The Ends of Human Life: Medical Ethics Ina Liberal Polity. By Ezekiel J. Emanuel. Harvard University Press. 307 pages. $34.95.
Medical ethics is impossible. At least today. In this country. This is the starting point of The Ends of Human Life by Ezekiel J. Emanuel, an oncologist and philosopher at Harvard. But we can correct this situation, according to Emanuel. All we have to do is deconstruct America. Here is how he reasons.
Medicine is committed to moral ideals -- treating the sick and relieving suffering. How one properly goes about that is the content of medical ethics, which is necessarily based on political philosophy. Only when the good life is specified by a political philosophy can a system of medical ethics be determined. For example, if the good life is defined as only possible when one is aware of others, then medicine is not ethically obliged to spend much time or money on patients who are vegetables. But in America our political philosophy eschews definition of the good life. Hence, we cannot now formulate a system of medical ethics. Emanuel would alter this situation by changing our political philosophy, in effect by disuniting the United States.
He would do this by establishing a series of small communities that would define the good life for themselves and thus be able to create their own medical-ethical guidelines. One community might agree that the good life is any life in which the heart is beating and the lungs breathing, and thus be in favor of all treatment of the sick no matter what. Another community would construe the good life as only that existence in which people are productive, and thus tolerate euthanasia for the useless.
The small communities would decide who could belong to them. Thus, there could be steel-worker communities, feminist communities, African-American groups, Ukrainian, you name it. To a community of homosexual men, for instance, any strategy to deal with AIDS might be deemed ethical, while spending money on prenatal research might be held unethical.
There are problems with Emanuel's thought. First, the obvious one: Many readers (myself included) will object that much of the medical ethics should not vary from community to community. Second, a fraction of Emanuel's audience will object to his making medical ethics a branch of political philosophy. Third, some may feel that present-day society does espouse a conception of the good life, that America is not nearly as ethically neutral as Emanuel says it is. Fourth, there is no reason why medical ethics could not be founded on negative principles -- e.g., Don't allow a patient to be in avoidable pain.
None of this should detract from the book's good features. Issues in medical ethics are hard to frame, and Emanuel states them clearly and without jargon. His proposals are probing. He recognizes that small groups (his communities) can make some decisions about proper medical-ethical procedures better than can the large ones (the federal and state governments) that we are ever more employing.
I only wish Emanuel had gone further -- right back into the past of 30 years ago. For even his communities cannot definitively answer many of the ethical questions that confront physicians like me every day in our practices: Should a patient with a terminal illness in a coma have any infections treated with antibiotics? Should he be artificially resuscitated if his heart stops? These questions -- unlike those having to do with abortion and euthanasia -- can be answered in an ethically justifiable manner either way depending on the circumstances, which can only be ascertained by the smallest group imaginable: doctor, patient, and family. So that doctors will be able leaders in this endeavor, we should pick medical students very carefully, train them in a few simple ethical rules, and then vigorously protect them upon graduation from the distractions of endless government regulations and threats of lawsuits. Would this be a flawless system? Of course not. But it worked well in the past. And we would not have to destroy the political fabric of the country to implement it.
- Richard J. Lanham
The Fettered Presidency. Edited by L. Gordon Crovitz & Jeremy A. Rabkin. American Enterprise Institute. 335 pages. $14.95.
Energy in the Executive: The Case for the Strong Presidency. By Terry Eastland. The Free Press.. 392 pages. $22.95.
There is a widespread belief that the American presidency is not working very well. Images of paralysis, gridlock, failure, limitation, and weakness dominate the literature. After presidential wars, scandals, a resurgent Congress, and the public's restiveness, students of the presidency have become more sensitive to the checks and constraints on presidential power: So much separation, so little power.
The two books under review here see the separation of powers, combined with divided government (a Republican president with a Democratic Congress), topped by Democratic Party intransigence, as the core problem. Both call for less separation of power, with more power going to the president. Both prescribe what amounts to Presidential Rule.
The Fettered Presidency is a collection of essays that focuses on the legal constraints placed upon the presidency. While there is some scant effort at partisan balance in authors, the list of contributors reads like a Who's Who of the political Right -- Elliot Abrams, Robert Bork, C. Boyden Gray, Jeanne Kirkpatrick, Irving Kristol, William French Smith, and others. Bork engages in Congress-bashing, arguing that the Democratic-controlled Congress has sought to encase presidents in a cocoon of legal codes that attempt to place criminal penalties on partisan differences. Surprisingly, Bork shows his ignorance of U.S. institutional relations when he writes that the Court is not a reliable ally of the presidency even when the president's position is constitutionally correct. This is just plain wrong. Every study of president/court relations clearly demonstrates that the courts usually side with the president in his claims of power. Too often the book's authors let their axes grind too hard, and important points get lost in ideological invective. This work's theme -- Who will rid me of this damn Congress? -- obscures rather than illuminates the otherwise important message that our politics are all too often fought out in the legal arena at the expense of political accountability.
Terry Eastland gives a more coherent, and slightly less partisan, dimension to the strong presidency perspective in Energy in the Executive. Eastland, who worked in the Reagan White House, recognizes that it may seem odd for conservatives to advocate a strong presidency, but notes that the best way for conservatives to achieve their policy goals is via Presidential Rule. This is of course an ends justify the means argument, always a tenuous position. But to Eastland, conservatives should play up the strong presidency model, not merely for self-interest but on a higher ground: the Constitution. Eastland argues -- incorrectly -- that the Constitution created a strong presidency. His interpretation, which draws heavily on Alexander Hamilton, was not the view of the Founders when taken in totality. True, the Founders sought a government with energy, but Congress clearly was to be the centerpiece of government. The Framers feared tyranny and thus sought to control executive power while also granting it enough power to remain strong. The model was more Aristotelian than Hamiltonian. The Founders could have set up a powerful presidency, but chose not to. Their decision-making model was not Presidential Rule but consensus. Thus, these proposals for Presidential Rule are not conservative, but radical.
The problem addressed in both these works is real, but the solution -- Presidential Rule -- is highly questionable, as well as very shortsighted and partisan. It is based primarily on whose ox is being gored. When strong Democrats are in the White House, conservatives decry the power of the presidency as a danger to the republic. At such times, the Right demands that Congress invoke its power under the separation of powers to rein in presidential assertiveness. During the past 24 years, however, when Republicans controlled the White House for 20 years but the Democrats controlled the Congress for most of that time, conservatives changed their tune. Curiously, calls for a more streamlined system of presidential government could be heard in the early 1960s from liberals who were similarly frustrated by the limits on presidential power when their chosen one was in power. One wonders if the conservatives in these two books will be so bent on presidential power now that a Democrat is to be inaugurated as president.
The real problem is not a fettered presidency but the inability of recent presidents to persuade Congress and the public that their vision should be followed. In short, it's a failure to develop a consensus that can mobilize an ordinarily lethargic political system to act. Yes, more efficiency; yes, power to the president; but within the context of democratic control and accountability. Our system can respond to presidential initiatives, but with a system of Presidential Rule, democracy withers.
- Michael A. Genovese