Is Bio-Medical Ethics Failing?


What medical ethics needs is more and better philosophy—and a return to the adventurousness and originality of its pioneering days. There have been successes—euthanasia and better treatment of animals to mention just two. But the field has in many ways dried up or become dominated by moralists bent on protecting privacy and confidentiality at great cost and ‘getting consent’, and in other ways ‘protecting basic human rights and dignity’. Medical ethics isn’t sufficiently philosophical, and when it is philosophical, it’s the bad arguments or a narrow range of arguments that often seem to make a difference. And there is the attempted scientification of ethics in empirical ethics, a kind of sociological ethics, surveying people’s opinions and practice. But this can never directly lead to answering the question: what should we do?

That’s Julian Savulescu, director of the Oxford Uehiro Centre for Practical Ethics, arguing in the Journal of Medical Ethics that bioethics and medical ethics are failing. In his article, “Bioethics: Why Philosophy Is Essential for Progress,” Savulescu holds that bioethics and medical ethics are insufficiently philosophical, claiming they are plagued by, among other things, a slavish appeal to codes and laws, a lack of sensible thinking about coercion and exploitation, a kind of thoughtless egalitarianism, moralistic rather than reasoned reliance on ideas like consent, dignity, and privacy, and, overall, a general timidity.

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Will MacAskill
Will MacAskill
6 years ago

Hear hear!Report

David Velleman
David Velleman
6 years ago

Bioethics as a sub-discipline of philosophy was born during a period of roughly 50 years in which medical and legal developments focused public attention on issues of reproductive technology, assistance in dying, and medical research. (I have listed some relevant dates below.) Since that period, the arguments on all sides of these issues have been mapped out, and many of the issues have either been resolved in law or become ossified in political movements.

There is no reason why fields of applied ethics should survive forever. New applications arise and gradually become commonplace. There were no ethical issues of digital technology in 1960; there are now. At some point, controversy over those issues will get resolved or ossified. Unfortunately, fields of applied ethics become entrenched in institutions that never die, even after they serve no pressing social purpose.

The Era of Bioethics:

1947: Nuremberg “Doctors Trial” concludes
1955: First intensive care unit in US created
1960: Birth control pill approved by FDA
1965: Griswold v Connecticut
1969: Hastings Center founded
1969: Term “living will” proposed in Indiana Law Journal
1972: Tuskegee study revealed
1973: Roe v. Wade
1975: Journal of Medical Ethics founded
1976: Karen Ann Quinlan case decided
1978: Birth of Louis Brown (first “test tube baby”)
1978: National Commission for the Protection of Human Subjects issues the “Belmont Report”
1980: First contract for gestational surrogacy
1988: “Baby M” case (first trial over custody of baby born to surrogate mother)
1989: Jack Kevorkian performs first public assisted suicide
1991: Patient Self-Determination Act requires hospitals to inform patients about advance directives
1996: NIH establishes Department of BioethicsReport

Ross McKinney
Ross McKinney
6 years ago

Savulescu is right on several fronts. The dominant forces in research ethics focus not on ethical principles, but on documents like US and EU regulations. Paternalism and protectionism reign, at the cost of much research that would benefit people. Why is it that an act that has no cost to the individual, like contributing their genetic sequence into database, is ruled out by the absence of consent? The principle in question, “Honoring autonomy should rule all medical research decisions”, is roughly the same as saying, “We all have the autonomous right to decide whether we wish to honor stop signs.” When there is a collective benefit, as Savulescu points out, we accept some restrictions on rights associated with autonomy. In the case of passive contribution of genetic information, there is the potential for benefit from understanding how diseases happen, and at essentially no cost to the individual. We have over-valued respect for persons by under-valuing the potential benefits of research, particularly for the affected. We treat research as if it was for the benefit of the investigator, not the ill and in-need. Human research subjects protection programs assume exploitation is the norm, not the exception, and thus we self-restrict the progress we should be making.Report

dmf
dmf
6 years ago

The field has largely been reduced to ensuring compliance with various legal/insurance standards, there was a brief glimmer of hope with the invention of “clinical” pragmatism but that seems to have faded, the most interesting/promising work these days is being done by folks with a background in actor-network-theory/STS like Annemarie Mol and co. and ethnographers like Paul Rabinow:
http://openwetware.org/images/7/7a/SB1.0_Rabinow.pdfReport

