Might the bioethical principle of individual decisional autonomy have a politically liberalizing effect on soft authoritarian communities?

Abstract

According to the bioethical principle of individual decisional autonomy, the patient has a right of informed consent to any medical or experimental procedure. The principle is politically liberal by advocating significant individual freedom as guaranteed by law and secured by civil liberties. When practiced in illiberal communities, might it have a political liberalizing effect? I respond first by analyzing cross-national norms of individual decisional autonomy to identify tensions with illiberal community; second, by examining examining Singapore in a single case study to show that liberal bioethics does not promote political liberalization; and third, by showing that the possibility of practicing liberal bioethics in research, clinically as well as in education, does not require a democratic order, and that liberal bioethics is unlikely to encourage the liberalization of illiberal political communities. Hence, it may never contribute to the development of globally effective cross-national norms for the legal regulation of bioethical research and clinical practice. Fourth, to bolster this analysis, I anticipate several possible objections to various of its aspects.

The bioethical principle of individual decisional autonomy—the patient or research subject has a right of informed consent to any medical or experimental procedure—is politically liberal in the sense of advocating, in clinical contexts, a significant level of individual freedom and liberty, especially as guaranteed by law and secured by governmental protection of civil liberties. Might that principle extend beyond the medical clinic or research laboratory to the larger society, specifically with a liberalizing effect when exercised in illiberal communities?

In four parts, I consider this question empirically. First, I analyze cross-national norms and guidelines that might draw on what I construct as one epistemic identity of bioethics: individual decisional autonomy. In that context, I analyze the political inconsistency between an illiberal society (understood as a community that is neither politically free nor politically fair for its members) and bioethics so understood.

Second, I examine Singapore in a single case study. Its norms of citizenship are marked by soft authoritarianism and the developmental state. These norms are not reflected in the guidance it receives from the Bioethics Advisory Committee, a nongovernmental institution dedicated to biomedical research ethics with a mandate to advise the government periodically on relevant issues. In that way, among others, the bioethical principle of individual autonomy does not encourage political liberalization in Singapore’s political system.

Third, I explore the political potential of bioethics in nonliberal communities with regard to the citizen as bioethical subject. I show that liberal bioethics does not require a democratic order with open, competitive elections with universal franchise, together with legal rights of expression and assembly, and that liberal bioethics is unlikely to become a force for political liberalization. I conclude that liberal bioethics is unlikely ever to encourage the liberalization of nonliberal political communities. In theory, the social construct of bioethical decisional autonomy might seem to offer a political tool, at least in some circumstances. In practice, it is a weak tool at best, and more likely none at all.

To be sure, this notion of autonomy does not find universal embrace. On one account, decisional autonomy in medical ethics (such as the principle of informed consent for a patient’s treatment or her participation in a trial) seeks to prevent patient coercion or deceit and, as such, should be independent of an appeal to respect for autonomous choices, which, in any case, cannot be defended when exercised in favor of choices that are “self-centred, pig-headed, impulsive, random, ignorant, out of control and regrettable or unacceptable for these and many other reasons” (O’Neill, 2002, p. 28). Better is a “principled autonomy” that is “expressed in action whose principle could be adopted by all others” (O’Neill, 2002, pp. 84–85). Various other accounts for the sometime necessity of public health measures that trump individual decisional autonomy illustrate the most compelling challenges to individual autonomy in political community (Gregg, 2021). For example, a communitarian construction of public health as an irreducible good regards individual autonomy as properly circumscribed by epidemiologically indicated “public health interventions that go beyond standard constraints such as respect for basic liberties and individual choices, the harm principle and the conception of freedom as non-interference” (Radoilska, 2009, p. 135). Similarly, some “specific public health programs” that are “incompatible with liberalism” nonetheless “can be justified on soft-paternalist grounds” (Rajczi, 2016, p. 103). Advocates of state neutrality argue that mask mandates (during the COVID-19 pandemic, for example) can be legitimate only if the state can show that the “reasons that underpin some policy it seeks to introduce should be acceptable to the citizens to whom this policy applies” (Ismaili M’hamdi, 2021, p. 32). Finally, some accounts regard individual autonomy as often infeasible and urge instead a notion of solidarity as a new core value in public health to confront “risks that cross national, cultural, and identity borders” (Boas & Davidovitch, 2022, p. 1). Still, given its prominence in clinical and research ethics (Beauchamp & Childress, 2019), the bioethical principle of individual decisional autonomy remains a plausible candidate for considering possible liberalizing effects on illiberal communities and feasible bases for cross-national regulatory norms.

Fourth, I anticipate several possible objections to aspects of my analysis: the whether the norm of decisional autonomy can travel from bioethical contexts to society in general; whether the notions of illiberalism and authoritarianism can be analytically useful given their vagueness; the utility of a single-case analysis; and whether Singapore’s political governance displays authoritarian features.

1. Can bioethics offer a cross-national norm of individual decisional autonomy?

Bioethics examines, and attempts to resolve, normative issues and questions that arise in the fields of health care, medical research, and the life sciences. Its principles are applicable to any political context in which these activities take place. Some analysts argue that bioethical principles are meant to apply universally, quite regardless of political, social, or cultural contexts (Beauchamp, 2019). This conviction finds support in the requirements for cross-national norms and guidelines, as well as in the epistemic identity of bioethics as individual decisional autonomy. It is not defeated by the possible deployment of epistemic identity as a social construct and political tool, or even by the fact that pursuing bioethics in an illiberal society confronts constraints that pursing bioethics in a liberal society does not.

Cross-national norms

Even if the influence of bioethics on the political views of society as a whole is limited in illiberal polities (Klein, 2016), might the development of cross-national norms nonetheless promote local awareness and understanding of ethical issues in biomedical research and practice? If so, might the influence of bioethics thereby contribute to the development of cross-national norms and standards in biomedical research and practice? The fact that cross-national norms are developed and debated almost exclusively at the elite level of scholars, universities, research institutes, and governmental committees is telling. This fact is hardly unusual in the context of global governance, coordinated by transnational actors (and not just states) in ways broader than national governance. Limited spheres of liberal influence, cabined off from the larger illiberal state, is often one advantage among many enjoyed by global elites (Barnett et al., 2021; Lake, 2021).

This fact also provides the single most powerful empirical observation in response to the question: While the impact of bioethical norms on the broader society may be limited in most cases, might their development and dissemination contribute to broader public awareness and understanding—not only of ethical issues in biomedical research and practice but even to the social system and political system that hosts this research and practice? I answer no.

One explanation concerns the fact that the practical application of bioethical standards (individual decisional autonomy, above all) is likely to be influenced to some extent by local cultural, social, and political contexts. In liberal democratic settings, such standards may resonate in part with these environments; in illiberal settings, they will not. Hence, the aspiration to cross-national norms to regulate bioethical issues from a universalist position (a position typical of cross-national norms) neglects the decisive significance of local factors for the possible local, social, and political salience of bioethical principles. Liberal cross-national norms are unlikely ever to displace the local norms of illiberal governance, at least by means of argument and example.

