The Methods of Communitarianism Consensus from Fragmentation

Communitarianism is probably best characterized as a philosophy of public deliberation that tries to produce consensus on public matters—matters that include the topics typically considered in the field of bioethics. Of course, the important question is how to actually produce that consensus. Three general approaches predominate: the whole-tradition method, liberal communitarianism, and consensus in public judgment.

THE "WHOLE-TRADITION" METHOD: REVIVAL AND REVITALIZATION OF PARTICULAR TRADITIONS. The

"whole tradition" method of communitarianism sees the fragmentation of values and traditions as an almost insurmountable problem. Communitarians such as the philosopher Alasdair Maclntyre and the Christian theologian Stanley Hauerwas view moral concepts as only intelligible within the traditions in which they originated. Moral traditions, therefore, contain concepts that are incommensurable with those of other traditions, and that are untranslatable because they only make sense within their respective traditions. As a result, moral method must take the form of reviving particular traditions.

MacIntyre proposes that moral discourse take the form of a competition among revitalized traditions. Each tradition would express itself through a university in which the tradition would express and develop its worldview across the disciplines. The ultimate test of a tradition is the degree to which it can create a comprehensive worldview that accounts for the facts of the contemporary world and can respond to new challenges and crises that arise. MacIntyre also holds open the possibility that one worldview may simply be developed that is comprehensive enough to encompass the truths and strengths of other traditions. He clearly believes that the Aristotelian-Thomistic tradition is the most promising in this regard (MacIntyre, 1990, p. 81).

The whole-tradition movement in communitarianism is the most radical and pessimistic form of communitari-anism. It holds that there is (and can be) no genuine moral discourse in a pluralistic liberal society—and that the revival of whole traditions in toto is the only possible solution. Once such traditions are developed, people can choose among the views of the good life that are contained therein. The work required to bring this about is described by MacIntyre as being akin to the service that Saint Benedict and the monastic orders provided in keeping civilization alive during the medieval period.

LIBERAL COMMUNITARIANISM. Communal deliberation is intrinsic to communitarianism. So it is natural that some communitarians should propose that community members gather and deliberate to develop consensus. In bioethics, this approach is notably associated with the early work of Ezekiel J. Emanuel.

In his highly regarded book, The Ends of Human Life: Medical Ethics in a Liberal Polity (1991), Emanuel suggests that ethical decisions regarding medical care are best handled by the members of small cooperatives called Community Health Plans (CHPs). Members would have a choice of a variety of CHPs in their geographic area. In the early stages of the founding of the plan, members would articulate the fundamental value assumptions behind the plan. For instance, some CHPs could have a philosophy that is strongly geared toward preservation of biological life, while others might maximize palliative care options. Similarly, some might strongly favor choice in reproductive and contraceptive options, while others would promote religious approaches to family life. By organizing the CHPs according to nonnegotiable value choices, the CHP progresses easily beyond the shrill and interminable debates to the more subtle choices involved in developing a health plan.

In Emanuel's plan, each person would have a voucher that would be brought to the plan. As a result, the deliberation about values and coverage of treatments is also a resource-allocation process. Each member must think not only about his or her values in the abstract, but must consider how to balance the fiscal implications of those commitments against other values and potential needs. This discussion takes place within a communal dialogue among the approximately 10,000 members of the plan. In such a dialogue, a person comes to develop his or her deliberative capacities and refine and clarify his or her values.

The strength of such a proposal is that it embodies the virtues of a genuine deliberative democracy. Such a plan brings together the rights and responsibilities of each person, granting each the right to be true to his or her most fundamental value commitments, and to be self-determining in devising a health plan to meet those commitments. But, more importantly, it demands personal responsibility in accepting the allocation consequences of one's choices. One may choose to be part of a plan that explicitly provides a maximum amount of some services and minimizes other services, and one must live with the minimal services provided should he or she develop an illness that might benefit from a higher level of services. Because the plan respects the rights of each within a communal framework, it is sometimes called liberal communitarianism.

