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Paradigms and our shrinking bioethics.

Carl Schneider's "empirical perspective" on the contemporary bioethical landscape allocates pride of place to the physician-patient relationship and, within that relationship, to the notion of patient autonomy. According to his analysis, autonomy plays a paradigmatic role in medical ethics but, because the paradigm hangs on an oversimplified understanding of human relationships, it requires refurbishment or replacement. Such reservations (indeed, almost any reservations) concerning the role 6f autonomy challenge medical ethics on its most cherished theoretical territory and are certain to provoke considerable debate. Since I find Schneider's observations both persuasive and provocative, I look forward to that debate. However, because my own background' has equipped me with neither the knowledge nor the experience to contribute to it, I propose to follow Professor Schneider's lead in a different direction. As teachers, we discover that predicting what will puzzle beginners is a tricky business. Students breeze through our favorite "hard" problems only to get stuck on other, superficially simpler, ones fraught with unstated assumptions. As a neophyte bioethicist, I sympathize with their plight because, for me, the bioethics literature is most puzzling precisely where it is least contentious. Ample illustration can be drawn from the widely shared premises asserted at the top of the previous paragraph: What accounts for the fact that bioethics-a field that began, at least in some conceptions,2 with an expansive philosophical program-has been so tamed and confined that it is effectively synonymous with medical ethics? Why do its practitioners interpret their domain still more narrowly, restricting it to physician-patient relationships or more commonly to the enumeration of physicians' obligations? Why, when even that restricted domain ought to spawn a philosopher's feast of contending ethical claims, is the literature dominated by one recurrent theme-respect for patient autonomy? 3 Why is the scope of bioethics not itself a matter of intense controversy?