Nathan Emmerich, occasional commentator here at the JME blog has recently published an interesting piece in the Guardian which argues against us taking bioethicists as having a particular type of expertise. While I enjoyed and agree with much of what he argues I do have a couple of quibbles – in particular I worry that the emphasis on inclusiveness and democracy could in effect lead to the exclusion of the bioethicist, which I think would be a mistake.

The type of expertise he argues against bioethicists having is basically what I will refer to as authoritative expertise – someone who has authoritative expertise in a particular field ought to be deferred to when there is a disagreement – their opinion is “better” than ours as lay decision makers. So for example when deciding how long an object is, and whether it will fit in the boot of our car, we ought to defer to the chap with the tape measure, since their measured judgement is better than ours.

I use this example for a reason – Emmerich focuses on knowledge based expertise (no doubt because it is easier to explain to the lay public…) but this isn’t the only form of expertise that warrants some deference there is also expertise which is performative (in this case the act of measuring well). I’m inclined to think that if bioethicists deserve any deference it will be due to their performative expertise, rather than their knowledge.

Emmerich suggests however that bioethicists should not be taken as having authoratative expertise because he thinks knowledge about morality is more like knowledge about aesthetics than knowledge about facts. Hence we ought to give no more weight to the bioethicists opinion about an ethical issue, than we do someone heavily steeped in the Art’s worlds opinion about a piece of modern art – they have a “sophisticated” view but that doesn’t tell me what I should think about the piece.

He thinks bioethicists should conceive of themselves as thinking alongside, working with people to work out what to do rather than telling them what to do. He argues that commenting on the biosciences is particularly dangerous for bioethicists because it is different from medical practice in that its practice isn’t inherently involving ethical decisions – hence he claims bioethicists are tempted to make pronouncements and decide about ethical issues in the biosciences rather than work with bioscientists. As an aside I think this is exactly wrong – I doubt the empirical claim is true (ie that bioethicists proclaim and make decisions more about issues in bioscience than medicine) and I think the process of conducting bioscience does involve constant ongoing ethical decision making – it’s just a different sort of decision making, about the responsible conduct of science and dissemination rather than the treatment of patients. Nonetheless lets leave that aside.

So far so good – I don’t think bioethicists ought to be taken as overwhelmingly authoritative – the most uncomfortable experience I’ve had sitting on an ethics committee was when the committee treated me as a moral expert and simply deferred to my opinion in each case – it took awhile to break them of that. But I disagree with Emmerich about why this is the case. This is in part because I object to the metaethics he is assuming – the reason we find the expert in Art uncompelling is that the general opinion is that there is no truth of the matter when it comes to aesthetic judgements. And presumably Emmerich thinks the same about morality.

I broadly take the same view as Hobbes does here:

Of Man, Being the First Part of Leviathan. The Harvard Classics. 1909–14. Chapter V.

Of Reason and Science
And, as in arithmetic, unpractised men must, and professors themselves may often, err, and cast up false; so also in any other subject of reasoning the ablest, most attentive, and most practised men may deceive themselves, and infer false conclusions; not but that reason itself is always right reason, as well as arithmetic is a certain and infallible art; but no one man’s reason, nor the reason of any one number of men, makes the certainty; no more than an account is therefore well cast up, because a great many men have unanimously approved it. And therefore, as when there is a controversy in an account the parties must by their own accord set up for right reason the reason of some arbitrator, or judge, to whose sentence they will both stand, or their controversy must either come to blows, or be undecided, for want of a right reason constituted by Nature; so is it also in all debates of what kind soever. And when men that think themselves wiser than all others clamour and demand right reason for judge, yet seek no more but that things should be determined by no other men’s reason but their own, it is as intolerable in the society of men as it is in play after trump is turned, to use for trump on every occasion that suit whereof they have most in their hand. For they do nothing else that will have every of their passions, as it comes to bear sway in them, to be taken for right reason, and that in their own controversies, bewraying their want of right reason, by the claim they lay to it.

The point here is that when there is moral disagreement claiming to have the right judgement – the right reason – is like cheating at cards by claiming whenever it is your turn that the trump suit is whichever suit you have the most of in your hand. In other words the dispute is about which reason is right, hence simply saying “mine” does nothing to resolve this. But this view of morality is a bit more complex – I’m inclined to think there is a truth of the matter, it just isn’t easy to access, nor is it easy to show to others. Hobbes solution to the problem of irresolvable disputes is to establish an absolute sovereign who we both agree to defer to, and then we go with whatever they say. I roughly think that is right, with the conditional (that I suspect Hobbes would agree with) that we try to ensure that our absolute sovereign comes out with an answer that is as close to being right as possible. And given the complexity and the difficulty of divining moral truths that deliberation, debate and argument has a better chance of getting the “right” answer than having someone sit by themselves in a room and ponder it.

