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Dan Sulmasy’s Crystal Ball

4 Aug, 09 | by Iain Brassington

Dan Sulmasy has a piece on Bioethics Forum at the moment in which he considers the next 40 years of bioethics.  It’s a curious piece, making six main claims or predictions about the future, to which I’ll return in a minute: but before that, I think it’s worth looking at his scene-setting:

I suggest that bioethics has evolved through three phases: a religious phase in the 1950s and ’60s, a philosophical phase in the ’70s and ’80s, and a political-empirical phase from the ’90s to the present. Much as been written and said about the first two phases, but little about more recent history.

By the late 1980s, just as I was starting serious study in the field, philosophical bioethics had created a standard canon and had begun to rest on its achievements. Physicians, who found the language of philosophers alien but had been taking courses in bioethics, began re-engaging the field (or, in some cases, reclaiming it as their own). 

The general public, policymakers, and many of the new young students entering the field of bioethics by this time also began to complain that philosophy did not supply enough concrete answers to their pressing questions. They wanted solutions to social policy problems such as the distribution of health care resources, cost-containment, and physician-assisted suicide.

I’m interested to know whether this natural history of bioethics is accurate.  On the face of it, I’m not sure.  It – perhaps – describes the genesis of bioethics in the US, but I’m not sure that the subject has followed the same route in Europe, where there simply has not been a religious or political phase.  Bioethics has grown out of a renewed interest in applied ethics, which has grown out of good, old-fashioned, seminar-room ethics.  To the extent that claims are made about what should be done, and what the law should say, bioethics is “political” – but it isn’t political in the strong sense that I think Sulmasy uses the term; it isn’t about activism on behalf of this or that group (and it shouldn’t be, either).  And I’ve already articulated my suspicions of the supposed “empirical turn” in the subject; empirical studies may feed ethical debate, but they oughtn’t to be treated as a substitute.

But back to the six points, which I’ve edited down here.

1. I think we should avoid the temptation to make bioethics a clinical profession.  I completely understand the desire to set standards so that not just anyone can call herself a bioethicist and act incompetently, even harming patients in a hospital.  However, one could accomplish this goal by establishing general standards while leaving it up to individual institutions to determine how they will assure that such standards are met.

The most obvious point to be made here is that Sulmasy seems to be talking about bioethics as a profession in its own right more than as an academic pursuit (and I’ve blogged about my worries concerning this before); if you think that bioethics is a species in the latter genus, a lot of this point’ll make no sense.  Now, to the extent that there is (or could be) a sui generis profession of bioethics, the point does have some mileage.  Bluntly, we’d need to decide whether we’re analogous to dieticians or nutritionists.  (I’ve commented before on an advert that I found for a medical ethicist that seemed not to place that much importance on ethical competence.)  But Sulmasy’s point about standards should we go down the professionalised route is actually quite tough - if there are to be standards, how are they to be assessed?  Could we imagine – and would we support – some kind of Chartered Institute of Bioethics, indicating a specific level of qualification?  That’d seem hard on people who’ve just started out in their careers having spent the best part of a decade before studying philosophy to PhD level – why would we want to impose yet more exams on them? And what would we be examining to begin with, given what Sulmasy says in point (4) about bioethics not being a discipline?  The alternative might be that we go on publications – but, again, this is hard on newbies, and it’s a measure of bioethicist-ness that’s much more appropriate for the academic model anyway.

2. We should forswear our recent turn to politics and start engaging again in basic scholarship.  Our best hope lies in pursuing the fundamental questions. This will often take us back to basic inquiries such as those of moral psychology; the meaning of altruism; the meaning of the common good; what it means for human beings to flourish; the place of medicine in a well-ordered society; and critical thinking about rights, casuistry, utilitarianism, pragmatism, and other very basic questions that are essential to serious thinking about bioethical questions. In the end, this will not only be more productive, it will be a lot more fun.

Well, yes.  But now we’re back to the philosophical seminar room, more than the real-world professionalism of point (1).  And by “our best hope”, what’s meant?  Who is the “we”, and what is the hope we need?  It’s all a bit Obiwan Kenobi…

3. Similarly, I’d like to see a revival of interest in the philosophy of medicine, nursing, and the healing arts in general.