Joshua Knobe
6 years ago

Savulescu rightly notes that there has been a surge of experimental work in bioethics, but he then disparages this approach:

‘And there is the attempted scientification of ethics in empirical ethics, a kind of sociological ethics, surveying people’s opinions and practice. But this can never directly lead to answering the question: what should we do?’

In one sense, what Savulescu says here is clearly correct, and trivially so. Facts about people’s moral cognition can never directly answer questions about what we should do. One always needs some additional claim that allows one to go from the facts about moral cognition to the conclusion about what we should do. Moreover, it is quite right to say that this additional claim will typically be a substantive claim in moral philosophy, one that can be addressed using very traditional philosophical methods. Yet, having granted all of that, I don’t see how it is supposed to be any kind of objection to experimental bioethics.

For a helpful analogy, consider a philosopher who says that we can make progress in bioethics by considering metaphysical questions (e.g., questions about personal identity). In just the same way, one could point out that metaphysical facts will never directly answer questions about what we should do, in the sense that one always needs to add a substantive moral claim that tells us how these metaphysical facts bear on moral issues. Yet surely this is not in itself an objection to the practice of looking to metaphysics for help in addressing bioethical questions.

Similarly, one cannot refute experimental bioethics just by pointing out that it always relies on substantive philosophical claims about the ways in which the empirical facts bear on moral issues. The only way to refute experimental bioethics is to actually discuss those substantive philosophical claims and show that they are mistaken.

[Note that this is not supposed to be a criticism of Savulescu, who has a very sophisticated understanding of these issues, but rather a positive point about the relevance of experimental bioethics.]Report

jrs
jrs
6 years ago

I’d like to hear more about the indirect relevance of the experimental findings to the “what should we do?” question. What exactly is the “additional claim” that would allow us to move from facts about moral cognition (and we’re talking about experimental survey results about what’s right and wrong, right?) to facts about what we should do?

I see how theories of personal identity can be used in arguments or theories about morality. I don’t see how experimental results about our folk theory are relevant to such arguments or theories. As I understand reflective equilibrium, for example, I may be required to adjust the ethical principles that *I* espouse in response to *my* recalcitrant intuitions about cases. But I’m not required to adjust my principles in response to conflicts between my principles and the prevailing folk theory. There are may be issues about testimony and epistemic peers here, but it seems to me that those kinds of considerations bear on the question of what we should do in a *very* indirect way, much more so than work on personal identity (at least as some philosophers see the role of personal identity).

With all that said, I’m all for finding out what people believe.Report

Joshua Knobe
6 years ago

Hi jrs,

This comment is a very helpful one, which gets right to the heart of the issue.

The key thing to keep in mind here is the actual nature of the empirical contributions under discussion. A lot of experimental philosophy does indeed proceed by examining people’s judgments about cases, but the aim is not simply to arrive at a description of the patterns in these judgments. Rather, the aim is typically to test specific hypotheses about the underlying cognitive processes that give rise to them. Thus, the philosophical claims that will be relevant here are claims about the degree to which we should put our trust in the outputs of different kinds of cognitive processes.