I think the bioethicist is in a position to contribute something useful to such deliberation, debate and discussion in two ways, both of which require some expertise – even if it is not totally authorative expertise. The first way is this, the bioethicist I assume will have access to more knowledge both about what has been argued in regards to ethical theory and in regards to moves in applied ethics. Knowing these moves can short-cut some discussion and debate by showing paths that will lead nowhere – the implications and consequences of particular arguments. This I think is as useful an input as that of someone who – trained in an empirical discipline – contributes their knowledge of their discipline and its findings to the debate about a particular issue. Secondly, and perhaps more importantly, a bioethicist ought I think to have a certain sort of performative expertise. This is an expertise at argument and debate, at critical thinking, questioning assumptions and being aware just how arguments go wrong, in effect this is philosophical expertise.* Is this authoritative? I think at best only partially – largely it gives the bioethicist the authority to suggest that particular lines of pursuit won’t be fruitful. In any case I think philosophical reasoning is inherently democraticising – because of its origins and use in debate and discussion it ought to aim to up skill and inform everyone in the discussion, rather than claim special status – to go back to my man with a measuring tape analogy the good bioethicist tries to provide everyone in the discussion of whether object x will fit in the car boot with a tape measure for themselves.

There is a more general line of argument which can be drawn from Emmerich’s argument against expertise in regards to bioethicists which is an argument against involving “experts” in making bioethical decisions – in effect Emmerich implies that these being decisions by experts, even committees of multiple types of experts is anti-democratic – because it involves having others making moral decisions for “us” when that is actually our responsibility. Now of course a good bioethicist would question the assumption that being anti-democratic is bad, but I’m going instead to suggest that having others decide for you can be, and in this case is, perfectly democratic. Direct democracy is well known to have certain limitations, not the least that the electorate often wants contradictory things for example that given the option people will opt for lower taxes and higher social spending… I suspect that bioethical issues are an area where direct democracy will be unsatisfying – either because of intractable disagreements within the population (think abortion) or because the technical nature of the decision means that predictably decisions will be made that lead to outcomes that few in the population would endorse. In these cases it would seem sensible to agree to establish a group of decision makers (in Hobbesian terms a sovereign) to delegate this decision to. We do this in regards to most political decisions and hence it seems that establishing a public decision making body such as the HFEA can be a perfectly democratic response, as long as it is established in the right way (in this case in a process where it occurs as a result of legislation passed by a duly elected government). Such a body may not have the moral authority of the expertise of knowing the right answer but they are our best bet at getting somewhere close to it, and hence we ought to accept their decision making. Of course Emmerich is right to think that this needs to be a public facing process which should take into consideration public opinion and input from individual members of the public, but these should be taken as no more authoritative than individual expert’s opinions. Otherwise we are in effect allowing the public (or more accurately a tiny unrepresentative vocal bit of the public) claim “right reason”, when this isn’t warranted.

Emmerich identifies a real temptation and danger for bioethicists, it is tempting to act as moral authorities, and broadly speaking illegitimate to do so. But there are dangers in the other direction as well which we need to be wary of as well I’m inclined to think direct democracy worship is no better than the autonomy worship than many current bioethicists practice.

* I am in this piece using a less than inclusive definition of bioethicist – meaning someone who has at least some training in thinking philosophically about ethical issues – this doesn’t have to be formal education of course,and could be self taught,  but the argument I am making depends on bioethicists as having this – those who work simply empirically on issues in bioethics but have no normative engagement (if such a person actually exists) would at least by the standards of this piece not count as a bioethicist. Sorry.

It goes without saying that castrating sex offenders in order to control their behaviour is highly controversial. Likewise, describing something that damages a person physically as ‘treatment’ is problematic for many. That’s partly because of the image, reinforced even by publications as prominent as Time, that castration involves excising a man’s testicles with the single swipe of a scalpel.

Of course, there are those who would welcome the prospect of sex offenders being physically altered and would see this as just, given the harms that they have inflicted upon others (see the comments made about chemical castration article in the Daily Mail ).

In addition to concerns about the nature of the intervention there are also good reasons for worrying about the fact that in some European countries imprisoned sex offenders might choose to be castrated because it increases the chance of them being released earlier. Given that, it is not surprising that this practise has been scrutinised by the Council of Europe. Their view is that this ‘treatment’ is degrading and should be abolished. While there are reasons for having grave reservations about this practise, are they adequate for saying that this is something that should never occur and are these the reasons that the Council of Europe gives for abolishing this practice? If someone has a choice between remaining in prison for a long period of time or being castrated and having a chance at an earlier release could they choose castration voluntarily? The Council of Europe seem to assume that they could not and that is far from obviously true.