Cross-national bioethical norms can have a meaningful impact on the development of national and local policies and practices if they can transcend discussion solely at elite levels of society. Wide dissemination and translation into policy and practice at the national and local levels is unlikely where stakeholders beyond elite policymakers—from ordinary practitioners to civil society organizations to the public—are excluded (or exclude themselves out of disinterest or lack of information or trepidation about political involvement). Mechanisms for monitoring and enforcing compliance in any illiberal community are then possible only in elite, transnational spheres of science and scholarship, isolated and insulated from the larger society and the general populace. Some liberal societies practice a politics that, for illiberal reasons, attempts to isolate bioethical issues and debates from pluralist discussion and broad popular involvement (Charo, 2004).

Individual autonomy as the epistemic identity of bioethics

Still, the notion of cross-national norms to regulate bioethical practice reveals something important about the conditions necessary for a global embrace of relevant norms. Norms meeting uncoerced compliance across different cultures and political systems require a distinct identity plausible to all addressees: an “epistemic identity,” where epistemic refers to the reasonable and reflected quality of that identity, allowing, in medical research and clinical health care, for the norm’s consistent practical application across different kinds of political community and across diverse cultural commitments.

For bioethics, one epistemic identity among others is that of individual autonomy in the sense of the patient’s or research subject’s right to informed consent for any medical procedure. (Tom Beauchamp and James Childress (2019) propose three additional identities—non-maleficence, beneficence, and justice—while Jacob Rendtorff and Peter Kemp (2019) suggest dignity, integrity, and vulnerability.) The notion of individual decisional autonomy as an epistemic identity of bioethics is a distinctly political claim. The notion is political because it is more than a matter of institutional administration. It is political in the sense that its construction, interpretation, and application are matters of debate and deliberation, of making public policy and perhaps eventually revising it. As an epistemic identity, decisional autonomy offers itself as a site of competing social and political visions and values. After all, participants in political discourse are likely to disagree about how best to define the identity of various bioethical principles even as they can agree (at least in a counterfactual, ideal speech situation) on what eventually suggests itself as the best argument in any given debate (Habermas, 2000). Finally, decisional autonomy as an epistemic identity can be legitimate even in the face of reasonable disagreement about it.

Agreement on individual decisional autonomy as an epistemic identity of bioethics is possible even when it would challenge those aspects of an authoritarian state that strongly impede or simply deny such autonomy in society in general. Here, agreement is possible as long as that identity remains cabined within clinical practice and scholarly debate.

Epistemic identity as social construct and political tool

Assume a common understanding of the principle of individual decisional autonomy (even in the face of divergent understandings). With that assumption, consider two propositions about individual decisional autonomy as an epistemic identity of bioethics. From this perspective, I argue two points: (a) such an epistemic identity does not require a liberal political culture to function in clinical, research, and academic settings, but (b) liberal democracies clearly are more conducive to the wide implementation of bioethical principles—that is, implementing them beyond clinical, research, and academic settings.

(a) Epistemic identity does not require liberal political culture

On the one hand, bioethics is concerned with ethical issues generated in the fields of health care and medical research as well as in health-related applications of the life sciences. At its core, bioethics is concerned with ethical principles to guide decision-making in these areas. A case in point is the principle of individual decisional autonomy (as one epistemic identity of bioethics). It offers itself as a compelling candidate for the single most fundamental principle animating clinical bioethics. For that reason, among others, bioethics might seem likely to function within liberal and authoritarian communities alike. If so, then the ethical identity of bioethics does not depend on the political system that hosts it; it depends on the field of bioethics itself.

On the other hand, the illiberal state constricts the exercise of individual autonomy with significant and abiding consequences for the protection of individual rights and freedoms. Some of those consequences are relevant to ethical issues in health care and medical research. After all, some of those issues are subject to the state’s interpretation of the public good. In some cases, the state’s interpretation will differ from many of the values held by liberal democratic societies, such as popular democracy, freedom of expression, freedom of assembly, and the right to oppose the government in courts of law and at the polling booth.

But even as ethical considerations in health care and medical research may often be tied to broader social values and norms, relevant norms and values need not necessarily colonize the sphere of bioethics in authoritarian states. The sphere of bioethics may function independently of broader norms and values. For example, difficult questions about the relationship between individual autonomy and the public good, or about how to balance these competing values in different political contexts, need not entail an illiberal form of bioethics (whatever that might be). A notion of illiberal bioethics might be developed by analogy to illiberal human rights. In the latter case, authoritarian leaders, unable to challenge the global presence and prestige of human rights talk with persuasive counterarguments, instead reconfigure the content and framing of international human rights to correspond with illiberal visions, commitments, and governance, allowing leaders to claim adherence to human rights even as they violate their citizens’ human rights understood in a liberal sense (Ramberg, 2019). Perhaps an illiberal bioethics would, in Orwellian fashion, distort the notion of individual decisional autonomy in medical and research contexts, claiming to provide decisional autonomy to the individual even as it robbed the patient or research subject of any meaningful autonomy.

Further, broader social values and norms need not undermine liberal bioethics (which emphasizes individual decisional autonomy) as long as bioethics can operate with some degree of isolation from broader social and political norms of the host society. Even the epistemic identity of individual decisional autonomy is possible in authoritarian states if it functions within an elite “bubble” of medical and scholarly experts. If this epistemic identity is isolated from general society, state and society need not recognize the general political autonomy and civic freedom that this identity might seem to imply.

Even as it is guided by the notion of individual patient autonomy, the practice of bioethics in the clinic as well as in the classroom does not require liberal political community for its very possibility. The bioethics of patient decisional autonomy is entirely possible in authoritarian political community.

(b) Liberal governance is more conducive than illiberal governance to implementing bioethical principles

The difference between “cabined” bioethics and “un-cabined” bioethics is clear. A level of protection and support for individual rights and freedoms lower than what a liberal democracy can provide will isolate bioethics within the walls of elite institutions with limited contact with the state’s political community and system. A liberal culture and political community resonate with bioethical principles such as individual decisional autonomy precisely because that culture and community prioritize a range of individual rights and freedoms. Liberal democracies may be more conducive than authoritarian states to the implementation of bioethical principles because they offer a greater degree of individual rights and freedoms, as well as institutional mechanisms, to protect those rights. Liberal democracies provide more robust legal protections for individual decisional autonomy as well as greater opportunities for patient or research subject participation and empowerment. Finally, given its epistemic identity as individual decisional autonomy, bioethics in liberal democratic community offers a site for competing political interests. In liberal democratic communities, bioethics with this epistemic identity has a capacity to challenge restrictions on autonomy present even in democracies, indeed in many forms (Fagan, 2004). For this very reason, bioethics in illiberal communities implicitly (if inconsequentially) challenges central features of the political landscape.