Probably the best way to convey this point is with a simple example. We are now working on a series of studies to test the hypothesis that (1) people’s intuitions about the moral status of certain pharmaceutical interventions are the product of a tacitly essentialist conception of the mind. Now suppose that one also establishes the claim that (2) we should distrust our intuitions to the extent that they are the product of this sort of tacit essentialism. (The argument for this latter claim would not proceed using experimental data but rather using very traditional sorts of philosophical methods.) Together, claims (1) and (2) provide support for a conclusion that would be highly relevant to bioethics, namely, that we have specific reason to distrust our intuitions about the moral status of these pharmaceutical interventions. In other words, if you started out with an intuition that these interventions were morally wrong, you might want to discard that intuition when you are engaging in reflective equilibrium.Report

Moti Gorin
Moti Gorin
6 years ago

Savulescu is right that much of contemporary bioethics is insufficiently philosophical, that important distinctions are often run together (e.g., coercion and exploitation), and that a heavy emphasis on legal requirements and institutional norms can undermine creative thinking and moral progress. This leaves me a bit puzzled by David Velleman’s take on bioethics. If I’ve understood him, Velleman is claiming that legal decisions or political ossification can render ethical questions otiose and that the continued treatment of or interest in such questions is best explained by institutional inertia.

I can’t see how many of the problems in bioethics differ in any relevant way from problems in other areas of philosophy (both applied and non-applied). As a society, we are deeply committed to forcing criminals to bear certain costs. Murderers are jailed and in some cases executed as a matter of settled law. And yet philosophers wonder about retributive justice, about the authority of the law or of government, about whether it can ever be morally justified to kill one person to save five, etc. Every four years we vote in a presidential election—a process firmly established by law—and the winning candidate is pretty much always someone who represents some ossified political movement or set of interests. Yet, philosophers continue to write about democracy, about the rationality or irrationality of voting, etc. “Taxes are due in April” is not going to appease the libertarian. And so on.

I can’t see why philosophers (or anyone else) should stop caring about authority, or justice, or democracy, etc., and I would like to think it’s more than institutional inertia that explains why we are still doing what we do, despite it’s very often serving no “pressing social purpose.” Similarly, I can’t see why philosophers (or anyone else) should stop caring about informed consent, or about how new technologies might impact our conceptions of our bodies, our minds, our lives, and our deaths, or about the uses to which information about our bodies might be put, or about the proper role of experts or governments in determining what kind of people will or will not come to exist, etc.

If Savulescu’s diagnosis of the problem with biomedical ethics is correct, then the solution is to try to do better biomedical ethics, not to leave it to settled law or to political movements.Report

jrs
jrs
6 years ago

Thanks for the response, Joshua. Now that I have a more accurate picture of the experimental work, I agree with your claims about this work.Report

Moti Gorin
Moti Gorin
6 years ago

I have a question for Joshua Knobe: Can you please say a little more about why you need premise (1) if what you ultimately want to do is conclude something like “pharmaceutical intervention X is morally im/permissible.” Don’t you just need a philosophical argument for why a certain essentialist conception of the mind is misguided/bad, coupled with the claim that the objection to pharmaceutical intervention X logically depends on the misguided/bad conception of the mind? I guess I’m trying to get clear on what you mean by “cognitive process.” Initially I thought you meant something like the processes that are distinguished according to whether they are instinctive as opposed to deliberate, happening in this part of the brain rather than that one, etc. But in the case you describe the “cognitive process” looks more like a logical inference (i.e., from a certain conception of the mind to a judgment about the permissibility of some kind of intervention on that mind/brain), in which case it’s not a question of whether people have intuitions that are trustworthy, but rather a question of whether or not some belief people have rests on a conception of the mind that is philosophically indefensible. I hope my question is clear enough.Report

Joshua Knobe
6 years ago

Hi Moti,

I wouldn’t want to focus too much on this specific example, but it does seem like it might help to illustrate a more general approach that crops up in a lot of recent work. The basic assumption is that we simply find ourselves having a certain moral intuition in these cases. We have no immediate access to the reasons why we have this intuition; we just find ourselves feeling that a certain action is morally wrong. Then the experimental results suggest that this intuition is actually the product of a certain tacit conception we have of the mind and the self. Further philosophical work exploring that conception can therefore give us a better understanding of whether our intuition is actually warranted.

