• ethics

What should readers expect of a journal, not primarily of ethics nor of bioethics, but of medical ethics? The ‘Disclaimer’ on this journal’s inside front cover states that it is ‘intended for medical professionals’. That perhaps narrows the field: but what interests ‘medical professionals’? Writing in 1796, the young Samuel Taylor Coleridge, poet, polymath and professional patient, declared that ‘Physicians… are shallow animals: having always employed their minds about Body and Gut, they imagine that in the whole system of things there is nothing but Gut and Body’. Very soon he would have to revise this opinion, as a growing number of medical professionals became his friends and collaborators, exploring together the heady mix of scientific discovery and metaphysical speculation that made the intellectual world of the early nineteenth century so exciting, and so available. It was still possible for a physician, possessed of a reasonable general education, to keep abreast not only of the latest developments in the emerging sciences but also of what was new in the arts and humanities.

In the early twenty-first century, by contrast, that may be more difficult. The sciences have greatly multiplied, and often become so specialised that even other scientists may have difficulty in fully comprehending the intricacies and implications of developments in disciplines not their own; and similar difficulties may arise not only between scientists and practitioners of the arts and humanities, but also between scholars working in different branches of the arts and humanities. Gifted communicators, skilled popularisers and interdisciplinary journals of course, can and do go some way toward increasing mutual comprehension, and this too is what readers of the Journal of Medical Ethics, should expect from and, we trust, can find in its pages. Since the contents of those pages are now also available online however, it might be asked whether paperless publication of individual papers aids or hinders that process of mutual comprehension. Could our ability to search rapidly online for papers by authors or on subjects which reflect our own specialist interests mean that we miss significant work from other disciplines which might fructify our own questions by framing them in a different way? Or is the skilled online skimmer with an enquiring mind no less capable of interdisciplinary enlightenment? Answers, as so often, await further research.

An example of how different disciplines, not in the sciences but the humanities, may see the same phenomenon very differently is included in this issue of the journal. In the exchange between Chris Durante ( see page 77 ) and Tom Beauchamp ( see page 84 ) the meaning of multiculturalism is interpreted differently according to whether it is perceived through the lens of political or of moral philosophy. That this can and should interest medical professionals and is of importance for medical ethics is illustrated by Durante’s discussion of how a Catholic who opposes physician assisted suicide might, as he puts it, ‘be capable of tolerating the general legality of this act despite morally condemning any particular instance of assisted suicide’. The Catholic might be able to do this, Durante suggests, ‘by implementing the theory of legitimate cooperation with evil…, which is indigenous to the Catholic moral tradition’, significant implications of which he then clarifies in some detail. Beauchamp’s response to Durante does not discuss this specific example. It focuses rather on the more theoretical question of whether multiculturalism is ‘primarily concerned with establishing a political system with moral undertones rather than a moral system with political ramifications’, as Durante argues, or, as Beauchamp holds, is ‘primarily a moral theory about obligations to tolerate moral differences in the face of conflicts between cultural groups’. These different theoretical interpretations however, clearly could have important practical implications for how the divisive question of physician assisted suicide might or might not be resolved in the context of contemporary multicultural society.

If multiculturalism is a significant phenomenon of contemporary society, no less is that of an ageing population. Medical professionals working in the field known variously as Geriatric Medicine or Healthcare of the Elderly, have over the past half-century developed and refined knowledge and skills particularly appropriate to patients, many with multiple pathologies, some with impaired autonomy and others approaching death: ‘to cure sometimes, to relieve often, to comfort always’ and, pace transhumanists, “to add not years to life, but life to years’, have been the watchwords of many geriatricians, and standard examples of ethical questions arising in medicine of the elderly have been about how actively to investigate or treat, or about what care (residential, nursing home, or hospital) is most appropriate. These ethical questions are often urgent, of practical import, and entirely appropriate for geriatricians to ask: but in a landmark paper published in this issue of the journal ( see page 128 ), Christopher Wareham argues that they do not add up to what could properly be called an ‘ethics of ageing’, indeed that such an ethics does not yet exist.

Reasons for this, Wareham suspects, include the ‘perceived negative associations between ageing, decrepitude and death. Internet searches for ageing and ethics’, he reports, ‘result almost exclusively in articles about what to do with expensive ageing populations, or end-of-life decisions in old age.’ ‘Yet ageing’, he argues, is a ‘fundamental aspect of life… a process which, on some definitions, occurs throughout life’: ‘problems created in so-called mid-life crises’ for example, ‘are often heavily linked to ageing’ and ageing may be ‘a necessary part of human flourishing since the phases of ageing are important contributors to the meaning and value of life’. A further reason for not limiting the ethics of ageing to ‘issues involving the elderly’, he suggests, is that in this approach, ‘ageing persons’ tend ‘to be seen as objects of ethical dilemmas and policy rather than as central – the subjects or agents of ethical discourse.’

Responding to these limitations, Wareham maps out what he considers the ‘proper scope of the ethics of ageing’, defined as ‘a field of normative enquiry encompassing ethical issues facing a person in her situation as an ageing person.’ Accordingly, its ‘subject matter’ should include ‘questions concerning right ageing’, such as ‘the duties and rights of ageing persons’ and of ‘good ageing’ such as how ‘can we age well or meaningfully?’ Examples of questions which would fall within the scope of the ethics of ageing include: how far ageing is most appropriately defined, biologically in terms of functional decline, or ethically in terms of wisdom and experience; questions of ‘intergenerational rights and duties’; ‘questions about good, meaningful lives’, including those concerning ‘the value or disvalue of ageing-related death’; and issues raised by technology, such as the use of robots in care on the one hand, and on the other, ‘the ethical implications of technologies directed at altering the ageing process by modes of slowing, preventing, reversing or even escaping ageing’.

These questions, Wareham emphasises, represent only ‘a fraction of the work that can justifiably be said to form part of ageing ethics’, but even in his brief outline of the proper scope and subject matter of ageing ethics, putting lifetime experience of ‘the ageing person’, and not just ‘the elderly’ at ‘the centre of ethical analysis’, Wareham has proposed a significant and potentially fruitful paradigm shift in contemporary thinking about the ethics of ageing. Like the discussion of multiculturalism by Durante and Beauchamp, and indeed all the other papers in this issue which there is not space here to review, Wareham’s paper demonstrates that in the early twenty-first century there are more than sufficient matters of vital ethical, social and political interest to medical professionals for interdisciplinary discussion of them, and for medical ethics itself, to flourish.