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What is it to do good medical ethics?
  1. John Harris
  1. Correspondence to Professor John Harris, Institute for Science Ethics and Innovation, The University of Manchester, Stopford Building, Oxford Road, Manchester M139PL, UK; john.harris{at}manchester.ac.uk

Abstract

This brief paper addresses the question of what it is to do good medical ethics in two parts: First, I consider the problem of how to get started in medical ethics, conceived of as an academic discipline rather than simply to get started being ethical in a medical or biomedical context. The second part gives my own take on the question ‘what is bioethics for?’

  • Ethics
  • History of Health Ethics/Bioethics
  • Philosophy of Medicine
  • Philosophical Ethics
  • Public Health Ethics

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First steps

An important first step in doing good medical ethics or bioethics involves simply doing medical or bioethics, and possibly of course doing even not so good medical or bioethics. So, we should start by thinking about how it is possible to get started in bioethics and indeed in any academic or scientific endeavour. Let me start therefore with the next generation of bioethicists, the people many of us are involved in educating or at least talking to and debating with and who therefore one way or another pay our wages.

Seamus Heaney, in the Introduction to his translation of Beowulf, reminds us that: words in a poem need what the Polish poet Anna Swir once called ‘the equivalent of a biological right to life’…essential to the process [is] some sense that your own little verse-craft can dock safe and sound at the big quay of language. And this is as true for translators as it is for poets attempting original work.1

And this is also true for us, particularly for graduate students and early career scholars in bioethics.

Undergraduates, graduates, postdocs and early career lecturers interested in making original contributions to their subject (which certainly all of these, certainly once they become graduates should be doing) and who are possibly interested also in an academic career, need something similar: help in developing the sense that their little research craft can dock safely at the big quay of academia.

We need to develop more imaginative and more embedded ways of enabling both the launching and the happy return of research craft of all sorts.

Courses

Postgraduate bioethics conferences such as those organised onlinei can very effectively function as one important stage in that journey; another such example is the first research conference run by the Institute of Medical Ethics.ii This was a 1 day conference held in 2014 called ‘The cutting edge in biomedical ethics research’ and was designed ‘to enable academics and students to present the results of their research activities in analytical and empirical medical ethics’.

More substantial (but not necessarily more useful) contributions are made by fully fledged courses in bioethics such as those pioneered by my colleagues and me at The Centre for Social Ethics and Policy at Manchester University and the one at Kings College London, both of which date from around 1986. These two Masters programmes, the first of their kind in Europe, have, in particular, been welcoming both to recent graduates and serving professionals across a wide range of disciplines, and there are now many other such programmes. Raanan Gillon at Imperial College London has also for many years run a marvellous and highly popular annual 1 week intensive course in medical ethics which started in 1983 and which continues each September to attract especially doctors and health professionals but also bioethics postgraduates keen to interact with health practitioners.

Another way of encouraging starters in bioethics is the boost provided by senior or established academics making a point of offering opportunities for joint authorship of academic papers to their students and less well-established colleagues.

Indeed, I have long thought that academic groupings in bioethics, particularly interdisciplinary ones, might find it productive to think of themselves more along the lines of a science ‘wet-lab’ where projects and the papers they generate are undertaken by teams which undertake different aspects of the research project and usually coauthor their publications.

Mentoring and coauthorship

Another model to think about might be the renaissance studio in which established ‘masters’ work on projects with talented apprentices. Of course, if we were to revert to the studio model of production we would have to ensure more scrupulous arrangements for attribution that were normal in, say, the Florence of the Medici. But, for example, when Filippo Brunelleschi took the 16-year-old Donatello with him to Rome to work on architectural projects or when Verrocchio took the young Leonardo da Vinci under his wing as an apprentice in Florence, they were as much developing talent as taking on cheap and possibly exploited assistants. But even though in the renaissance studio, as now, the apprentices were poorly remunerated (or often not remunerated at all), they had an unparalleled learning experience which often equipped them for life.2 I am not of course suggesting that we continue (or relaunch) the exploitative elements of apprenticeship, but rather suggesting that it is in a sense exploitative to take money from students or work from early career colleagues, without ensuring that commensurate career opportunities are also part of the deal.

Many senior academics have publishing opportunities that juniors do not. Moreover, such established academics often have more of such opportunities than they want, need or can fulfil. One possibility is the sharing of those publishing opportunities. Many such projects so to speak, ‘come our way’ uninvited (by invitation to contribute to a symposium or edited volume, for example). Another strategy is for established academics to think about those potential papers or projects which provide opportunities to productively share the various tasks involved and also the experience of bringing a project to market through all aspects of the publication process including of course sharing the credit or blame by joint authorship.

