Cross-national norms

Even if the influence of bioethics on the political views of society as a whole is limited in illiberal polities (Klein, Reference Klein and Yorke2016), 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., Reference Barnett, Pevehouse, Raustiala, Pevehouse, Raustiala and Barnett2021; Lake, Reference Lake2021).

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, Reference Charo2004).

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 (Reference Beauchamp and Childress2019) propose three additional identities—non-maleficence, beneficence, and justice—while Jacob Rendtorff and Peter Kemp (Reference Rendtorff, Kemp, Valdés and Lecaros2019) 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, Reference Habermas2000). 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.

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, Reference Hashemi2009).

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.

Norms of citizenship

According to Kerry Holden and David Demeritt (Reference Holden and Demeritt2008), the bioethics administrative culture in Singapore distinguishes between

If respect here refers to the paramount “legal requirement to obtain informed consent from the research subject” or patient (Holden & Demeritt, Reference Holden and Demeritt2008, 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, Reference Tan and Preece2022) 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, Reference Lee, Teo, Chung and Cho2023), 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, Reference Lee and Abdullah2022).

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, Reference Gregg2015). 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 (Reference Dahrendorf1995) in a different context:

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, Reference Slater, Rahim and Barr2019). 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., Reference Lustrilanang, Suwarno, Rizki, Omar and Said2023).

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, Reference Gregg2023).

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 (Reference Levine2010), 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 (Reference Lempert, Moreno and Berger2010) 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, Reference Holden and Demeritt2008, 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, Reference Holden and Demeritt2008, 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 Reference Salter and Salter2007, p. 576). According to David Reubi (Reference Reubi2000), 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.Footnote 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).Footnote 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 (Reference Krishna and Menon2014) 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 (Reference Elliott, Ho and Lim2010) 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, Reference Mills2020)—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 (Reference Reubi2000) 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, Reference Thompson and Case2015), like the term Western norms (e.g., Inglehart, Reference Inglehart2008), 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, Reference Dodds and Thomson2006; Montgomery, Reference Montgomery2016).

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, Reference Chang, Sajó, Uitz and Holmes2022) 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 (Reference Lee and Abdullah2020) 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, Reference ten Have and Gordijn2011).

(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 [Reference Gielen and Gielen2020] 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,

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, Reference Gregg2012). 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 (Reference Rawls1999) 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 (Reference Jasanoff2007) 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 (Reference Holden and Demeritt2008, 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, Reference van de Werfhorst2019). 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, Reference Gregg2021).

(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., Reference Kim, Young and Lee2019; Ortiz-Millán & Kissling, Reference Ortiz-Millán and Kissling2020; Tunc, Reference Tunc2021). 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, Reference Asplund2020; Liu et al., Reference Liu, Xian and Du2022; Reineke, Reference Reineke, Wohlers and Fletcher2022). 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., Reference Charitos, Ballini, Cantore, Boccellino, Di Domenico, Borsani, Nocini, Di Cosola, Santacroce and Bottalico2021; Fabbri et al., Reference Fabbri, Ginoza, Assen, Jongsma and Isasi2023; Inoue et al., Reference Inoue, Masui, Harada, Hong and Kokado2023). 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, Reference Campbell2019; Picón-Jaimes, Reference Picón-Jaimes, Lozada-Martinez, Orozco-Chinome, Montaña-Gómez, Bolaño-Romero, Moscote-Salazar, Janjua and Rahman2022; Quah et al., Reference Quah, Chua, Lua, Wan, Chong, Lim and Krishna2023).

Second, consider examples of liberal political reforms influenced by the bioethical principle of individual decisional autonomy: Ballantyne et al. (Reference Ballantyne, Newson, Luna and Ashcroft2009), Gonzálex-Vélex et al. (Reference Gonzálex-Vélex, Melo-Arévalo and Martínex-Londoño2019), and Romanis (Reference Romanis2023) 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 (Reference Lang2020), Madera (Reference Madera2022), and Yesil (Reference Yesil2022) 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, Reference Ruzzene, Kincaid and Van Bouwel2023). 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 [Reference Weber1913] 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, Reference Pacewicz2020).

(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 (Reference Sen1999) 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.Footnote ³