11 Sep, 12 | by Iain Brassington
On his blog in The Independent, John Rentoul has a long-running feature called “Questions to which the Answer is No“. In it, he examines the kind of screaming rhetorical-question headline much beloved of certain middle-market tabloids: “Is this photographic evidence of Nessie?”, “Does coffee cure cancer?”, “Does coffee cause cancer?”, “Does MMR bring down house prices?“* and so on.
Here’s the first in an intermittent parallel series from me: “Questions to which the Answer is Eh? What are you on about? No, really: what?“. For the inaugural post, step forward Dan Sokol, the BMJ”s “ethics man”, who asks in his latest column, “Is Bioethics a Bully?”. The answer to this is Eh? What are you on about? No, really: what?.
(A warning before I start: I’m about to go off on one. Even by my standards, this is big. You might want to go and make tea.)
The general thesis of the article is this:
Bioethics, in its current form, has bullying tendencies. Ironically, it often adopts a paternalistic attitude towards clinicians, treating them as an ethically deficient species. Although bioethics should not shy away from pointing out ethical concerns in medical practice, sometimes forcefully, it must not give way to negativism or, worse still, to a zeal to condemn. Clinicians are easy targets and, without a command of the fancy theories and language of the accusers, possess few means to respond formally.
Is the thesis true?
Well, to get things going, I’m just going to note my puzzlement at the first word of the second sentence. Maybe Dan thinks (or is pandering to a audience that supposedly thinks: I don’t know whether it really does, though some of its members might) that bioethics is at least substantially reducible to banging on about not being paternalistic. But, of course, that’s not what bioethics is. Some bioethicists might spend time thinking about paternalism; and some of those some might reach the conclusion that paternalism is bad; and some of those some of those some might get as far as saying or writing something about paternalism. But, still, many more have little to no interest in paternalism. So there’s no irony here unless bioethics is basically about discouraging paternalism – or even campaigning for anything in particular – which it isn’t. On the irony scale, I rate this part of the argument as scoring Alanis out of ten.
(I’m going to include clinical ethicists as a subset of bioethicists here, mainly because that’s what seems to be going on in Dan’s piece - but treating bioethics as being reducible to clinical ethics is another problem. Clinical ethicists might be the closest most BMJ readers get to bioethicists; but that’s a bit like saying that builders of bird tables are the closest most people get to conservation workers, therefore conservation work is mainly building bird tables. A curious bit of synecdoche.)
That aside, the article does raise at least one important point:
[W]hat makes a bioethics expert? If you need a bioethicist for a lecture or a report, where should you turn? There is no Royal College of Bioethics, no MRCB (bioethics) exam, and an MSc or PhD in the subject is no guarantee of knowledge or quality.
I’ve expressed my own worries about this point on the blog before. It’s true that – just as anyone can call himself a nutritionist – anyone can call himself a bioethicist. And there are some monumental charlatans passing themselves off as bioethicists, often (though not always) as a pretty obvious front for some particular cause. Bioethics does have a low reputation among philosophers, and it’s not hard to see why.
That said, what about the rest of the article? Let’s work through it, paraphrasing as we go.
Bioethics is a hotchpotch of disciplines, ranging from sociology to law. Although there is infighting about the dominant discipline within bioethics, philosophy is, arguably, king.
(Would that it were…)
The inclination of philosophy is towards abstraction. Modern medicine, on the other hand, is a pragmatic discipline. Abstraction is rare. This contrast between the theoretical and the concrete, coupled with the ever present temptation for academics to appear clever, creates a danger for bioethics: through the use of theories and esoteric language, bioethicists can obfuscate, confuse, intimidate, or antagonise the very clinicians and patients they seek to help.