Bioethics at the intersection of science and politics

There is no necessary or inevitable relationship between science and the political organization of society. Science implies no particular social or political order. Science and technology entail no normative values relevant to political organization. By contrast, political life is constructed on normative commitments; there is no politics without them. Science and technology do not require a democratic public sphere even though the liberal ideals of institutional transparency, the greatest possible availability of information and its free and robust exchange, and the right to oppose political, social, and cultural orthodoxies when science leads in that direction serve the advancement of science better than does the more politically sensitive environment of authoritarian states. Authoritarian political communities can certainly be devoted to science and its advancement (Hashemi, 2009).

Thus, while a liberal bioethics might involve public deliberation and other forms of public participation in science, it need not do so as the very condition of the possibility of science. Further, the project of democratizing science, of somehow rendering science available for wider public deliberation and debate, is a project political not scientific. This project seeks not to change science but to make society more rational by making it more science-literate and more science-embracing. And it seeks to make society more democratic because it would involve more of the citizenry in public policy debates that concern science, its possible applications, and its regulation by law and administration.

Bioethics is a humanistic evaluation of biomedical science’s impact on humans. But whereas science cannot be a force for democratizing the public sphere, bioethics in principle could be such a force, given its epistemic identity of individual decisional autonomy. Thus bioethics, but not science, can resonate with some values in liberal democracies. To that extent, bioethics, but not science, might imply a state and society devoted to political liberalism. That is, individual decisional autonomy could imply that the patient’s status within clinical research and medicine should—on normative grounds—find a corresponding status in wider society and its political culture. So understood, bioethics offers itself as a scientifically informed, humanistic project inherently opposed to political community that subordinates the civil rights of citizens to, say, the imperatives of economic development. Singapore is just such a community.

2. Singapore as a case study

Bioethics is a global field that encompasses diverse perspectives and traditions, developing in the course of significant dialogue and exchange of ideas between different viewpoints, traditions, and cultures. As in any other country, in Singapore, the field of bioethics is shaped by cultural, political, economic, and other factors. I examine the institutional pursuit of bioethics in Singapore along several dimensions: the country’s norms of citizenship, marked by soft authoritarianism (as well as imperatives of the developmental state); the mandated guidance that the government receives from the Bioethics Advisory Committee; and the bioethical principle of individual autonomy, which has never encouraged political liberalization in the country’s overall governance (George, 2007). As a single case study, Singapore sustains my claim: in most cases, the tension between liberal bioethics and nonliberal political community is politically and socially without consequence.

Norms of citizenship

According to Kerry Holden and David Demeritt (2008), the bioethics administrative culture in Singapore distinguishes between

Western cultures and how Asians perceive bioethics. We [in Singapore] do understand that autonomy is a concept that was drawn up by the Western countries and if you look through our reports, we seldom use the word autonomy, but rather, most of the time, we say respect for the individual. (p. 82)

If respect here refers to the paramount “legal requirement to obtain informed consent from the research subject” or patient (Holden & Demeritt, 2008, p. 81), then it means individual autonomy. But it might instead refer to an alternative to a Western idea about autonomy characterized by selfish individualism, by contrast with a more communitarian orientation toward collective decision-making norms and, say, Confucian traditions of filial piety. It could even refer to behavior that is officially and socially preferred because it shows deference and respect to authority figures, particularly government officials and senior leaders, and because it encourages groups and individuals to maintain (the pretense and appearance of) harmony and avoid public challenges, debates, and confrontations, above all with respect to governmental policies, the laws, and judicial holdings. Respect so understood offers an authoritarian alternative to political liberalism, on several levels. It may lead to self-censorship and discourage critical political thought and participation in the political process, including lawful, peaceful oppositional activities that would challenge policies or decisions that may not be in the community’s best interest. It may regard governmental policies as beyond question and limit transparency and reduce the effectiveness of checks and balances on governmental power, including avenues for holding government officials accountable for their actions and decisions. And it may encourage patient hesitancy to question medical advice, and so encourage overreliance on physician judgment. Then the patient would not receive comprehensive information about treatment options, potential risks, and alternatives. This would reduce the patient’s informed decision-making and discourage active participation in his or her health care decisions.

But if understood to mean individual autonomy, the term respect conflicts with Singapore’s norms of citizenship as constructed by the government’s political culture. Those norms exclude citizen assembly for political ends as well as citizens’ freedom of political speech. They are conditioned by the state’s soft authoritarianism and the state’s conceptualization of Singapore as a developmental state.

Soft authoritarianism

The precise nature of Singapore’s governmental structure remains a matter of debate. Some political scientists have analyzed Singapore’s political system as a form of “soft authoritarianism” (Tan & Preece, 2022) because it combines various traits of authoritarianism—restrictions on political freedoms and limited democratic participation, among others—with elements of democracy, such as regular elections and legally protected freedoms in the private sphere.

Widely supported by the citizenry (Lee & Teo, 2023), the state and government have delivered, for more than half a century now, social stability and social cohesionas well as prosperity within a robust economy, with achievements in education, health care, and infrastructure and very little corruption (in sharp contrast to all other Southeast Asian countries). These achievements are tied to a governance that stresses social stability in part by means of tightly controlled media and restrictions on political protest.

The ruling power, the People’s Action Party, has been in office continuously since the country’s independence from Malaysia in 1965. Over the years, it has consistently won a large majority of seats in parliament. The administration routinely deploys its authority to stifle electoral opposition and to limit political dissent, in part by harassing opposition parties and politicians through legal and economic stratagems, including defamation laws and restrictions on freedom of speech (Lee & Abdullah, 2022).

In the soft authoritarian state, the citizen has a certain range of choices. She need not be a communitarian. She need not be particularly interested in society’s welfare. She may or may not be deeply alienated from the state and its political system. She may have withdrawn into a private niche to pursue consumerist individualism (Gregg, 2015). To be sure, this mentality is hardly peculiar to Singapore. And it characterizes democratic polities as well—yet not, or not always, or not exclusively, as a matter of state or governmental policy. In Singapore, by contrast, the government actively discourages advocacy of democratic alternatives and perpetuates a political culture well captured by Ralf Dahrendorf (1995) in a different context:

Authoritarianism is not totalitarianism. Authoritarian rulers will not brook active opposition, but they leave people alone as long as they do not attack the powers that be. Law-abiding citizens who assiduously attend to their own affairs and otherwise live inoffensive private lives need not fear the wrath of their leaders … But those who criticize government for its unaccountable power, those who use their freedom of speech to expose nepotism, those who dare put up alternative candidates at elections, are in trouble. The limits of civic freedom are tightly drawn. (pp. 29–30)

Or, as the Singaporean journalist Cherian George wrote three decades ago, “in Singapore, better to mind your own business, make money, and leave politics to the politicians” (The Straits Times, July 11, 1993).

