Public healthcare is by definition everyone’s business. Yet there is considerable disagreement about who should take part in its development. This problem is most pronounced when the issue is one of widespread social concern, and one on which there is a great range of views: scientific, clinical, political, moral.

I recently attended a conference on organ donation at Keele University. I was particularly interested by Jonathan Montgomery’s paper, which raised the idea of public ethics, and Jean McHale’s, which discussed possible criminal regulatory options. To what extent, and in what ways, should public policy relating to organ transplantation accommodate ethical principles, how are these derived, and what is the upshot for alternative perspectives that are disregarded by the policy? Some people treat “ethics” as something purely personal: you have your view, and no one can tell you it’s wrong. But whilst everyone is entitled to his or her opinion, in practice we cannot just enjoy an unfettered freedom to do whatever we choose. Legal, professional, and other regulatory constraints on our freedom mark boundaries that can’t be crossed, no matter what we deeply believe. There are some matters on which it is necessary to have overriding rules or principles. To establish these in a defensible and non-arbitrary way is to engage in “public ethics.”

Personal views on organ transplantation differ radically. Compromise in the sense of finding a happy middle ground is not available between the different positions. A policy that responds only to people’s actively recorded choices seems to set an unduly restrictive default, yet a policy that amounts to conscription seems anathema to many of the dominant paradigms that underpin a liberal democratic system. So what do we do if we want an ethical basis to transplantation policy? Public consultations may provide answers, though doubts will then be raised about the questions that were asked or how representative and informed the respondents were. Committees of the great and good may be formed, but it is hard to imagine their very composition not being questioned, or the nature of their authority. Our lawmakers may be bold, though the political risks, or even just incomplete understanding, may prove problematic. And practice in the wards will likely just carry on as usual anyway, unless fundamental change is instituted there (perhaps without particular concern for what law and policy say).

I fail to see quite how idealised politics—a politics that works only from morality—can be usefully developed without a view to real politics. It probably can’t be, in which case the forum for discussions on “public ethics” should surely be seen as a more broadly political one. Ethical argument has an important role: without it, how could we recognise a better system? But the discussions cannot just be highbrow abstract argument. There may be value in discussing, for example, the moral permissibility of allowing markets in organs, public ownership of organs, and so on. But to lead to change, such debates must account for social and political reality, and solutions will only be realised if proper account is given of the politically possible. This requires an understanding of what people want and will accept, what practitioners will do, and what can be accommodated in law and policy. The ethical questions are important, but in public ethics the overall answers require a truly collaborative effort. As Montgomery argued, the upshot will house ethical concerns, but will almost certainly not stand as a robust ethical argument such as one would expect to find in a single-authored work of moral philosophy.

John Coggon is a research fellow in the School of Law at the University of Manchester.