Of course, the proposal for CHPs suffers from the practical difficulties of any community-based initiative. Although our best selves may develop in a context of dialogue and deliberation, many persons will simply not wish to devote the time and energy needed to participate meaningfully. Emanuel acknowledges that the model of the New England town meeting (the model on which the CHP is based) usually becomes dominated by a small, highly participatory group in whom the silent majority comes to have confidence (Emanuel, pp. 231—232). However, if stable communal consensus can be developed in ways that do not require the direct participation of most citizens, such approaches may recommend themselves to communitarians.

CONSENSUS IN PUBLIC JUDGMENT. Proxy dialogue and balancing values. One of the striking facts concerning bioethics is that public debate has produced areas of stable consensus, most notably in the United States, concerning informed consent to treatment and the principles concerning end-of-life decision making. Similarly, some studies have suggested that the American people may, in general, be less fragmented in reference to their values than is usually thought to be the case. Contrary to the radical communitarians such as MacIntyre, there may be empirical reason to be optimistic that a society can achieve stable consensus on moral problems that occur within public and quasi-public institutions.

The public debate concerning informed consent and end-of-life decisions has not been one with a clearly identifiable locus, but has taken a variety of forms, including court decisions, state referenda, and the policy deliberations of institutions such as professional societies and accreditation agencies. The public has been informed in a variety of ways, including media coverage of court decisions, public education efforts when referenda are introduced, and portrayal of these issues in entertainment programming such as television medical dramas. Somehow, over time, a consensus has taken shape.

Consensus, in this context, has tended to mean a set of principles that are widely accepted. It does not mean unanimity, for a large pluralistic society will always include those who disagree. Similarly, the interpretation and application of the principles will constantly require refinement because of the wide variety of possible circumstances in which they may be needed. As a result, debate may seem to be ceaseless, but the object of the debates actually becomes more refined. For instance, the consensus on forgoing life-sustaining treatment includes a distinction between forgoing treatment and assisted suicide (though the state of Oregon does not adhere to this distinction in a substantive way). The consensus also holds that patients who have lost their decision-making capacity (i.e., they have been deemed "incompetent") have the same rights as other patients. While all U.S. states adhere to this general principle, the evidentiary standards regarding the incapacitated patient's prior wishes can differ substantially among states (Meisel, Snyder, and Quill). Although these are important disputes, they do not undermine the widely shared areas of agreement.

Of course, identifying that a society has achieved a stable consensus is not always a simple task. Public opinion polls can measure the public's views, but it is not always obvious when the data reflect a stable consensus. It is often the case that responses to poll questions reflect mere fleeting preferences. Although communitarianism is premised on the idea that people must come to discover their wishes, or how their values translate into preferences, how this happens on a grand scale is somewhat mysterious. However, some suggestions have been made.

First, a consensus is probably more stable if it is able to balance several competing values that are important to a society. For instance, the consensus on forgoing life-sustaining treatment has been relatively stable for more than a decade because it reflects the balancing of important values and considerations (Kuczewski, 2002). A patient's ability to participate in the decisions regarding his or her medical care, especially as one nears death, is fostered and balanced against the duty of society and the medical profession to protect patients, especially those who are vulnerable due to lack of decisional capacity. Policy proposals that tip the balance heavily in favor of patient self-determination, such as those for legalizing assisted suicide, have met with limited success. Similarly, proposals that eschew patient autonomy in favor of the physician's duty to do no harm, such as futility policies, continue to remain outside the consensus (Helft, Siegler, and Lantos).

Second, in situations in which the content of consensus gains widely shared acceptance without direct participation by the citizenry, some sort of "proxy dialogue" might have served as a substitute for direct participation (Yankelovich, 1999, p. 167). That is, representatives of various positions and interests might achieve recognition, and their interaction might forge a position that accommodates the major values at stake. By having the process play out publicly, the solution is internalized by much of the citizenry. Furthermore, consensus is semiperformative (Moreno, p. 52).

