The “Choice” Bazaar
By Daniel Callahan
Some years ago I wrote a book on abortion that espoused women’s legal right to choose abortion, which was later cited in Roe v. Wade. It should have made me popular with feminists, but it did not and for one reason: I also argued that abortion is an ethical choice, and that not all abortions would necessarily be good choices. Trained as a philosopher, I pointed out that a traditional part of morality is deciding how to make good choices in the shaping of one’s life. No, I was indignantly told — the choice of abortion is a “personal choice” which needs no ethical justification, by either the woman or anyone else. That’s what women’s freedom is all about.
I thought about those exchanges recently when I started to notice how choice seems to have become the all-purpose ethical term, used by liberals and conservatives, right and left. It is used by the left to defend gay marriage, almost any and all procreation choice, and the right to choose end-of life-care as one sees fit, including physician-assisted suicide.
“Choice” was used by the right to object to the requirement that everyone take out health insurance as part of the new health care legislation. People should be free to make their own choice about buying health insurance (though they lost out as a result of a recent Supreme Court decision). Mayor Bloomberg lost out last year on a proposal to tax people’s choice of sugared beverages, and came under fire this year for his proposal for a limit on their serving size (the ban was recently approved by the New York Board of Health). The beverage industry waged an all-out war against his proposals, citing people’s right to their own choice about how they care for their bodies.
Paul Ryan has been the leader of Republican efforts to reform Medicare by expanding the role of choice in deciding what kind of health insurance to buy under his plan to subsidize the program. But there is a twist in that instance about choice. The aim of that reform is to expand the range of choices not only in the name of freedom but also to control costs — putting “skin in the game,” as the saying goes. But it is well known that forcing money choices on patients often keeps them from doing things important for their health. The Republicans also rejected any feature in the drafting of the Affordable Care Act that would impose pressure on physicians to accept the results of good medical evidence from research. They should be completely free from government interference and allowed to make their own diagnostic and treatment choices.
Quite apart from the political use of the word, “choice” has also been a recurrent feature of the marketing of new medical technologies. Many are introduced in the name of expanding patient choices. Prenatal diagnosis for women at possible risk of a disabled child was introduced in the name of choice, putting no pressure on women one way or other to accept the procedure. But as a result of social pressure and in the name of responsible parenthood, it is almost as routine now as taking a pregnant woman’s blood pressure. A variety of new genetic tests can now determine someone’s likely medical future, including the possibility of Alzheimer’s and just about every other potentially lethal disease. No one will be forced to make use of that information; it will be a matter of choice, it is said. But if the history of new technologies is any guide, it will soon be considered ethically irresponsible not to make use of them.
What is to be made of the invocation of “choice” as a popular tool for winning a political battle — or of rejecting “choice” as the right way to win an ethical struggle? It depends on the other side of the coin. I believe public health trumps choice in the sugared beverage battle. Is it legitimate to use the word choice as a euphemism for unpopular causes? I don’t think so. Paul Ryan is using it in a way that hides the gradual reduction of Medicare benefits. Euthanasia supporters are either hiding or sugar-coating their policy goals. When new technologies are introduced in the name of choice should we believe it? Well, only if you want to ignore lessons from past technological innovations.
That’s all I choose to say for now.
Daniel Callahan is President Emeritus of The Hastings Center and author of the forthcoming book, The Roots of Bioethics: Health, Progress, Technology, Death (Oxford University Press).