Developmental state

The first imperative of the developmental state is economic growth and maturation (Slater, 2019). In Singapore’s case, the developmental state is understood to require the subordination of the individual’s civil rights even as the state advocates equality under the law, meritocracy in schools and society, and one of the world’s most successful campaigns against corruption (Lustrilanang et al., 2023).

In pursuit of economic development, Singapore seeks to position itself as a world hub for biomedical research and innovation, with significant investment in research infrastructure and development. The country’s understanding of bioethics aligns with that of the West in part because Singapore wants to ensure that its research practices meet Western standards, including in the field of bioethics, so that it can draw Western investment, participate at world-class levels in related areas of research and development, and reap the economic rewards. Bioethical thinking in Singapore appears to be largely addressed to Western audiences.

Although the views of the citizenry in Singapore with respect to bioethics are not easily generalized, given a likely range of views and perspectives, it would appear that (as in the West) bioethical debates are largely isolated from the general populace. The level of public interest in, and knowledge of, bioethics as a public policy issue is generally low in all countries, and the recommendations of expert committees and scholas may not be widely known or understood by the public. This lack of public engagement in liberal democratic societies may reflect in part a lack of engagement between the experts and the broader community (Gregg, 2023).

The vision of the developmental state drives Singapore’s felt need to reassure the West that in technical areas such as biomedical research, it meets Western standards—including ways of framing bioethical issues—and to portray Singapore as a reliable partner in research and development but also as a safe venue for bio-industrial capital investment. Even as Singaporean bioethicists may be addressing Western audiences in part because of the importance of international collaboration with, and investment in, the biomedical research industry, the state’s developmental imperative addresses foreign researchers in another way. According to Aaron Levine (2010), Singapore permits scientists to derive new human embryonic stem cell lines from embryos that remain after the completion of fertility treatment. By means of somatic cell nuclear transfer, scientists may be able to create human embryonic stem cell lines genetically matched to individual patients. In this way, among others, Singapore positions itself as among the most permissive countries in the world with respect to somatic cell nuclear transfer, toward influencing the geographic preferences of scientists working in more restrictive national environments. In most Western countries, the technique is very controversial and faces greater restrictions. Indeed, in the United States, the scientific as well as political controversy surrounding human cell embryo research appears to undermine Richard Lempert’s (2010) belief in the possibility of a “progressive bioethics.”

Guidance from the Bioethics Advisory Committee

Singapore’s bioethical template of “internationally standardised regulation to protect the rights and autonomy of clinical research subjects” (Holden & Demeritt, 2008, p. 71) is one way the country observes principles of bioethics dominant in the United States and Europe: “We [in Singapore] conform to international guidelines and we have focused very much on a US centric type of approach”; moreover, “we hope to aspire to the highest international standards” (Holden & Demeritt, 2008, pp. 79–80).

Singapore’s cabinet draws on ethical review committees to frame ethical guidance on difficult topics of research and clinical medicine. In this respect, the country’s bioethical framework does not appear to be grounded in any particular local values and cultural traditions—even as competing interests may seek to influence committee membership and agenda setting, and even if committees become political sites in “carrying out their political task of reconciling cultural concerns with scientific progress” (Salter & Salter 2007, p. 576). According to David Reubi (2000), these committees have adopted the set of issues recognized by Western liberal democracies—from research on human beings to clinical trials, and from genetic testing to cloning—as a “carbon copy of the catalog of issues addressed by bioethical commissions in other developed countries and by international organizations like UNESCO” (p. 155).

Consider one of Singapore’s committees in particular. The state in 2000 created the first local institution dedicated specifically to biomedical research ethics: the Bioethics Advisory Committee (BAC). Its mandate is to advise the government on potential ethical, legal, and social issues generated by research in the biomedical sciences and to propose polices on these issues. Its goal is to protect the rights and welfare of individuals. ¹ To that end, and to ensure that research involving human subjects is conducted in an ethical manner, it stresses the principle of the individual patient’s informed consent, which champions a form of individual decisional autonomy. Its focus on protecting the rights and welfare of individuals is reflected in its guidelines on issues such as stem cell research, genetic testing, and mitochondrial genome replacement technology. Since its creation, it has published 10 “consultation papers” on pressing practical issues ranging from “Human Stem Cell Research” (2001) to “Ethical, Legal and Social Issues Arising From Mitochondrial Genome Replacement Technology” (2018). ² The papers develop guidelines and techniques toward protecting the rights and welfare of the individual from the dangers posed by research on human genetics.

In their soft authoritarian cast, two features of the BAC’s approach reflect Singapore’s political culture and the state’s norms of citizenship. First, individual interest may be subordinated to group interest (measured against the alternative: group interest subordinated to individual interest). Second, individual interest may be subordinated in a top-down approach (as distinct from, say, a two-way dialogue between the government and the citizenry as well as other stakeholders, including physicians, scientists, and the biomedical industry). To be sure, generalizations may not capture the extent to which the BAC balances individual and group interests, or subordinates individual interests to group interests. Generalizations may not capture the degree to which the BAC engages in a two-way dialogue with stakeholders in developing its recommendations and the degree to which its approach is sometimes top-down. (These factors may vary depending on the specific issue under discussion and the context of that discussion.)

One distinguishing feature of Singapore’s top-down governance structure is public policy’s explicit orientation on technical knowledge and expertise. As an institution that periodically formulates considered responses to pressing bioethical issues and then presents those responses for governmental consideration for possible public policy formation, the BAC expresses this technocratic style. While potentially politically significant in its role as an expert advisory body, it has no direct political power. Its work generally furthers the government’s goal of developing the country into an Asian hub of world-class medical technologies (among other forms of high tech) capable of sustaining interaction with Western counterparts and drawing Western capital investment—again, without liberalizing consequences for the structures and culture of Singaporean governance.

Bioethics in Singapore does not encourage political liberalization

Five conclusions follow. First, there is, in principle, reason to believe that bioethics in Singapore could encourage political liberalization. Scholarly literature documents empirical evidence that the application of bioethical principles in medical research and clinical practice (such as autonomy, beneficence, non-maleficence, and justice) has sometimes spilled over into political cultures and has sometimes contributed to liberal political reforms. Indeed, depending on the specific issue, the social context, the political culture, as well as relevant value commitments of the political community, spillage occurs across the spectrum of political alignments. This finding is unsurprising inasmuch as these principles intersect with broader social and political issues and perspectives. They lead into, and sometimes issue from, political debates, policy decisions, and legislative acts.