Now here’s the first big problem: the use of theories is not an issue. It’s a good thing. Criticising bioethicists for using theories is like criticising epidemiologists for using them; but without theories – the germ theory of disease, for example – there could be no such thing as epidemiology. Neither could there be philosophy. Theories are a lens the use of which helps us make sense of the world. Theories are good. Neither are they particularly esoteric. For sure, there’s the occasional bit of jargon (and it is occasional); but good philosophy aims for clarity, and jargon is perfectly compatible with that. It serves as a shorthand way of communicating a potentially rich idea. For example: if I use the phrase “Formula of Universal Law”, then that’s a sign that I’m talking about the Categorical Imperative, and Kant, and doing things with a certain set of ideas. There’s nothing exclusionary there: it’s just that, if you’re interested in a debate, you owe it to yourself and the other participants to furnish yourself with some background. In just the same way, if a physician talks about amyloid plaques, there’s no reason why I can’t go off and learn a bit about them, and then participate fully in that debate. It’s jargon, but it’s in the service of clarity, and anyone can learn it. A sophisticated debate probably requires sophisticated language; moaning that it’s obfuscatory misses the point completely, and the idea that using it is an attempt to appear clever is a calumny.
And if I’m right on this, it explodes what follows:
Members of research ethics committees often complain that a researcher’s “participant information sheet,” replete with medical jargon, is incomprehensible to its intended readers. The same criticism applies to much bioethical prose. If the writing is aimed at ordinary clinicians, then it should be understandable to them. In the words of Raanan Gillon, one of the fathers of modern medical ethics, “ethics should be basically simple for it is there to be used by everyone, not just by people with PhDs in philosophy or theology.”
You don’t need to have a PhD to engage with bioethics writing: but you do need to have your brain switched on, and you do have to be prepared not to understand everything straight away because – gasp! – different disciplines require and reward different skills, different writing styles, and different styles of argument; and they take a lot for granted because starting each and every debate from first principles is just stupid.
Things get even stranger, though.
Clinicians are told (or possibly “advised”) what to do by bioethicists, in research and clinical ethics committees, lectures in medical schools and elsewhere, and books and articles. These instructions are given at a safe distance from the nitty gritty of practice. The emphasis is on legal and ethical barriers, medical errors, violations of this or that guideline or principle. The tone is negative, and a whiff of disapproval fills the air. It is not surprising that bioethicists are seen by some as so called ethics police, disempowering or threatening the medical profession with a barrage of criticisms.
The idea that practitioners are advised about what to do by ethics committees is hardly surprising: that is implicit in their function, inasmuch as that it’s an ethics committee’s job to approve certain things, and if they aren’t approved, then that committee will offer advice about what needs to be done. What about the other stuff?
Well, things are a bit more complicated than they’re presented as being here. We need first to be clear about what’s going on when an ethicist (allegedly) tells practitioners what to do. At least a lot of the time, that isn’t really what’s going on; rather, a case is being made for a certain approach, or a certain course of action. In the case of papers and books – by which I mean monographs, rather than textbooks - that makes perfect sense: noone in their right mind would treat a paper as an instruction – especially so if, as Dan himself admitted a bare few sentences ago – ethicists tend to deal in abstractions; and that isn’t what they’re for. Of course, there’re sometimes thought experiments and hypothetical cases, and it might be that an argument will be presented along the lines that if conditions a and b obtain, it would be advisable to do φ and avoid ψ-ing. (I did quite a lot of ψ-ing when reading the BMJ piece, by the way…) And, of course, the writer of a book or paper might want in the end to change minds and practices. But if it was a matter of telling people what to do, writing a book or paper would be a really odd way to go about it. There’s a difference between making a case for something, and issuing a bare instruction. Ethics - at least when it’s done well – belongs to the former category.
(I always tell students when I meet them for the first time that, by the end of the course, or lecture, or whatever, they’ll be more confused than they were at the start – but they should be confused in a richer and more satisfying way. If a student leaves my seminar thinking that they know The Answer, I leave thinking that something has gone terribly - and maybe dangerously – wrong.)
In lectures, things might be a little different. We have to take care here, though, because Dan is treating the business of bioethics as centering on regulation, and that distorts things horribly. One of the functions of an ethics lecture – particularly in the UG curriculum, but the point applies to any that’s aimed at medics – is to talk not so much about what to do, but about how to think about what to do. That’s for a couple of reasons: the first is that it’s interesting, and the second is that simply rehearsing rules, precedents and guidelines is a waste of time, since (a) it’d be more efficient just to provide the URL of “Duties of a Doctor“, and (b) if it’s true that ethics is about more than the issue of, and obedience to, bare instructions, what’s really important is the ability to interpret those rules, precedents and guidelines so that they can be put to use or dismissed as appropriate.
