Bernice A. Pescosolido

Through "Bioethics with a Human Face" Carl Schneider crafts a lens to view in sharp and clear focus the nature of the bioethics' debate, the central linchpin of patient autonomy in these discussions, and the limits encountered when intellectual debates confront empirical reality in the world of medical decision-making.' As the end point to his arguments, Professor Schneider asserts that social institutions inevitably shape the nature of future medical decisions; the fascination lies in exploring how particular social institutions will influence their specific character.' This ending point presents my starting point, for it raises a paradox. How could the same set of social institutions, or perhaps better said, the same socio-historical context, produce two paradigms-biomedicine and bioethics-that so clearly oppose one another?

The simple answer is an historical one. The rise of American modern medicine at the turn of the last century heralded a professionally dominant class of medical practitioners never before seen and so set the stage for the later appearance of the new discipline of bioethics which stands as a counterpoint to this incredible power over health, illness, and healing.' The more complex but more accurate and useful answer lies in taking a sociology of knowledge approach to understanding the modern medical profession, the bioethics discipline, the interaction of the individual and society, and the general nature of intellectual debates. Both biomedicine and bioethics developed as a response to social problems. The development marked, reflected, and addressed inherent societal tensions, particularly regarding the balance of expertise and individualism. Both were set within the larger paradigm of modern society which shaped the range of possibilities for the terms of a modern, science-based medicine and the discourse surrounding the problems that bioethics addresses. Further, both reflect the rhetoric of innovation through exaggeration, particularly in intellectual debates that promote and accompany the development of paradigms and the adoption of social policy that follow from them.

I will pull the lens back even further than Professor Schneider does, back beyond an overview of bioethical literature and its connection to modern medicine and patient preference. I argue that biomedicine and bioethics represent socially constructed phenomena shaped by individuals engaged in intellectual debate, actual practice, and political action, who confronted real problems of life and death in the context of industrial society. In this light, I extend Professor Schneider's striking synthesis of intellectual debate and empirical reality in bioethics in three ways.

First, in light of characteristic tensions in modern society, a socio-historical understanding of the rise of the modern medical profession and the bioethics' discipline requires a link to both larger structures of power and cultural values. This contextual view requires neither notions of conspiracy nor functional imperatives; rather, it requires a more subtle and sophisticated view of social change and social structures. Second, difficulties associated with the centrality of the autonomy principle arise not only from specific findings which show a clear disjuncture between what bioethicists argue people want and what people in fact tell us they want, but also from the underlying view of how individuals make decisions. This takes discussions of medical decision-making into the current, lively debate in social science disciplines about the utility of decision-making. Bioethics, implicitly if not explicitly, views it as a rational calculus process. Finally, these considerations raise questions regarding the utility of centralized autonomy in bioethics. These questions arise not because centralized autonomy in bioethics fails to connect significant portions of present reality, as Professor Schneider persuasively documents, but because it represents a crucial mismatch of the problems and issues that may loom on the threshold of the twenty-first century. In essence, I argue that the quest for patient autonomy may be misguided, given what social scientists, particularly sociologists, theorize and have begun to document concerning contours of the new, transitional form of society we are in, be it labeled post-modern, post-industrial, neo-modern, or otherwise. Each of these arguments are dealt with in a separate section below.