A consensus is furthered when an announcement is made that there is a consensus on certain points. People generally do not wish to overturn consensus for its own sake. Thus, when one announces consensus and proceeds to state the specific points, people will probably prefer to assent. This assent would seem more likely to be freely given if the citizens are able to recognize their values as being respected in the points of consensus. Dissent would seem more likely to follow if the consensus is ideological in the sense that it traces all its points to only one value or principle, rather than representing the array of values that are relevant to the issues under consideration. These values may be identified a priori by surveying the goods generally considered characteristic of a particular sphere of human activity (Walzer, pp. 6-10), or by empirical approaches that assess the values of the community involved.

Relationships, casuistry, and pragmatism. On the most pragmatic level, communitarians often approach ethical issues by beginning with the norms of the relationships involved, rather than the rights of the individual. In this way, communitarianism provides the foundational philosophical assumptions for the customary workings of popular methods in bioethics, such as casuistry, pragmatism, and the four-principles method. Bioethics, especially clinical bioethics, has often proceeded as if a number of persons have a stake in the outcome of the case, and that dialogue and negotiation leading to consensus are better than a simple assertion of one person's rights. These practices are more easily justified within a communitarian conception of the person as being essentially related to those around him or her than on the liberal conception of the individual. However, this does not necessarily result in a tyranny of the interests of the majority, as there may be spheres of being in which individual rights are more authoritative, and irreconcilable conflicts may have to be resolved in favor of certain individuals no matter in which sphere of endeavor it takes place.

Casuists such as Albert Jonsen and Stephen Toulmin assert that that the kinds of norms that predominate in various types of cases result from the nature of the relationships involved in the particular case under examination. Cases in which the relationships are intimate are more generally decided in favor of values such as beneficence and caring. In these kinds of cases the boundaries between persons are fluid, and looking out for the good of the other is often called for by the situation. In impersonal situations, in which persons are more likely to be strangers, solutions are more often found in the direction of autonomy and individual rights. Nevertheless, specific circumstances can render these generalizations inapplicable, and some spheres of interaction (e.g., healthcare) can embody elements of both an ethics of strangers and an ethics of intimacy. As a result, paradigm cases for each kind of bioethical issue must be sought and taxonomies of paradigms and variations established (Jonsen and Toulmin, pp. 291-292).

Similarly, the famed four principles approach, also known as principlism, takes the physician-patient relationship as the starting point of medical ethics (Beauchamp and Childress, pp. 12-13). Principlists argue that ethical problems arise when any of the four main obligations of physicians to patients (respect for autonomy, nonmaleficence, beneficence, and justice) come into conflict with another of the principles. The goal then becomes to resolve this conflict of principles. This method assumes that members of society share a common morality, and that it is interpretable within the confines of the healthcare system (Beauchamp and Childress, pp. 401-405). These same assumptions are shared by many communitarian bioethicists. However, communitarian philosophers have made advances on the static understanding of the moral principles of the principlists. For instance, Emanuel's communitarianism includes a theory of the physician-patient relationship. This relationship, in its highest expression, focuses on helping the patient to interpret and discover his or her health-related values and how they apply to the choices before the patient (Emanuel and Emanuel). In this framework, patient autonomy is an essential element, but in many situations it is seen as the outcome of an interpersonal process rather than as the starting point of the interaction. Others with communitarian leanings focus on familial relationships as the starting point of an ethic.

Thomas Murray, a sociologist by training, argues that bioethics will make more progress toward consensus on controversial issues by starting with a tapestry of relationships that are prized by persons in a society. He notes that familial relationships are often among those that give distinctiveness to life. By creating such a tapestry, and describing the goods fostered therein, he believes that some of the so-called unending debates in bioethics can be defused. For instance, Murray asserts that conclusions in the abortion debate often exceed the premises and are inconsistent with other practices of adherents of the conclusions. Murray believes that the strength of the conclusions is probably a derivative from perceived threats to valued relationships (Murray, pp.173-174).

James and Hilde Nelson have begun the work of developing an ethics of intimate relationships that takes familial relationships as the starting point. This kind of work exemplifies the nuances of contemporary communitarian bioethics in that it results in generalizations about specific spheres of relationships. Furthermore, the kinds of generalizations that are developed give moral weight to those whose interests are most affected by situations, rather than invoking individual rights.

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