The second is that, if medics were really interested in the first, they’d have become philosophers, or studied ethics, in their own right. A lot of the time, they want a nice handy guide to what the law says, and what they should do. That’s fair enough. But then a couple of things needs saying. First, concentrating on “legal and ethical barriers, medical errors, violations of this or that guideline or principle” is the whole point, and errors and violations provide decent illustrations of what can go wrong, and of how the law and regulations have developed. Second, if a big part of what medics want from an ethics lecture is a handy and easily-used set of instructions about what to do, then it’s utterly otiose to complain that ethicists are at their most visible when offering (or channelling) advice and instructions.
“To make matters worse,” the article continues,
most professional bioethicists are not clinicians, so these bitter instructions are usually given by people with no medical qualifications. They are removed from the pressures of everyday practice, issuing commands like generals far from the battlefield. But unlike military generals, bioethicists have not fought their way to the top, rising up the ranks. They cannot say, “I’ve been there.”
So what? Why does that make matters worse? Not being a clinician doesn’t preclude being able to talk about how to spot and solve moral problems. If a medic came to an ethicist for advice about how to separate conjoined twins, then the fact that the ethicist had no surgical experience would be a problem. But a medic who came along with that question to an ethicist would be strange anyway. What she might more productively ask is whether they should be separated, given that current medical knowledge indicates this kind of operative risk and prognosis and so on. You don’t need ever to have done so much as apply an elastoplast to be able to offer useful and insightful things on that. Maybe those things will amount to making a case for pursuing or avoiding a particular course of action; maybe it’ll amount to offering a way to think about what to do.
Being a medic and being an ethicist are different things. They aren’t antagonistic. Sometimes an ethicist will seek out a medic (or a medical paper) to get a fuller understanding of what’s going on in a particular illness. But you don’t have to be an expert in medicine to talk interestingly about it – only to do it.
(When Dan says that “a good bioethicist should get his or her boots dirty by spending time in the muddy trenches”, I’m therefore tempted to wonder which muddy trenches he means. If it’s ward practice that he has in mind… well, since he has not (to my knowledge) been a medic himself, this means that he must with this statement have torpedoed his own credentials as an ethicist. In which case, why is he filing copy in an ethics column to begin with?)
And so, finally, we’re in a position to tackle the thesis of the article head-on. Since it’s never actually explained what the alleged “bullying tendencies” of bioethics are supposed to be, it’s hard to mount much of a defence: but on the evidence presented in the rest of the piece, the main objections seem to be that bioethics can be technical, opaque to the outsider, and removed from day-to-day practice. That being so, the response is threefold. Yes, it can (and that’s not a bad thing); yes, maybe (but only because it has to be technical - and, anyway, tu quoque); and yes (but that doesn’t matter, because it’s a different thing). The second-rank objections seem to be that bioethics is abstract, and that it’s directly interfering. The response to these is also threefold. It can’t be both at once; abstraction is an indissociable part of thinking about conduct; and direct “interference” is a response to the demands of the medical profession.
There is no zeal to condemn – though cases in which things have gone wrong are much more interesting than cases in which nothing does, and are so much more likely to generate papers and comment. Clinicians are not particularly easy targets – if they feel picked on, they should see some of the volcanic rudeness that philosophers reserve for each other, both in person and in print. Complaining about “fancy theories” is basically a rehearsal of the travelling preacher’s complaint against booklearnin’. And complaining that there are few means to respond formally is simply false: write a paper, and send it to a journal (especially one like the JME, which is avowedly catholic in its list of contributors). If it’s good – and sometimes even if it isn’t - it’ll be published.
But don’t, whatever you do, write Uriah Heap-ish straw-man articles in the BMJ.
*Not actually a real headline.