For someone whose life history is one that has been constructed around the infliction of harm upon other human beings, could the reduction of the passions that contributed to this harm benefit that person and help to recalibrate a life that has gone badly awry? While castration seems like an extraordinary measure for working toward that end, perhaps it is something that should be available in some cases.

Guest post by:
Professor John McMillan
University of Otago,
Bioethics Centre

For a fuller discussion see his online first paper.

Thanks to Brian Earp for bringing this release from the US’ National Institute of Mental Health to my attention; it concerns the Institute’s decision to move away from DSM as its diagnostic tool.  DSM has been enormously successful – in terms of having established itself at the centre of psychiatry – but it has been enormously controversial, as well; the NIMH moving away from it is very big news indeed.  Whether the new model that they’re going to be working on will be any better, of course, remains to be seen.

The important bit seems to be this:

NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

One or two things about the statement leap out at me. more…

It’s going to be a little while before regular blogging resumes here – I’m aiming to get back up to speed in the next 10 days or so – but, in the meantime, the special edition of the JME devoted to The Paper Of Which We Do Not Speak is now out and available here.  Some of the papers are open access; others aren’t.

For better or worse, part of being unable to do much blogging at the moment is that I’m not going to be around much to mod any comments that come in – as I’m sure they will – over the next few days.  Don’t go thinking you’re being blocked: it’s much more likely that I’m marking essays.

26-28 June, Woodbrooke Quaker Study Centre, Birmingham

(via Andrew Edgar)

Can the language of compassion capture the moral problems confronted by the NHS, or might it obfuscate and distract us from more subtle and demanding issues?

Through a series of plenary addresses, workshops, panels and shared opportunities for discussion, “Compassion Fatigue” will provide an opportunity to explore the language of compassion, and the impact that it has on the practice of health care provision.

More details below the fold. more…

Blogging here has been light for a little while, and probably will be for a little while longer because of Stuff and Things – but something caught my eye in Sunday’s Indy* that struck me as worth comment.  It was a full-page advert placed by JTI, which describes itself in the small print as “a leading international tobacco company” (and it is).

Anyhoo… the main bit of the ad is a copy of an email, obtained by an FoI request, apparently from the UK Department of Health to the Australian Department of Health and Ageing; it reads as follows (with the highlighting copied from the ad here as closely as I can manage):

Dear [redacted]

I work on the UK government’s tobacco policy team, with [redacted] and you will be aware that the UK government is considering the introduction of plain packaging of tobacco products.

As I’m sure you’re aware, one of the difficulties regarding this is that nobody has done this and therefore, there isn’t any hard evidence to show that it works.   Therefore, I am wondering whether the Australian government drafted any type of impact assessment or cost analysis in which the likely benefits and costs are measured, and if so, whether you would be willing to hare the information with us.

Many thanks,

And then in bold underneath, JTI’s copywriters have added:

WE COULDN’T HAVE PUT IT BETTER OURSELVES

Now, the email is dated the 10th of May 2011.  Australia’s plain-packaging law came into effect on the 1st December 2012; as far as I’m aware, Australia was the first country to pass such a law.  So, at the time of writing, there could not have been any hard data about its impact.  There could not possibly be any hard evidence to show that plain packaging works to reduce smoking rates.

The argument of the advert – actually, no: the subtext, since it’s not really an argument – is that the UK government should not introduce plain packaging because of the lack of hard data.  This seems to amount to a claim that governments should not introduce policies without hard data concerning their efficacy.  And there’s something correct about that for the most part.  But hard data are only available in the wake of the introduction of a policy.  If the policy is novel – as it is – then JTI would seem to be committed to the claim that no government should be the first to introduce a policy; which is as much as to say that no government should introduce it at all.

It’s understandable that that’s what they think.  But why not just say so?  Isn’t this ad just rather disingenuously dressing up opposition as something else?

Or have I missed something?

*Saturday’s Indy, with its column-inches devoted to Andrew Wakefield, is worth rather a lot of comment: more than I can offer at the moment.  I’ll point you in the direction of Martin Robbins in the Staggers instead.

Guest Post by Kerry Gutridge* and A.M. Calladine

Imagine you are a doctor, nurse or teacher and someone in your care asks for a razor.  The person you look after wants to slice into their own skin and draw blood. They are compelled to hurt themselves.  They have an overwhelming urge to feel a momentary visceral sense of pain.  Would you provide them with a blade?  Is it ever right to enable people in your care to harm themselves?