Second, in the context of bioethics in Singapore—that is, a conception of bioethics more or less identical to its conception in Western democracies, namely, as possessing an inherently liberal valence—the term autonomy generally means that the patient possesses decisional autonomy in clinical medical settings. But the term does not extend to broader notions of agency and autonomy in the sense of freedoms of expression and assembly, or in the sense of rights of participation in democratic processes and institutions (such as voting or running for office).

Third, the epistemic identity of a bioethics centered on individual autonomy has never functioned as a site of competing political visions—for example, the competing values of a liberal democratic community and those of an authoritarian one. A clinical perspective that champions individual autonomy has never encouraged, politically, an illiberal polity to become somewhat more politically liberal (liberal in the sense of open, competitive elections with universal franchise, together with meaningful legal rights of expression and assembly). The institutional structure of bioethics in Singapore does not appear capable of being a force for democratizing the public sphere of an illiberal state.

Fourth, Singapore’s government (as well as independent advisors on relevant public policy, including the BAC) adopts Western bioethical standards. It also adopts those of international organizations, such as UNESCO. In particular, it adopts the standard of patient decisional autonomy. Yet it does so without adopting Western democratic political standards for the country in general. To be sure, decisional autonomy in some cases is weaker in Singapore than in the West. For example, Lalit Krishna and Sumytra Menon (2014) discuss the common practice of a patient’s children or other relatives (often in collusion with, say, hospice home care nurses or cancer center clinicians) impeding the patient from learning about his or her potentially fatal diagnosis, arguably from paternalistic Confucian ideals of filial care (preventing suffering occasioned by cognizance of one’s own dire medical status). Doing so contravenes the Singapore Mental Capacity Act and the Advance Medical Directive Act, which promote the patient’s decisional autonomy. John Elliott and colleagues (2010) note that, despite the BAC’s claim to have adopted conventional Western principles (including beneficence, autonomy, justice, sustainability, and reciprocity), the government legally regulates biomedical research with a “light touch” and accords individual rights less weight than do Western states. It does so for reasons ranging from a Confucian emphasis on communal harmony and cooperation, to enhancing Singapore’s competitive edge in the world market by regulating less than competing countries.

In short, the adoption of bioethical standards by illiberal states does not necessarily require the adoption of broader political or social values, such as democracy or individual rights. While the Singapore government has been criticized for adopting a selective approach to individual autonomy (Mills, 2020)—promoting it in some areas of biomedical research and practice while restricting it in other areas, such as political speech and assembly—the government is generally immune to such criticism. In other words, Singapore can embrace the epistemic identity of bioethics in the narrow sense of the clinic yet reject it in the wider, derived sense of individual political liberties—say, of expression and assembly and democratic political participation. As Reubi (2000) notes, “This will to import Western ethical values is in stark contrast to the promotion of Asian values and opposition to undesirable Western norms like human rights that informed Singapore’s policies up to the late 1990s” (p. 154, n. 4). Note that the term Asian values (e.g., Thompson, 2015), like the term Western norms (e.g., Inglehart, 2008), is understood in many different, often incompatible ways.

Note also that Singapore’s importation of liberal bioethics does not entail that Singapore must address the same normative issues of bioethics addressed by liberal democracies. These include allowance of contested, public deliberation, accommodation of diversity in ethical positions and value commitments, and facilitation of effective participation in public policy formation by affected persons and other citizens (Dodds & Thomson, 2006; Montgomery, 2016).

Singapore’s importation of liberal bioethics may one day raise concerns and generate debates like those in the West. For example, questions about the appropriate balance between individual autonomy and social responsibility could be relevant both in liberal democracies and in soft authoritarian states such as Singapore. After all, bioethical standards based on individual autonomy (even if the promotion of patient decisional autonomy is confined to clinical research and practice) potentially create tensions with an illiberal political system that prioritizes state control and social harmony over individual rights and freedoms. It remains to be seen whether changed social and political circumstances in a future Singapore might activate such potential.

Fifth, Singapore demonstrates how liberal bioethics can be cabined in an illiberal community. It can embrace the epistemic identity of bioethics in the narrow sense of the clinic—for example, by invoking the principle of patient decisional autonomy—even while rejecting it in the form of individual political liberties in society generally, such as freedom of expression, assembly, and democratic political participation. In this way, the Singapore case demonstrates that the principles and values of bioethics are not necessarily dependent on, or otherwise linked to, the broader political or social values of the host community.

Complex is the question of whether the government’s project of importing Western ethical values in any way complicates its promotion of “Asian values,” here defined as emphasizing the importance of community and social harmony over individual rights and freedoms (Chang, 2022) and by its opposition to what it views as undesirable Western norms, such as individual human rights. Equally complex is the question of whether the government’s emphasis on the importance of community and social harmony over individual rights and freedoms complicates its engagement with Western ethical values and standards—including those of bioethics—as part of its effort to develop a knowledge-based economy and to position itself as an internationally competitive biomedical research hub. One can imagine reducing the tension between these two approaches through a hybrid method that draws on both Asian and Western values and traditions. In that spiri, Kathryn Muyskens (2020) sees potential for the nonetheless contradictory mix of modern Western and traditional Confucian filial traditions in Singapore regarding the duties of young people toward aging parents and intergenerational social justice more generally. In any case, doubtful today is the achievement of some kind of truly global dialogue on constructing shared values able to underpin bioethics and its relationship to broader political and social values (ten Have & Gordijn, 2011).

3. The political potential of bioethics in nonliberal communities

Singapore instantiates a general “bio-political” phenomenon: the deployment in illiberal states of bioethics in clinical and scholarly settings does not affect a general political landscape that denies such autonomy in the form of civil rights. Three aspects inform this phenomenon: (a) as bioethical subject, the citizen may enjoy individual decisional autonomy in clinical settings, an autonomy that the state denies her in political community; (b) the political individualism of bioethics contrasts with political communitarianism; and in this sense, (c) liberal bioethics in clinical settings does not require location within a democratic order.

(a) Individual autonomy in clinical settings

Liberal bioethics envisions the patient as autonomous with respect to clinical decisions that affect her. It does not view her as an autonomous citizen in the sense of a member of a political community with freedom of expression, assembly, and participation in democratic processes and institutions. Illiberal states construct the patient no differently: here, too, clinical autonomy neither requires nor entails political autonomy. We saw as much in Singapore’s case. It is possible, in principle, that a clinical perspective that champions individual autonomy may encourage politically illiberal polities to become more politically liberal, particularly if this perspective found wide embrace and if it strongly impacted public discourse. But there is no evidence that bioethical principles tend to influence general social norms. (And, typical of many universalist perspectives, Joris Gielen’s [2020] theological resort to a notion of “common morality” in global bioethics cannot redeem its own empirical claims.)

