Some years ago I wrote a book on abortion that espoused women’s right to choose abortion and was later cited in Roe v. Wade. That should have made me popular with feminists, but it did not and for one reason: I also argued that it was an ethical choice and that not all abortions would necessarily be good ethical 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. Around the same time I was having that argument I encountered an exceedingly right-wing advocate of market freedom. He told me it is not up to those who sell things in a free market to pass judgment on the morality of what’s sold or of those who choose to buy them. That’s what market 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 procreational choices, and the right to choose end-of life-care as one sees fit, including physician-assisted suicide.
It was used by the right to object to the requirement that every one 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 is under fire this year for a proposal of a limit on their serving size. 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.And Paul Ryan has been the leader of Republican efforts to overcome Obamacare in the name of more choice by consumers about the kind of health insurance they decide to buy.
But there is a twist in the GOP’s use of choice in this instance. Its aim is to expand the range of choices not only in the name of freedom but also to force people to make choices in the name of cost control, 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 ACA legislation that would impose pressure on physicians to accept the results of good medical evidence from research: they should be free from outside interference and allowed to make their own diagnostic and treatment decisions, doing so in the name of the traditional Hippocratic freedom of physician choices. I would in these cases say that “choice” is a code word for a reduction of Medicare benefits. Just as on the other side, “choice” has now become a code word for euthanasia and physician-assisted suicide.
Quite apart from the political uses of choice language, it has also been a recurrent feature of the introduction of new medical technologies. Many are marketed 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 has become as routine as taking a pregnant woman’s blood pressure.
A variety of new diagnostic procedures are being pursued to determine someone’s likely medical future, including the possibility of Alzheimer’s disease as well as 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 way of winning a political battle or of rejecting choice as the right way to win an ethical struggle? I would answer: it depends against what other value choice is being used? I believe health trumps choice in the sugared beverage battle, and it is sensible to point that out. 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, and euthanasia supporters are either hiding or sugar-coating their aims. When new technologies are introduced in the name or choice should that be believed? Well, only if you think the lessons from technological innovations on the fate of choice are irrelevant.
That’s all I choose to say for now.
Daniel Callahan, cofounder and President Emeritus of The Hastings Center, has two new books: a memoir, In Search of the Good: A Life in Bioethics (MIT Press), and The Roots of Bioethics: Health, Progress, Technology, Death (Oxford University Press). This commentary originally appeared in OUP Blog.