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Journal of Medicine and Philosophy, 31:205–212, 2006Copyright © Taylor & Francis Group, LLCISSN: 0360-5310 print/1744-5019 onlineDOI: 10.1080/03605310600712760

NJMP0360-53101744-5019Journal of Medicine and Philosophy, Vol. 31, No. 03, April 2006: pp. 0–0Journal of Medicine and Philosophy

Bioethics as Biopolitics

Bioethics as BiopoliticsJ. P. Bishop and F. Jotterand

JEFFREY P. BISHOPPeninsula Medical School, Cornwall, United Kingdom

FABRICE JOTTERANDThe Brody School of Medicine, Greenville, North Carolina, USA

I. INTRODUCTION

From its inception, bioethics has claimed to be a project of reflection on themoral issues raised by new technologies. Yet, in its present form there is aperception of a gradual transformation in bioethics. This transformation ischaracterized by an increasing politicization of bioethical issues, that is,one’s “bio-ethical views” will reflect one’s political assumptions concerningthe nature, goals and values that should guide the biomedical sciences. Or,perhaps better stated, bioethics has always been a biopolitics and the politi-cal dimension is only now coming into relief for bioethicists.

One clear example of the emergence of what may have always been abiopolitics is how and by whom ethical reflections are conducted in theUnited States at the federal level depending on who occupies the WhiteHouse. Under Bill Clinton, the National Bioethics Advisory Commission(NBAC) was chaired by Harold T. Shapiro and reflected a certain politicalagenda and specific moral perspectives. The National Bioethics AdvisoryCommission expired in 2001 and was replaced by the President’s Councilon Bioethics, created in 2001 by President George W. Bush and headed firstby L. Kass and currently by Edmund D. Pellegrino. The Council reflects like-wise specific political and moral sentiments as various issues such as theuse of embryonic stem cell for research and human cloning attest.

The current malaise concerning the nature and goals of the field of bio-ethics is characterized by a lack of substantive reflection, which is mirroredin the difficulty of establishing a normative ethics for science in general and

Address correspondence to: Jeffrey P. Bishop, MD, Principal Lecturer in Medical Ethicsand Law, Peninsula Medical School, Royal Cornwall Hospital, Truro, Cornwall, TR1 3HD,United Kingdom. E-mail: jpbishop@pms.ac.uk. Fabrice Jotterand, PhD, Visiting Assistant Pro-fessor, The Brody School of Medicine, Department of Medical Humanities, 2S-17 Brody Med-ical Science Building, Greenville, NC 27834, USA. E-mail: jotterandf@ecu.edu

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the biomedical sciences, in particular. Edmund D. Pellegrino, for instance, israther pessimistic concerning contemporary bioethics’ ability to generatemoral guidance. In his assessment of the trajectory of the field of bioethicsas a tool for reflection concerning science, technology and medicine, henotes that there is a tendency “toward the gradual abandonment of the ideaof normative ethics and moral truth of any kind” and the tendency toemphasize procedures and public policy (Pellegrino, 2000).

This issue of The Journal of Medicine and Philosophy criticallyaddresses the question of how discourses in bioethics are imbedded indeep political assumptions, hence, the depiction of bioethics as biopolitics.The term biopolitics was first coined by Michel Foucault at a conference onsocial medicine in 1974 (Foucault, 1976, p. 152). Foucault continued histhinking on biopolitics in his lectures delivered at the Collège de France(Foucault, 2004). In these lectures Foucault articulates a notion of powercontrary to that of his earlier works (Madness and Civilization, and Birth ofthe Clinic) where power is primarily a restraining and oppressing force. Hisnew use of the notion of power in biopolitics takes on the character of thesustenance offered by politics to create structures that enable populations toachieve new freedoms and vitalities. The state comes to wield power overlife, but now an enabling power that is not just repressive, creating insteadthe conditions for new capacities (Foucault, 1988, p. 160).

II. MEDICINE AND POLITICS

Quite independent of Michel Foucault, the authors in this issue are dealingwith a question at the heart of bioethics and biomedicine today, namely thequestion of the relationship between medicine and politics. They offer cri-tique and constructive analysis from the macro-level of bioethics (especiallyGriffin Trotter and John H. Evans) to the micro-level of the operating room(see Alan Bleakley). We find arguments suggesting that the way forwardwill require a modest reframing of public bioethics, and still other argu-ments suggesting the need for radical reconceptualisation of bioethics. Wealso find arguments suggesting a top down reformulation will only perpetu-ate a biopolitics, and that the best way forward is to frame bioethics withinthe ethical call of the Other.