(b) The political individualism of bioethics contrasts with communitarianism

Whereas liberal individualism is concerned with individual rights, communitarianism is concerned with collective self-determination. The premise of individual rights readily conflicts with collective self-determination. A politically communitarian orientation values commitments to certain forms of community over competing claims of individual liberties. The citizen who freely embraces political communitarianism favors a state that provides the social, political, and economic conditions for a secure individual existence within a social order of secure individual existences. She expects communitarianism to deliver a social harmony and collective good greater than what a more individualistic social order might deliver. For her, that expectation diminishes counterclaims concerning the importance and benefit of the political individualism instantiated by personal rights and freedoms.

With respect to bioethics, however, the communitarianism/individualism divide appears not to matter. Bioethics in clinical settings functions equally and similarly in liberal individualistic and communitarian communities alike. We cannot be surprised by the ambivalence of bioethics to the general social norms of political community. Consider a prominent example of ambivalence. The United Nations’ 1947 Universal Declaration of Human Rights speaks to two different value commitments simultaneously: liberal individualism and communitarianism. It posits, as the standard features of the nation-state to which it addresses itself, democratic representation, universal suffrage, periodic elections, and genuine proceduralism. Yet the declaration cannot plausibly be understood to address itself solely to democratic states, otherwise it would hardly be a universal declaration, or one whose coauthors included persons from authoritarian states such as the former Soviet Union. Further, article 21 proffers rights not only to protect individual autonomy—which inevitably challenges some group memberships, but equally rights to group preservation—which, in some cases, challenge individual preference. Article 21 states,

Everyone has the right to take part in the government of his country, directly or through freely chosen representatives. Everyone has the right to equal access to public service in his country. The will of the people shall be the basis of the authority of government; this will shall be expressed in periodic and genuine elections which shall be by universal and equal suffrage and shall be held by secret vote or by equivalent free voting procedures.

To be sure, neither liberal individualism nor political communitarianism is possible if rendered absolute within society. Any such effort would be impossible but incoherent as well, for all the historical, sociological, economic, cultural and psychological reasons that lead human communities to generate a wide range of mixtures of the two. For example, democratic theory includes some measure of individual autonomy even as it pursues some measure of just distribution among citizens of social and economic welfare rights. Another example: any plausible notion of human rights supports individual rights as well as group rights (which at points conflict with one another). Human rights to individual liberty and autonomy neither require nor entail a specifically democratic organization of government and society (Gregg, 2012). Put another way: some forms of nondemocratic society can still provide a measure of individual liberty and autonomy.

The individual autonomy implied by bioethics, if understood as an autonomy not necessarily oriented in democratic ways, resonates with the International Covenant on Civil and Political Rights. It provides that “All peoples have the right of self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social, and cultural development” (United Nations, 1966, article 1). A right to self-determination is not necessarily a right to a specifically democratic form of self-determination. For example, John Rawls (1999) envisions such a self-determining community in his account of illiberal, “decent hierarchical peoples” who, because they honor a minimal list of human rights (unlike “outlaw states” or “benevolent absolutisms”), deserve inclusion in a scheme of international relations developed out of a liberal idea of justice that implies toleration of such peoples (p. 65). On this account, such communities, even as nondemocratic, could still offer the “right to life (to the means of subsistence and security); to liberty (to freedom from slavery, serfdom, and forced occupation, and to a sufficient measure of liberty of conscience to ensure freedom of religion and thought); to property (personal property); and to formal equality.”

In short, a right to self-determination can be compatible with domestic laws and regulations that generate or preserve various kinds of inequalities among groups and individuals—even to the point of infringements of other fundamental interests of members, such as favoring members of one religion with regard to occupying positions of authority in the state.

Communitarian group membership organized around the common good as properly trumping individual preferences might violate individual autonomy—but not necessarily. In some political communities, group membership could be compatible with individual autonomy. For example, group membership might restrict the citizenry’s freedom of religious belief without precluding it altogether. Today, several nation-states, both democratic (for example, Israel, Peru) and illiberal (for example, Saudi Arabia, Belarus), allow for legally privileging one religious confession over others.

Consider additional ways that the liberal individualism of bioethics may function in illiberal states. First, some authoritarian polities might welcome some degree of individual autonomy. They are more likely to recognize some degree of rule of law—to the extent that it does not threaten a self-selected party’s monopoly on power—than any degree of democracy. Rule of law in private and civil matters, or in matters of contract and tort, need not threaten the state and contributes to social order. Second, forms of legal equality are possible in some authoritarian communities. To the extent that citizens enjoy equal legal standing in most day-to-day matters of civil and criminal nature, in access to medical care and primary education, or in housing and welfare, they may freely accept political subordination—as in Singapore. Third, individual liberty and legal equality do not require the specific social conditions necessary for democracy (such as popular franchise or electoral politics). In short, individual liberty and legal equality are possible where collective self-determination can be more than merely group domination, even if it never rises to the level of democratic self-determination.

(c) Bioethics is an unlikely force for political liberalization

The conclusion that bioethics is unlikely ever to be a politically liberalizing force follows from three arguments. First, it is possible in principle that a clinical perspective that champions individual autonomy could encourage politically illiberal polities to become more politically liberal—particularly if this perspective were widely embraced and if it impacted public discourse. But a clinical bioethical principle is unlikely to affect general social norms. The relationship between clinical perspectives and political change will always be indirect and contingent on many factors. And bioethics itself offers no plausible means of facilitating or encouraging political change when deployed in illiberal states. Bioethics is unlikely ever to serve as a carrier of political liberalism. It usually exists within an elite institutional and cultural bubble marking it off from the larger political culture in which it is embedded. As such, its influence is limited to certain elites or academic institutions, without broader impact on the political culture of the society in question. To be sure, while bioethics is incapable of singlehandedly democratizing the public sphere of illiberal states, sometimes it might play a role in promoting critical reflection and dialogue on ethical issues—even under authoritarian political conditions.

Second, while bioethics will not necessarily generate a direct force for political liberalization, its emphasis on individual autonomy and decision-making may sometimes contribute indirectly to political and administrative processes becoming more open and democratic by promoting transparency and accountability in decision-making. For example, the pursuit of biomedical research and innovation generally requires a high level of intellectual freedom and the open exchange of ideas. This requirement might sometimes encourage the adoption of attitudes that are more politically liberal, at least on the part of participating personnel and institutions.