At first glance such questions may appear shocking and seem likely to elicit a strong gut reaction. Surely it can’t be right for people in a position of authority, with a duty of care to be seen to apparently condone or provide a means for vulnerable people to engage in such self-destructive behaviour?

Yet recent media reports (such as this and this) suggest that such a choice has already been made.  Teachers at Unsted Park gave a “special needs” pupil sterile Bic safety blades so they could injure themselves in the privacy of the school bathroom.  According to reports, staff checked in on the pupil every two minutes.  After the pupil had finished cutting teachers cleaned and dressed their wounds.

The news story attracted a predictable sense of outrage.  Readers commenting on newspaper message boards found the school’s decision at best incomprehensible and often disgusting and immoral.  According to the top-rated comments on the Daily Mail website:

That’s Nuts!  What’s wrong with these people??!!!

And

Absolutely shocking, I am by far an expert in the field but that sounds ridiculous to me

Unfortunately such feelings of revulsion and disgust are not limited to the comment boards of the Mail.  One of the authors of this blog was told by another academic that their doctoral abstract on the subject of self-harm made them feel physically sick.

The news reports on the case at Unsted School are vague.  The nature and severity of the pupil’s injuries are unclear and the age of the pupil is put between seven and nineteen.  Without more detailed information it would be disingenuous to comment at length on this specific case.  The Unsted Park School policy of allowing the pupil to self-harm has since been abandoned after some of the teachers complained to the local authority.

It is not the first time that the issue of institutional enablement or allowance of self-harm has been subject to scrutiny. more…

Maybe he should have been invited to contribute to the special edition: Somegreybloke seems to have the debate wrapped up perfectly…

So there’s this letter published in the Journal of Bioethical Inquiry that moots the idea that the top biomedical ethics journals might be institutionally racist.  In it, Subrata Chattopadhyay, Catherine Myser and Raymond De Vries point out that the editorial boards of a good number of journals are dominated by members who are located in the global North – countries officially listed as being high or very high on the development index, with only 1.3% drawn from countries classed as least developed.

Developing World Bioethics has the highest proportion of its editorial board located in the least-developed nations; but even there, the figure is only just over 11%.  On the face of it, this doesn’t look too good, especially given the proportion of the world’s population in general that lives in the poorest countries.  The JME, by comparison, draws 100% of its editorial board members from people located in highly and very-highly developed nations.

Still: this isn’t likely to be the whole story.  Udo Schucklenk – a founding editor of DWB, of course – takes issue with the letter on a number of grounds.  For one thing, he he suggests that Chattopadhyay et al might be performing a sleight of hand with their metrics; by lumping together countries ranked as high and very high on the development index, they’re lumping together the UK, Germany, and the US with Iran, Malaysia, and Jamaica.  Neither Iran nor Jamaica is a classic basket-case economy; but, still, “high” and “very high” development covers a vast range of income levels.  Treating all these countries in the same way obscures that there’s a huge range of locations from which editorial staff may be drawn.

I’ll come back to this in a moment. more…

Guest Post by Julian Savulescu

Around one third of men worldwide are circumcised.  It is probably the most commonly performed surgical procedure.  Circumcision is also one of the oldest forms of attempted human enhancement.  It is and has been done for religious, social, aesthetic and health reasons.

Circumcision has a variety of benefits and risks, many of which are discussed in this issue.  There is some dispute about the magnitude and likelihood of these benefits and risks.  Some argue that the risks outweigh the benefits and circumcision should not be performed on children who are not competent to make their own decisions.

If it were true that the risks of circumcision clearly outweighed the benefits, great harm has been done and is being done globally through this procedure.  Around one third of men have been harmed.  This is an extraordinary public health injury.  Presumably, some would be entitled to compensation.

The fact that few people think that there is not such a bad situation affecting millions of men indicates that most people implicitly believe that circumcision is not a significant harm, if a harm at all.  (This is an example of the kind of argument called modus tollens: if p, then q; not-q; therefore not-p.)

It is reasonable to conclude either that:

1) It is not clear from existing evidence whether the risks of properly performed circumcision outweigh the benefits, or vice versa.

Or

2) If circumcision is against the interests of an infant, it is only mildly so.

In general, people should make their own decisions about body modification and human enhancement when this is possible.  Such an approach speaks in favour of waiting until a child is adult to make his or her own decision about circumcision.  And procedures which are not clearly in a child’s interests should not be performed on that child.  However, religious and other social exclusion may make delay in circumcision psychologically harmful. more…