In addition, the authors represent several different disciplines includingsociology, psychology, and theology, in addition to philosophy and bioeth-ics but also provide an international perspective, hence reinforcing thenotion that bioethics “requires” politics in addressing bioethical issues trans-nationally. The diversity of insights into the political nature of bioethicsgives credence to the suspicion of many that bioethics has become, oralways has been, a biopolitics. Moreover, the authors also represent fourdifferent nations from three different continents. The sum of their insights

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illustrates the extent to which, as a world-wide phenomenon, bioethicsemerges as biopolitics.

Finally, and at the risk of caricaturing the contributors to this issue, wewould like to point to the broad political stances taken by these authors.The fact that there is such a diversity of political starting points for ourauthors—from Liberalism to Libertarianism to Communitarianism—suggeststhat this issue of the Journal of Medicine and Philosophy brings to the forefront of bioethics what has been implicit for a long time, namely the biopo-litical. Taken together, the authors engage issues of bioethics and biopoli-tics, from the macro level to the micro level, from the conceptual to thepractical, from the scientific to the clinical, and from the critical to the con-structive. Whether one thinks that bioethics has become, or has alwaysbeen, a biopolitics, it is clear that this phenomenon can no longer remainunacknowledged by our discipline.

Taken together, the authors published here identify something not sodifferent from what Foucault said was the dream of modern politicaldemocracy—a pervasive biopolitics in which the life of the population isboth managed and valued. Foucault’s point about biopolitics is that, withthe rise of the contemporary governmental structures, indeed at the verydawn of contemporary government there is a concern with the biopolitical,the health of the public, the health of the body politic (Foucault, 1988,p. 160).

Still, for Foucault, biopolitics is not necessarily lamentable, but insteadis an ambiguous, or possibly even a polyvalent condition of modern life. Onthe one hand, a biopolitics might come to shape the destiny of peoples forthe better, the dream of Liberalism; but it might come to shape the destinyof peoples against their wills, a concern of contemporary libertarians. Onthe other hand, through a biopolitics, biomedicine as a body of expertisemight assist peoples to achieve greater heights of personal enrichmentthrough personal and individual freedom, the dream of Libertarianism,which often leaves others behind thus destroying egalitarianism, a threat tothe sensitivities of liberals. Thus the spectrum of political tendencies withinthe discipline of bioethics reveals a tension on various levels: not only canethical issues not be settled by mere moral reasoning due to our lack ofconsensus at the foundational level, but one also is confronted with theeven more disconcerting conclusion that the domain of “public reason” (i.e.,the polis) is characterized likewise by dissensus as the authors of this issueattest in their contributions.

Two of our authors fall on either side of that kind of divide. John Evanscritiques the expertise model of bioethics, particularly when the expertisefalls into the hands of the public bioethicist and under the domain of ana-lytic philosophy. At the same time, Evans argues for a more egalitarian ver-sion of a technocracy, in which expertise can be more efficiently appliedtoward a commonly accepted end. To achieve this, Evans envisions a discourse

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utilizing the tools of social science to achieve a truly democratized bioeth-ics. Once we know that toward which we strive, he claims, we can thenapply technocratic expertise on how to bring those purposes about. In thisnew bioethics, we will also see interest groups with “house intellectuals,”bioethicists who will articulate agendas and rationales for interest groups. Ina way then, Evans is arguing for a more liberal form of bioethics, one thattruly represents the concerns of society, as opposed to the bioethics whichcurrently remains quite narrow and, at the same time, too universal to be ofany value, and too esoteric and unrealistic to be representative of a trulypublic bioethics.

Where Evans calls for modest reforms, Griffin Trotter offers us a radicalcritique of current bioethical discourse and suggests we abandon the con-temporary model. Trotter does so by reclaiming insights offered by ThomasHobbes, who so often has been ignored as central to contemporary politicalphilosophy. Trotter systematically offers the Hobbesian warnings aboutdeliberative democracy, and then illustrates how contemporary bioethicsconfirms the necessity of Hobbes’s critique. He concludes by offeringanother model of bioethical discussion and discourse, modus vivendi. Inthis neo-Hobbesian political philosophy, there is no illusion of deep moralcommitments, and there is no illusion that deep consensus is possible. Theonly thing to which partisans agree in modus vivendi is to discourse, no fur-ther elaboration on what counts as discourse is needed. Bioethics might besalvaged in its descriptive role, in which the bioethicist engages in articulat-ing the rich moral rationales of the disputants. Thus, in a way, both Evansand Trotter agree that bioethics has crossed some boundary and thatreform, whether modest or radical, is needed.