Third, while the deployment of Western bioethical models by an illiberal polity hardly entails the incorporation of Western values into its social and political fabric, that deployment may involve the selective adoption of certain Western values that participants—if not the illiberal state itself—deem useful or desirable. They might well reject others viewed as incompatible with existing political and social norms. If some kind of internationally accepted framework of bioethics regulation were possible—which seems just as doubtful as projects for universally valid human rights and truly global international law—the project for promoting health and well-being by biotechnological means might still have implications for the civic norms of illiberal states such as Singapore. For example, it might expose unwanted, unintended limitations of existing norms and practices in the state’s pursuit of economic and technological development. At such points, it might exert pressure for limited change in the general organization of state and society. Shaila Jasanoff’s (2007) notion of civic epistemology resonates here: the notion of culturally specific ways in which a citizenry expects the state to deploy knowledge and expertise on its behalf in decision-making. We find civic epistemology no less in illiberal political cultures today than in liberal ones. (This conclusion is hardly uncontested. (Pace Holden and Demeritt (2008, 83), whocontend that, in the developmental state, there is “no public as such to engage and thereby democratise science,” hence that “liberal ideas about public engagement and opening up science” may there be meaningless.)

Still, the conclusion that the liberal norms of bioethics are unlikely to bring about change at the level of political governance is very limited in scope. My predictive, probabilistic argument allows for its eventual empirical falsification. Consider one setting for implementing bioethical principles: health care education. Studies have long shown that university faculty and other scholars tend toward political positions that are more liberal than conservative (van de Werfhorst, 2019). This observation holds as well for institutions the provide health care education (sometimes with a bioethics component). Each year of instruction represents possibilities for influencing new medical and research professionals, some of whom will practice their profession abroad, potentially spreading the liberal valence of bioethics. A probability-focused argument must contemplate the possibility that the sheer number of widely dispersed health care professionals seeing hundreds of thousands of patients a year might well contribute to a very gradual, very general political liberalization of the governance and administration of at least some political communities.

Consider now an alternative approach: the argument that the norms of bioethics, and those of political governance, are never causally connected. On this view, each sphere is always independent of the other. This argument does not contemplate the scenario sketched in the preceding paragraph. But the COVID-19 pandemic, among other empirical phenomena, immediately cast doubt on the argument. It confronted communities worldwide with the question of whether epidemiological evidence, and public health policy, could justifiably mandate vaccination, public mask wearing, or even mandatory participation in contact tracing via one’s portable cell phone. Some nonconsenting persons rejected such measures as a violation of liberal autonomy, here understood as the right to control relevant aspects of one’s life, including matters of health, even those that may impinge on public health (Gregg, 2021).

4. Response to possible objections

At least four objections might be raised to my overall analysis: (a) skepticism that the bioethical notion of autonomy might seep into the larger society; (b) that the terms illiberalism and authoritarianism are too vague to be useful in empirical analysis; (c) that a single-case analysis can be adequate for my explanatory purposes; and (d) that Singapore’s political system is accurately described as soft authoritarian. I address each in turn.

(a) Can the bioethical notion of autonomy spread to society overall?

How empirically plausible is the notion that the bioethical principle of individual decisional autonomy might ideationally populate sectors of a political community beyond clinical settings? The scholarly literature discloses many examples of bioethical spillover. First consider general examples: Debates on abortion almost always involve bioethical principles such as bodily and decisional autonomy, reproductive rights, and the right to life. Bioethical thinking often influences various movements advocating for or against abortion (Kim et al., 2019; Ortiz-Millán & Kissling, 2020; Tunc, 2021). Bioethical principles of access, regulation, and the rights of individuals and families arise in debates over assisted reproductive technologies, including in vitro fertilization and surrogacy (Asplund, 2020; Liu et al., 2022; Reineke, 2022). Bioethical concerns about the clinical deployment of embryonic stem cells have sparked political debates and influenced legislative decisions regarding funding and regulation of stem cell research (Charitos et al., 2021; Fabbri et al., 2023; Inoue et al., 2023). Bioethical dimensions of patient autonomy and the right to die with dignity regularly influence political debates about the legalization of euthanasia and assisted suicide (Campbell, 2019; Picón-Jaimes, 2022; Quah et al., 2023).

Second, consider examples of liberal political reforms influenced by the bioethical principle of individual decisional autonomy: Ballantyne et al. (2009), Gonzálex-Vélex et al. (2019), and Romanis (2023) demonstrate how the application of bioethical principles, including reproductive rights and bodily autonomy, contributed to the liberalization of abortion laws, allowing greater access to safe and legal abortion services. Lang (2020), Madera (2022), and Yesil (2022) show how bioethical discussions of patient autonomy and end-of-life care have encouraged, in some countries, the legalization of medical aid in dying or euthanasia.

(b) Can the terms illiberalism and authoritarianism be useful analytically even if vague?

Can the polysemic terms illiberalism and authoritarianism find plausible application as empirical referents? While these capacious terms have no consensually agreed-upon definitions, my usage is hardly unusual. By illiberalism I mean a political viewpoint that rejects legal and governmental toleration of individuals in some of their social and political differences from each other ( usually as members of particular groups, such as discreet and insular minorities), including differences of normative convictions and preferences, both public and private. This rejection entails another: of dissent, public debate, and other forms of communicative openness. There are many forms of illiberalism; authoritarianism is one (and distinct from others, for example, feudalism). By authoritarianism, I mean a political system that encourages and enforces the individual’s more or less blind submission to governmental authority in ways that greatly circumscribe or simply preclude individual rights of expression, assembly, dissent, and advocacy for institutional and personnel alternatives to an authoritarian status quo.

(c) Can a single-case study be analytically adequate?

Why study one case rather than several? As a methodology, a single case study asks How does the outcome come about? and Why did the mechanism operate as it did in the case at hand? (Ruzzene, 2023). It is superior to a multiple-case study for identifying the complexity and intricacies of a unique case and uncovering patterns (such as the possible effects of liberal bioethics if deployed within a nonliberal political community). That pattern may lead to theory (in the way envisaged, for example, in Max Weber’s [1913] interpretive sociology). Theory based on rich qualitative insights about one case offers a basis for hypothesis-testing in multiple-case research. The latter focuses on possible, measurable correlations among cases by “flattening” the many particularities of different cases. In this way, single-case ethnography—analytically useful in itself—may also improve multiple-case causal inference (Pacewicz, 2020).

(d) How is Singapore’s system of governance best described?

Is Singapore’s political system soft authoritarian? Soft authoritarian regimes have democratically elected governments that, once in power (and giving lip service to democracy), repeatedly undermine liberal values and institutions—such as the rule of law, the separation of powers, inclusive elections, and independent news media—by strategically manipulating majorities of citizens and by co-opting or neutralizing the legislative and judicial branches of government. Such regimes differ from each other along various dimensions—for example, in the ways that Poland, Hungary, India, Brazil, and Turkey differ. In Singapore, the civil liberties of freedom of expression and freedom of assembly are restricted in soft authoritarian ways that the government justifies as necessary for the country’s economic and social stability development (a claim that Sen (1999) rejects in other contexts). Consider prominent examples.