Luck

I never had such opportunities when I was a student, but I certainly wish I had. However, I wish to take this opportunity acknowledge a particular debt of a different, but in a sense related, sort to Raanan Gillon, another contributor to this volume, and the second editor of this journal. Raanan may take the somewhat dubious responsibility for initiating me into the mysteries of medical ethics, as well as providing a paradigm of how to attract new authors to what I have come, thanks in a significant sense to Raanan, to think of as ‘our’ field.

I have enjoyed a long relationship with The Journal of Medical Ethics (JME). This began with a happy accident soon after I had moved to the University of Manchester in 1979. My first paper,3 ,5 in what I later discovered was sometimes called ‘medical ethics’, was a reply to a paper by the surgeon John Lorber on the ‘selective non-treatment of handicapped newborns,’ a subject which remains central to contemporary debate, and which had been published in the Journal of the Royal College of Physicians of London. When I first submitted my reply to Lorber I had received a very ‘sniffy’ letter back from the then editor of the Journal of the Royal College of Physicians, the sort of response one had literally to hold at arm’s length; it said something like: ‘your paper seems to be a paper within medical ethics…there is a journal for ‘that sort of thing’—the JME.’ It apparently had escaped the editor's notice that the paper to which I was replying, and which was on precisely the same subject, would also have been more appropriately submitted to a different journal, possibly because Lorber was a surgeon and I—a mere philosopher—was evidently a lower form of life. I accordingly looked up the JME, of which I had never before heard, sent off my paper and received a warm reply from Raanan Gillon, the then Editor, accepting it with enthusiasm and we have been close friends ever since. Ironically, I received, some years ago, another letter from the Journal of the Royal College of Physicians, this time from a subsequent editor, inviting me to let them have a paper if I had something suitable, and asking why I had never before considered publishing in their journal?

These are just some preliminaries, I must now turn to our central question: What is it to do good medical ethics?

What is it to do good bioethics?

In 19714, Hannah Arendt returned to themes explored in her Eichmann in Jerusalem.5 Her subject matter, which was the relationship between thinking and morality, opens with these words:iii To talk about thinking seems to me so presumptuous that I feel I owe you a justification. Some years ago, reporting the trial of Eichmann in Jerusalem, I spoke of “the banality of evil” and meant with this no theory or doctrine but something quite factual, the phenomenon of evil deeds, committed on a gigantic scale, which could not be traced to any particularity of wickedness, pathology or ideological conviction in the doer, whose only personal distinction was perhaps extraordinary shallowness…the only specific characteristic one could detect…was something entirely negative: it was not stupidity but a curious, quite authentic inability to think. (p. 417)iii

Arendt goes on to ask: Could the activity of thinking as such, the habit of examining and reflecting upon whatever happens to come to pass regardless of specific content and quite independent of result, could this activity be of such a nature that it “conditions” men against evil-doing? (The very word con-science, at any rate, points in this direction insofar as it means “to know with and by myself” a kind of knowledge that is actualised in every thinking process.) (p. 418)iii

And later Arendt notes in passing that: Thinking always deals with objects that are absent, removed from direct sense perception. (p. 423)iii

It seems improbable that thinking could ‘condition men against evil doing’ or indeed how such a hypothesis could be tested. However, Arendt's noticing that thinking always deals with objects that are absent identifies an important dimension of what it takes to act morally as opposed to simply acting well. Morality, whatever else it is, involves consideration of the interests (or rights) of all relevant interest holders. This involves more than sympathetic responses to those in need, but the active consideration of all relevant interests.

Even English law, not generally considered the most progressive of vehicles of moral progress, recognises that the idea of ‘neighbour’ refers to more than vicinity. It is difficult to improve upon Lord Atkin's famous analysis of the concept of ‘neighbour’ in his judgement in the case of Donoghue v Stevenson, a landmark in the development of tort law in the common law tradition.9 Who then in law is my neighbour? The answer seems to be persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.6

It is significant that Lord Atkin talks about ‘contemplation’ and ‘directing [the] mind’ when he is considering what morality and the law requires in relation to our responsibilities to others.

A necessary condition then for doing good bioethics is the analysis of what it is to do good, to be ethical. This, as I have tried to argue over many years, involves, in any given case, addressing and answering the question ‘what does the good consist of, all things considered?’7–11

Medical ethics and bioethics is obviously concerned with answering the question ‘what is it to do good, or indeed to be good, in the wide area of concerns and activities which arise from human engagement with the biosphere including of course ourselves?’ This in turn invites consideration of the question: ‘what might improve or worsen the world, for the answer to this question will indicate the ethics of likely outcomes?’