More philosophy, yes.  But is there really a discrete philosophy of medicine, philosophy of nursing, philosophy of gas-meter-reading and so on ad infinitum?  Or is there, rather, just critical, philosophical thinking?

4. We should continue to pursue the goal of truly interdisciplinary scholarship. The academy, in general, talks a great talk about being interdisciplinary, but delivers very little. Bioethics remains perhaps the last great hope for interdisciplinarity truly to flourish.   Bioethics has done a decent job, but we can go much deeper. The work will be hard, but rewarding.

I have no idea what is meant by the assertion that bioethics is the “last great hope for interdisciplinarity”.  Indeed, I have problems with the “I”-word as a whole: what’s the difference between being interdisciplinary and being intellectually curious?  For sure, it’s useful, admirable, desirable, and a whole lot else to be able to engage across the spectrum of human pursuits, and with researchers in other fields.  If that’s what interdisciplinarity is, then it’s hard not to think it good.  But it’s not an end in itself, and it’s possible to be a good scholar with a narrow focus, too.  I know that the Academy gets very damp about the concept of interdisciplinarity, and I suppose that, as a member of the academic set, it’s probably written into my contract that I should as well.  But I just don’t get it.

Sulmasy continues:

The wrong way to go about this, however, is to make bioethics into a homogenous mush. I am, frankly, quite troubled by the proliferation of degree-granting programs in “bioethics.” A smattering of sociology, philosophy, literature, law, and political science does not constitute a discipline that can interact with other disciplines in a productive dialogue.

True – and we’re back to the question in point (1) about how wide we want the gates to be with this.  There are some utter cranks who pass themselves off as bioethicists, and I have no doubt that there’s a number of comparably cranky bioethics “qualifications”.

Bioethics is not a discipline. It is a fascinating field of inquiry that can productively attract scholars from many disciplines in a dialogue. Each can learn from the other, and all can contribute to a richer understanding of the questions that confront us. 

There is plenty of work to do in finding out how better to facilitate interdisciplinary scholarship. Exactly what can a sociologist do for a philosopher or a historian for a lawyer? Can it develop beyond a series of pictures at an exhibition to form some sort of coherent unity? Bioethics is the field in the best position to explore these questions.

I’m worried here about a confusion of interdisciplinarity and non-disciplinarity.  But if bioethics is not a discipline, and if it is nonetheless interdisciplinary, then it would seem to be nothing more than the Lagrange point at which all disciplines concerned with the biosciences meet.  Bioethics, on this account, is what happens by accident when people with vaguely coincident interests meet in the pub - and that doesn’t seem right, either.  Moreover, if it is right, bioethics does not seem to be in any position to explore questions of what sociologists can do for philosophers - that would be meta-bioethics.

I’m so terribly confused.

5. I think it is time we started working on new theories of bioethics.

Really?  What would a “theory of bioetics” look like?  Does Sulmasy mean here some sort of new philosophical synthesis?  But – even assuming that such a thing would be possible – why, and what would it presuppose?  (At a guess, it’d presuppose a norm telling us how to go about the synthesis; but if we can have that norm, why go about forming new ones?  It looks like all the normativity is there, uncontaminated, and waiting to be picked off the shelf.)

6. Finally, let me suggest that medical schools would do well to embrace programs designed to train clinicians in philosophy and theology, just as they now train clinicians in molecular biology and neuroscience. For the field of bioethics to be respected in academic medicine, it needs to embrace its basic sciences.

It’s perhaps true that bioethicists need to be scientifically literate – or, at least, to have a tamed scientist nearby to help out.  (If that’s interdisciplinarity, then so be it – but I’d call it simple good taste.)  But there’s no reason for ethicists to be clinically trained that I can see; and nor is there a need for medical schools to train philosophers much beyond awareness-raising of how to spot a moral problem when it stalks the wards.  Medical degrees are there to teach people to make us well; the ethics component is to teach them to think critically about their actions.  But that’s really not the same as training doctors to be ethicists – though if they want to study ethics in more depth, that’s obviously a very good thing indeed.