With regard to freedom of expression: First, the Sedition Act criminalizes acts that promote feelings of ill will and hostility between different racial and religious groups. While intended to maintain social harmony and prevent racial or religious tension, the law stifles freedom of expression and can be applied broadly to silence dissenting voices, curbing legitimate discussions and criticism of government policies. The language used in the Sedition Act is vague and open to broad interpretation, leaving room for potential abuse. The law’s lack of precise definitions and specific parameters for what constitutes seditious acts makes it difficult for individuals to gauge whether their actions or speech might be unlawful. The act’s very existence, and its enforcement, have a chilling effect on political discourse and civil society activities. Individuals and organizations may self-censor their statements and actions to avoid potential legal repercussions. The act lacks adequate safeguards to prevent its misuse.

Second, the Defamation Act (which extends from traditional media to online content) allows individuals to file civil and criminal defamation suits against persons who allegedly make defamatory statements. It has had a chilling effect on freedom of expression and investigative journalism. Journalists and other writers are hesitant to report on sensitive issues or engage in robust public discourse because they fear potential defamation lawsuits that could lead to significant financial penalties or even imprisonment. Under the Defamation Act, the burden of proof lies with the defendant to prove the truth of his or her statements. This requirement places an undue burden on individuals or media organizations facing defamation suits because proving the truth of a statement can be challenging and costly, even if the statement is factual. Further, the Defamation Act leads to an uneven playing field in defamation cases: wealthy individuals or organizations may exploit the law to silence critics or to intimidate journalists who likely lack resources to mount a robust legal defense. Further, the act does not include a specific defense based on the public interest. So even if a statement is in the public interest, and merits public discussion, it may not necessarily constitute a defense against a defamation claim.

Third, the Protection from Online Falsehoods and Manipulation Act (POFMA) allows the government to order the correction or removal of online content deemed false or misleading; noncompliance can result in penalties. It grants the government excessive power to determine what constitutes online falsehoods and manipulation. It allows ministers to issue correction commands and take-down orders without judicial oversight. The government unilaterally decides what information is false or misleading. While POFMA does provide for limited avenues of judicial review, the process favors the government. Challenging correction or take-down directives in court can be time-consuming and costly, such that individuals and smaller entities cannot easily contest government decisions effectively. Further, POFMA’s definitions of false statements and public interest are vague and open to interpretation, discouraging individuals and media outlets from engaging in public discourse on controversial topics for fear of inadvertently violating the law.

Finally, POFMA does not provide adequate protection for whistleblowers and anonymous sources who may be hesitant to come forward with critical information because they fear being targeted by the government.

With regard to freedom of assembly: The Public Order Act and the Public Entertainment and Meetings Act require organizers to obtain permits from the police for any outdoor event that involves a gathering of a certain number of people. The definition of what constitutes a public assembly is quite broad and even small-scale gatherings may require permits. The authorities closely monitor events to ensure that they adhere to the conditions specified in the permits. Failure to obtain the appropriate permits, or violations of their conditions, can result in fines or imprisonment. Note that Freedom House rates Singapore as “partly free,” with a political rights score of 19/40 and a civil liberties score of 28/60. ³

Conclusions

In clinical settings, bioethics does not require the host community to construct the individual as possessing decisional autonomy. And the patient’s decisional autonomy neither requires nor entails liberal democratic political community.

Further, bioethics is unlikely ever to serve as a carrier of political liberalism. It exists within a highly specialized, elite sphere insulated from the larger political culture in which it is embedded. Nothing suggests that the future will see a more popular bioethics influencing significant numbers of ordinary citizens. For that reason, bioethics in a more liberal Singapore—for example, as imagined by Chee Soon Juan (1994)—likely would be indistinguishable from bioethics in Singapore today. Chee imagines a country with a free and independent media; that allows robust freedom of expression and association and a robust civil society; with less governmental involvement in the running of businesses, and with less economic regulation, within an expanded system of social security with greater welfare for the poor. To be sure, it is possible that bioethics in a more politically liberal Singapore would be somewhat different because the political and cultural context would be different. One concludes as much from Dan Slater’s (2019) argument that the long-term survival of the hegemony of the People’s Action Party requires continued economic development which, in turn, could entail the evolution of stable authoritarianism into forms of democratization. One form might be greater public awareness of, and engagement with, bioethical issues. Another form might be a Bioethics Advisory Committee subject to more public scrutiny and accountability.

Be that as it may, the notion of the individual’s decisional autonomy so central to bioethics has greater prospects for general influence in liberal democratic communities than in illiberal societies. In the ideal case, bioethical questions would find consensual answers through a process of rational argument—even if bioethical questions will never find objective or scientific answers. In liberal societies, as in illiberal ones, bioethical disagreement is often intractable, as are most kinds of normative disagreement. Bioethical decision-making will often be intractable as well. The most plausible resolution of bioethical controversies and disagreements is less a matter of consensus-building through rational argument and more a matter of “political” bioethics in which decisions find legitimacy through procedural means (Gregg, 2022, ch. 1).

This argument finds support in the conceptual resonance between the bioethical principle of individual decisional autonomy and proceduralism. Proceduralism depends on a notion of autonomy. A person’s autonomy guarantees the legitimacy of the political processes that are addressed to her, as a citizen, and ideally in which she participates. Legitimacy can only be tied to the formal procedure of decision-making (oriented in part on finding majority preferences), and not to the substance or content of the outcome, because all persons have many normatively thick value commitments unlikely to find consensual agreement. Specifically democratic political arrangements, however, must be “normatively thin,” lest they unfairly violate the thick norms of some citizens and privilege those of others (Gregg, 2003b). Proceduralism in liberal democracies offers a way forward in the face of intractable value commitments: each citizen has an equal say in the political process, normally (though not always) through voting. Majoritarian proceduralism seeks to preserve the autonomy of those who participate in that process while resolving disagreement among parties with sometimes profoundly different beliefs and value commitments. If bioethics is fundamentally “political” in a liberal sense of the term—of the public, discursive, deliberative contestation of competing public values toward finding agreement on their implications for the formulation of public policy endorsable by as many members of the community as possible at any given time—then majoritarian proceduralism offers a plausible and politically legitimate decision-making process in the face of enduring bioethical disagreement.

But if this vision of the bioethical principle of individual decisional autonomy is plausible (if at all) only in in liberal democratic communities, it offers no basis for cross-national regulatory norms on a global basis. A global bioethics, desirable for cross-national regulation, remains utopian (Hellsten, 2008). A more empirically plausible goal would be some kind of “enlightened, bioethical localism.” Such a localism could combine proceduralism—the notion that no rule is acceptable apart from a formal, agreed-upon method and that an acceptable method yields an acceptable rule—with pragmatism: a belief system in which belief is not so much truth guided as behavior guiding (Gregg, 2003a). On that non-utopian basis, an enlightened localism might adjudicate among competing normative commitments and interpretations using local criteria in the abiding absence of universal standards.