Numerous other recent studies have this same basic structure. Even if one focuses just on studies that suggest that people’s moral intuitions reflect tacit conceptions of the mind or self, one might look to recent work by Eddy Nahmias, Dylan Murray, David Shoemaker, David Faraci, George Newman, Julian De Freitas, Derek Leben, and many others.Report

Moti Gorin
Moti Gorin
6 years ago

Thanks, Joshua, that’s helpful. I’ll have to follow up on those references.Report

David Velleman
David Velleman
6 years ago

Thanks, Moti Gorin. Your points are well taken, so I have to rephrase what I was trying to say.

There have always been theoretical issues about birth, death, consent, and so on — and there always will be — but they didn’t call for an applied sub-discipline until a confluence of social and technological developments presented us with a family of choices that hadn’t existed before. We suddenly needed a concerted effort to solve practical problems arising in a fairly specific arena. Without that social need, philosophy about those issues would not have coalesced into a discipline with it’s own programs, institutes, and journals focusing primarily on medicine, and there wouldn’t be a blog post titled “Is Bio-medical Ethics Failing?”

The theoretical issues remain, but society has made choices about medical practice at the beginning and end of life, and where those choices remain controversial, the controversies are often political. My thought was that if “bio-medical ethics” is “failing” as a discipline, the reason is that we no longer need a *discipline* under that rubric. There are still things to say about the beginning and end of life (full disclosure: I’ve tried to say some), but they can be said without there being such a thing as bioethics. (Embarrassing disclosure: my title at my institution includes “Professor of Bioethics”).

(And now I have to sleep off last night’s champagne.)Report

Julian Savulescu
Julian Savulescu
6 years ago

Thanks for this interesting discussion. Joshua, I did not intend to disparage experimental philosophy. I am a big fan your work and we do this kind of think at the Centre. I was referring to the simple minded empirical approach that reads off what ought to be done from people’s attitudes or behaviour, or surveying intuitions. In fact, I think the two most important kinds of research necessary for moral progress are philosophy and cognitive science (as well as history, anthropology, sociology etc). As I have argued, we need to be understand the nature of human moral decision-making, its strengths and limitations. That is primarily a scientific endeavour – the kind of thing you have done so well. But we also need to philosophy to evaluate this and to decide what to do and be, as you acknowledge.
I have to say I was a bit surprised by David Velleman’s claim, “There is no reason why fields of applied ethics should survive forever.” I think I understand the idea that motivates this – for example, the arguments around euthanasia are now pretty well rehearsed and it is hard to see how there will be great theoretical progress (but there may be). As he says, the main issues seem to be political or social. My claim in the paper was that many positions have ossified in precisely the wrong direction. Moreover, it is hard to see how applied ethics could ever be obsolete. We will always have to make decisions about what we ought to do, how we should change society, use new technology, etc. Nick Bostrom has produced an important new book on Superintelligence – I don’t think we have even scratched the surface of ethics of AI. Christine Korsgaard just gave a really stimulating set of Uehiro Lectures in Oxford arguing for even greater respect and treatment of animals than even utilitarians like Peter Singer advocate. I have tried to think about the ethics of creating human pig chimeras for organs, which is occurring in Japan and the US. I don’t believe we have exhausted the issue of the moral status of creating such novel life forms. If anything, applied ethics will increase in importance as technology becomes more and more powerful and our power relentlessly increases. I think it is an exciting time to be doing philosophy but we ought be reserved about the kind of progress that has been made so far in applied ethics, but Art Caplan has a different view.Report

Joshua Knobe
6 years ago

Hi Julian,

Thanks so much for this clarification. Now that I have a better understanding of what you had in mind, I agree that your conclusion is completely correct.

In any case, I’ve really enjoyed the recent experimental research coming out of your centre, and I very much look forward to seeing what you folks come up with next!Report