Our next two authors take a different approach to biopolitics. TomKoch and Christopher Newell give us a glimpse from the margins of societyand from the margins of bioethics. Koch asks important questions, like whyis it that the discourse in bioethics is so narrow? Why do we not entertain ortake seriously voices like Wesley J. Smith? Smith has not been taken seri-ously, especially by the liberal establishment in bioethics. Such radicalvoices, he claims, are not taken seriously, and thus any claim to consensusis unfounded. Sure there is a semblance of discussion in journals, but thediscussions often collapse into ad hominem attacks on religious perspec-tives at the water cooler, or even in national conferences. Who starts the adhominem attacks depends on the perspective from which one comes. Kochhints at a fundamental issue at the heart of tolerance, namely that on theleft, tolerance tends to mean tolerant of anything non-traditional, but intol-erance for anything traditional. On the right, tolerance is for all things tradi-tional, but intolerance for anything coming from the left.

Christopher Newell gives another description from the margins, thistime the margins are those of a society that creates the abnormal by biopoliticallycreating the normal. Newell is a bioethicist who identifies as disabled, and

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perhaps all those disability scholars who have been writing in recent yearshave understood the depth of biopolitics precisely because they have beenoppressed by it. Disabled voices—literally those voices which have beendisabled by society because they are not heard by society—have beensilenced as rejected knowledge he claims. That knowledge has beenrejected by both the political left and the political right because they sharethe same dream of a healthy—read normal—polis, and they share the samesense of the necessity of technological progress. But Newell also points outthat politicians of many different political persuasions come to use thevoices of the disabled insofar as these voices can achieve their partisanagendas. Then the disabled voices are moved out of the public eye andback on the shelf to be used again when another agenda needs to bepushed. Newell concludes, however, that there is something deeper offeredby people who live with impairment in their accounts of a lived experienceof disability, and it is the actual lived experience that bioethics rejects. Newellconcludes that, when disability voices are no longer perceived as purely cri-tique, he will know that a disability perspective has arrived. For, as he sopoignantly concludes, perhaps the human condition is a condition ofdependency, something about which he knows. And his knowledge ofhuman dependency contradicts the ideologies of rational autonomousagency of modernity.

Both Koch and Newell seem to be saying that the view from the mar-gins of mainstream society illustrates precisely the point that both Evans andTrotter engage. There is a poverty of discourse at the heart of bioethics.Thus, the dream of a biopolitics that enables the members of a society is nota reality. Koch and Newell, perhaps because speaking from the margins, areless optimistic about the enabling, capacity building possibilities of biopoli-tics. For them, biopolitics remains oppressive.

Our last two authors take a slightly different approach, one looking atthe imperative for scientific and technological development and the otherlooking at the mundanely clinical. Amy Laura Hall sees something inher-ently political in the notion of progress which animates biomedical science.Her philosophical methodology utilizes historical narrative to bring intofocus the drive for progress as instantiated in the discourse around the 1933Chicago World’s Fair and in the discourses surrounding the drive for anduses of atomic energy. What emerges from her narration is the way inwhich the telos of progress is never questioned and how the politics ofprogress come to produce a purely proceduralist bioethics. When someonefrom the so-called developing world questions the imperative of progress,the “developed” world answers with the need for equal distribution of thefruits of technology, or the assurance that the autonomy of the developingworld will not be violated. Hall claims that there is a sense in which the justdistribution of the fruits of technology, and the consent of those who willbenefit from it, assures the morality of the progress itself. The politics of

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progress produces a proceduralist bioethics precisely because the telos ofprogress is never questioned. Yet, there is something altogether more sinis-ter at work in the politics of progress, namely the need of the “developed”for the “developing” world to remain underdeveloped in order for the“developed” world to gauge its progress.

With our final author we move from the quest for progress in scienceand technology to the mundanely clinical, namely the daily routines of theoperating theater, the operating room. Alan Bleakley and his colleagueshave carried out qualitative empirical research with operating theater teamsin order to examine the dynamics of the operating theater and the inher-ently political nature of communication within the surgical arena. Bleakleyuses this research as the occasion to question the individualism that givesrise to the political hierarchies in the operating room, and how these hierar-chies may in fact produce mishaps and errors. The individualism that givesrise to experts working in isolation is the same individualism that gives riseto the dominant bioethics. Even the virtue ethics that gives rise to calls forprofessional integrity and professionalism has become too individualistic.Bleakley, instead, calls for a virtue ethics that finds its imperative in the callof the Other—a call that calls one out of oneself. The surgeon and the scrubnurse and the post-operative nursing staff are all called out of their individ-ual professional identities to become a community, a team. They are calledby the needs of the other—the patient—into a community for the good ofthe other. The community, the polis, the politics of the operating theatershould emerge out of this call, Bleakley claims. He urges a virtue ethicsthat arises as a communal response to the call of the Other.