As for the point about theology…  What?  What would that add to anything?  Ethics is a branch of philosophy, and there’re still philosophers who’re non-ethicists and/ or terrible ethicists and of whom, as such, we oughtn’t really to take much notice on matters bioethical.  Why should theologians – who may be brilliant at studying exhortions cooked up by pre-scientific and semi-literate (or illiterate) people a couple of thousand years ago – be thought of as being able to say anything coherent (let alone interesting) about bioethical problems just because of their discipline?  I could bang on about this for ages – but I’ll point instead to a recent post by Russell Blackford and end by quoting from that post.  Delete the words “religious leaders” and insert the word “theologians” in its place, and you’ll get the gist of my position.

[M]any people in the bioethics community are fed up with the never-ending resistance from religionists to rational bioethics. Some of them are asking what credentials religion has anyway. Religious leaders are, of course, able to put their arguments in public, like anyone else. But they cannot expect anyone to defer to them if they rely on controversial religious claims.

It’s one thing for the state to protect us from internal and external violence, to provide a social/economic safety net, and to engage in a variety of other functions that can be given some secular justification or other. It is another thing for it to ask what the views are of various religious traditions when it is confronted by an issue such as stem cell research. But this is just what has been happening. I suggest that religious leaders should be free to put their arguments, but if the arguments depend on doctrines such as ensoulment, the views of God, the sanctity of the natural order, and so on, these popes and priests should not expect to wield any influence. Those are not the sorts of worldly concerns that should influence government policy.

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  • Sorcha Uí Chonnachtaigh

    Iain,

    A most interesting post – thanks for drawing our attention to Salmasy’s piece too.

    It is quite long and raises more than a few points…

    1. Natural History of Bioethics – you think Salmasy is really documenting bioethics in the US. I do think however that there has been a religious phase in Europe if not in the UK. In Ireland and on the continent medical ethics was very much entwined with the religious (clergy/theologians) which in turn developed into bioethical inquiry more generally. While I don’t think it was necessarily a long phase, I think it may have been a stepping stone in the history of European bioethics.

    2. Foreswearing Politics
    While the more basic questions (as Salmasy puts it) are important, I can’t understand the resistance to politics? Maybe I’m understanding him wrong: if he means that bioethicists should avoid fuelling political divides (say on the issue of assisted death), I can understand where he’s coming from. However, bioethics – with it’s attendant policy/legislation implications – is political. To ignore that is to ignore something very significant about bioethics. To fail to engage with the politics around bioethics is mere cowardice. (Is that too strong? I don’t care.)

    3. The Dreaded Disciplinarity Question
    There is constant back-and-forth about this. Yes, bioethics is a field of academic research that is populated by many disciplines, ie. multi-disciplinary. Interdisciplinarity requires some sort of integration of methodologies/approaches that is rarely seen in bioethics (in my experience – I could be wrong). By the way, I think for bioethics to succeed as an interdisciplinary field, we would have to be careful to consciously maintain high quality research within our specific disciplines as well as working with and across other disciplines.
    [Iain, I wonder if you think that is utter rubbish??]

    4. Theology
    I don’t feel too strongly about this one way or the other, as an areligious individual, but it might be worth pointing out that there is a great deal of theological scholarly work on social morality (some of it is even progressive!) and morality more generally, which may have something to contribute to (bio)ethics. (In answer to your question, “Why should theologians…be thought of as being able to say anything coherent (let alone interesting) about bioethical problems just because of their discipline?”)

    Having said that, there is no reason why theology/religion should be given prominence, which it often is, and it certainly wouldn’t be a *necessary* component of bioethical training for students in the healthcare professions.

    Lots to ruminate on this afternoon!

  • Iain Brassington

    Sorcha – I think you’re right about a lot of this, and perhaps I could have been clearer.

    In respect of the religious origins of the subject, while it may be true that religious concerns motivated the flagging of certain problems, I don’t think it follows that there was ever a religious turn in the subject per se; nor did it grow out of religious arguments. European bioethics, as I see it, has always been an almost completely secular affair, and is at its most successful when it is.

    This speaks to your (4), too: whatever important work there has been on social morality carried out by theologians, it’s hard to see what the theo- prefix has added; what’s the difference between this kind of work and moral anthropology or just plain old ethics?

