would. There is very little information available about these individuals, but it is plausible that these staff members, being less involved in academia, may have more diverse views than academic bioethicists and may better reflect the views of the public. Or they may not. Yet to claim that we have a snapshot of bioethicists’ views from this small survey is surely an overreach. While it certainly is true that if we look at ASBH or Association of Bioethics Program Directors (ABPD) membership we are nowhere near as diverse as the public, it is not clear we can say this if we include all those who are doing hospital ethics work. As an organization, ASBH is committed to providing resources and support for those engaged in the work of healthcare ethics consultation; I worry that relying on this study could mislead us into developing materials that mirror those surveyed and are thus not reflective of the broader community engaged in this work.
Finally, Pierson et al. challenge readers to consider these data in areas where “they may have special insight or around which they may influence policy or political discourse” (9) and to “reflect on how our perspectives may resemble or depart from the views of others” (22). To this end, I encourage readers to consider what we need to know that this survey does not tell us. Even the authors admit that it does not tell us anything about the normative validity of the topics surveyed. Yet to responsibly engage in policy development or political discourse, bioethicists must interrogate the liminal spaces: what is the full range of expression of these matters? How should members of a pluralistic society attend to all those who might have a view and a voice, and what role can bioethicists have in developing those distinct outlooks and sharing their contributions? With whom should we engage as healthcare ethics consultants to ensure a diversity of values are on and at the table? What can robust intersectionality give us that is crucial for advancing policies and practices that support a more just and inclusive society? ASBH strives to be the home for such conversations in a way that reflects strong traditions of inter-disciplinary discourse, empathy, and collegiality.