III. RETHINKING BIOETHICS

Taken together, the essays in this issue of the Journal indicate that Foucault,on the one hand, may have been correct about biopolitics and yet woefullymistaken on the other hand. As moderns we cannot escape political space.Yet, what our current authors show us is that the biopolitical is a moderninvention. In killing the king, we but diffuse power along democratic lines.The sovereign becomes the self who defines and subjects himself. We findthe individual who governs himself. We are but a loose configuration ofsovereign subjects—the contradiction at the heart of Western politics. Thecontributions to this issue seem to show us that the political left wing andthe political right wing belong to the same political beast, each flapping in adiscordant and counter purposive manner. These articles uncover a bioeth-ics which is necessarily a biopolitics. But they all show us that we are a farcry from any dream Foucault, or the French Revolution, or modern publichealth initiatives might have had about the enabling capacity of a biopolitics,

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and indeed these authors seem to ask whether that dream is even possible—a point well noted by Giorgio Agamben.

“Today, politics knows no value (and consequently, no nonvalue)other than life, and until the contradictions that this fact implies are dis-solved, Nazism and fascism—which transformed the decision on bare lifeinto the supreme political principle—will remain stubbornly with us”(Agamben, 1999, p. 10). Nazism and fascism, because they so blatantlydefined a life worth living, are only the most obvious and disquietingamong biopolitical totalitarianisms (Agamben, 1999, p. 4). There are othertotalitarianisms, less obvious and thus more subtle, seductive, and danger-ous. Why is it that, at the very moment when democracy seems to have pre-vailed over totalitarianism, modern democratic societies becomeindistinguishable from it? (Agamben, 1999, p. 10) At one level, each of ourauthors seems to be saying that we just need to better manage the biopolit-ical to avoid totalitarianism.

Yet, at another level, each of our authors smells something rotten in amodern bioethics as a biopolitics, for there is a sense in which the taskagainst totalitarianism is not manageable at all. Agamben notes a confu-sion about the fundamental categorical pair of Western political philoso-phy: the notion of zoe—spiritual or sacred or bare life—as opposed to thenotion of bios—the communal or political life. He claims that the West hasset about to elevate the bios politikos to the level of zoe in order to over-come the totalitarianism of the monarch who decides who lives and whodies. Thus the dream of Western political democracy is to politicize “thenatural sweetness of zoe” (Agamben, 1999, p. 11). Yet, the categorical pairof zoe/bios detracts from the more primordial pair of exclusion/inclusion.What modern versions of biopolitics have forgotten, or perhaps havenever known, is that in conflating zoe and bios, one misses the more fun-damental aporia of exclusion/inclusion. Biopolitics, according to Agam-ben, cannot merely be Foucault’s enabling power, but always necessarilycollapses into totalitarianism. In not acknowledging the more fundamentalaporia of exclusion and inclusion, the biopolitical endeavor of the Westbecomes complicit with the drive to define who has zoe worthy of politi-cal life and who does not (Agamben, 1999, p. 8). Our authors all, in theirdifferent ways, find aspects of bioethics to be complicit with a rottennessat the heart of biopolitics. Is what they all recognise in contemporary bio-ethics the stench of totalitarianism?

REFERENCES

Agamben, G. (1999). Homo Sacer: Sovereign Power and Bare Life. (D. Heller-Roazen,Trans.). Stanford, CA: Stanford University Press.

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Foucault, M. (1976). ‘La crisis de la medicina o la crisis de la antimedicina,’Educación médica y salud, 10(2): 152–170.

Foucault, M. (1988). ‘The political technology of individuals,’ in L. H. Martin,H. Gutman, & P. Hutton (Eds.), Technologies of the Self. Boston: University ofMassachusetts Press.

Foucault, M. (2004). Naissance de la biopolitique: Cours au collège de France(1978–1979). F. Ewald, A. Fontana, & M. Senellart, Eds. Paris: Gallimard/Leseuil.

Pellegrino, E. D. (2000). ‘Bioethics at century’s turn: Can normative ethics beretrieved?,’ The Journal of Medicine and Philosophy, 25: 655–675.