    In respect of (2) and (3), I agree almost completely. If an analysis of a problem leads an ethicist to conclude that a policy is indefensible and should be ditched, then that is political in some sense. But it’s not the sense that I detected in S’s post; and there is a big difference between the criticism of a policy decision and activism to change a policy. Moreover, I don’t think that the cool analysis at which we should be aiming could ever be partisan, which also seems to be implied in the kind of politics about which S is talking.

    As for interdisciplinarity… yup. You need some kind of norm to manage it, and to tell you why it’s necessary – and that’s not the sort of thing you can establish, derive or discover through more interdisciplinarity without circularity.

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  • Sorcha Uí Chonnachtaigh

    Too true Iain! (On your last point.)

    As to the first, regarding the benefits of theo-, I agree it’s not a special contribution, just a contribution. The only difference I can see would be foundation principles, which add nothing. It was just to point out that it is a separate discipline in which this kind of work is done, same may be said for moral anthropology but not of others. I may have already mentioned that I don’t care much to defend theology and now I feel like I am, so I’ll stop!

    With regard to politics and bioethics – I should have read DS’s post more fully before commenting. Having now done so, I’m still not sure if the problem he points to is a case of bioethicists becoming overly involved in partisan discussions of a bioethical nature, or if it is really a problem of politicians using bioethical issues in an emotive, polarising manner to inflame moral outrage. If the problem is with politicians, then maybe bioethicists should become more publicly active to change the dynamic of such debates?? I’m not thinking you necessarily disagree…I’m just hijacking your critique of DS (apologies).

    On interdisiciplinarity – yep.

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    Medicine and health care generate many bioethical problems and dilemmas that are of great academic, professional and public interest. This comprehensive resource is designed as a succinct yet authoritative text and reference for clinicians, bioethicists, and advanced students seeking a better understanding of ethics problems in the clinical setting. Each chapter illustrates an ethical problem that might be encountered in everyday practice; defines the concepts at issue; examines their implications from the perspectives of ethics, law and policy; and then provides a practical resolution. There are 10 key sections presenting the most vital topics and clinically relevant areas of modern bioethics. International, interdisciplinary authorship and cross-cultural orientation ensure suitability for a worldwide audience. This book will assist all clinicians in making well-reasoned and defensible decisions by developing their awareness of ethical considerations and teaching the analytical skills to deal with them effectively.

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  • http://www.medhumanities.org Daniel S. Goldberg

    Iain,

    This is an excellent, provocative commentary, but I would like to say as both a committed interdisciplinarian (indeed, as someone who has completed a Ph.D in an interdisciplinary field, medical humanities) and as someone with advanced training in applied ethics, there are many ways of sharpening the predicate “is interdisciplinary studies.”

    In the U.S., there is an unusual professional group entitled the “Association of Integrative Studies” that has made it their business to clarify what is and what is not meant by the term “interdisciplinary.” I agree with Dr. Sulmasy that the Academy tends to wax about the term without any clear sense of what it means or what it entails, but I also have a vested interest in believing, and do believe, that he is right that doing so is of critical importance.

    While a blog comment is obviously not the place to go into a detailed discussion of what counts as interdisciplinary work, and why it matters especially to concerns of health and illness in society, I did just want to register both that I think the concept is important, and in fact that it can be sharpened to render it meaningful in practice. (As a devoted Wittgensteinian and non-essentialist, I neither want nor think it coherent to search for a definition of “interdisciplinary”).

    In any case, I hope to practice such a form of life in my own work, though, for all the talk of the importance of interdisciplinarity, there is, both in my experience and in the evidence on the matter, little reward and every punishment for attempts to practice as such in the U.S.

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  • David

    As I engage more with European bioethics and what I find is more willingness to engage with religious ideas, often mediated through philosophers such as Habermas, Kant or Heidegger. In the UK philosophy is a kind of aspiring middle class that seeks solace in despising theology as it in turn is despised by the natural sciences. In fact much critical reflecton on human action has in the past and continues in the present to be mediated by theology. Even in this country much bioethics is quitely religious in inspiration or context. It is not alll bedside Benthamism, thank goodness.

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