My own take on this problem involves: … an exploration of the responsibility shared by all moral agents, to make the world a better place. Karl Marx12iv is noted for the idea that the purpose of philosophy cannot simply be to understand the world, but must also be to change it. This thought however is not original to Marx, it is implicit in the writings of many philosophers, Plato certainly wanted to change the world for the better and The Republic is devoted to systematic ways to achieve a better society. Locke, Rousseau and Bentham would all have been equally at home with the idea. Indeed, as Bertrand Russell said, talking of Jeremy Bentham: There can be no doubt that nine-tenths of the people living in England in the latter part of the last century were happier than they would have been if he had never lived. So shallow was his philosophy that he would have regarded this as a vindication of his activities.13 Russell's irony will not be lost on even the most literal of readers. It is a sad comment on the philosophy of the twentieth century that in the four score years since Russell's essay was written, concern with the real world, no less than with attempts to make it better, have continued to be seen as evidence of lack of philosophical depth by the majority of professional philosophers and Russell's own attempts to make the world better are not, even now, ranked by most philosophers as among his significant philosophical contributions.14

I would today add that the all too many philosophers who complain of the lack of philosophical depth in bioethics are both ignorant of the corpus of work they denigrate and, for the most part, have never themselves attempted to contribute, as Bentham certainly did, to the happiness of humankind. Many also take too restricted a view of the scope of this corpus. For me, it includes the work of, inter alia, Derek Parfit, John Rawls, Tom Nagel, Ronald Dworkin, H.L.A. Hart and Joseph Raz among many others.

Let me add that I include the making of better people in the idea of what it takes to make the world a better place and I would include animal health as a significant objective alongside human health.

There is of course no one paradigmatic activity of bioethics. Bioethics is now an irredeemably interdisciplinary activity. My own particular interest has involved considering the impact of new and both possible and probable technologies and of policies concerning them and in attempting to judge, as objectively as I can, the quality of the reasons for and against their introduction. Inevitably, I have found myself criticising the plethora of bad arguments that are always advanced as obstacles to change. This is not, I believe, because I am a natural radical, but rather because I am a natural sceptic. I have found that all too many people are like the mother who said to her daughter ‘go and see what your little brother is doing and tell him to stop!’ When I go and see what the scientists are doing, I usually find that they are doing a good job and that we should remove rather than increase obstacles in the way of their progress.

On 12 May 2008, John Sulston and I gave a Public Lecture at The Sheldonian Theatre in Oxford entitled ‘What is Science For?’15 In that lecture, we advanced two obviously true, but startling to many, propositions: that in the future there would be no more human beings and no more planet Earth. There would be no more human beings because, either we will have been wiped out by our own foolishness or by brute forces of nature or, we may hope, we will have further evolved by a process more rational and much quicker than Darwinian evolution (a process I described in my book, Enhancing Evolution14). Equally it is certain that there will be no more planet Earth. Our sun will die and with it all possibility of life on this planet. By the time this happens, it is possible that our better evolved successors will have developed the science and the technology needed to survive and to enable us to find and colonise another planet or perhaps even to build another planet, and in the meanwhile to cope better with the problems presented by living on this planet. Either way, not only are these not things we should worry about in a negative way, they are things we need actively to plan for if we, or our successors, are to survive into the far future.

The precautionary principle has a lot to answer for. At first sight, it seems obvious: we should be careful and only introduce new technologies when we are absolutely sure they are safe. What could be wrong with that? This is often treated as one of the most secure moral imperatives: to be ultra-cautious in permitting new research and in introducing new technology. However, the ‘precautionary principle’ is often invoked in circumstances in which it is far from clear in which direction (if any) caution lies. We cannot know which way caution lies without having some rational basis for establishing the scale of likely dangers that will result from pursuing particular programmes of research and innovation and comparing those with the ongoing costs of failing to pursue the research to a successful conclusion. As I am perhaps overfond of noting: ‘If the so-called precautionary principle had held sway in the Garden of Eden it is doubtful if any of us would be here now, for there was then simply no basis for forecasting the success or failure of our species or charting a successful programme for the future.’8

Doing good bioethics, involves at the very least, acceptance of some responsibility to make the world a better place, to ensure that life on Earth flourishes and to think, I believe, about these grand objectives when building and launching ‘our little research craft’.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • i http://www.postgradbioethics.com, see also Twitter @PGBC2014 for details of such events.

  • ii See http://www.instituteofmedicalethics.org

  • iii Here and below I draw in thoughts I recently developed in my “Thought and Memory”. In: Coggon J, Chan S, Holm S, Kushner T, eds. From Reason to Practice in Bioethics. Manchester: Manchester University Press, (forthcoming) 2015:28.

  • iv What Marx actually said was: “The philosophers have only interpreted the world, in various ways; the point however, is to change it”.12

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