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‘The moral life’ the novelist and philosopher Iris Murdoch wrote, ‘is something that goes on continually, not something that is switched off in between the occurrence of explicit moral choices. What happens in between such choices is indeed what is crucial.’1 She wrote that in the 1970s, at a time when both popular discussion and the academic study of bioethics were just getting off the starting blocks; and in the bioethical context such advice often tended to be overlooked in favour of a more exciting focus on acute moral dilemmas and quandary ethics. Today, by contrast, the significance of what ‘happens in between… explicit moral choices’ in bioethics, and especially in medical ethics, is receiving much more of the attention it deserves, and among the papers in this month's issue of the Journal, this theme is developed by authors from a variety of countries in a number of different and illuminating ways.
Canadian authors Hunt and Carnevale for example, drawing on anthropology and hermeneutics, develop and illustrate a framework for bioethics research focused not on ethical dilemmas or problems, but on the broader moral experience of how values which individuals or groups feel important can be ‘realised or thwarted… in mundane and everyday settings’ (see page 658). As with other hermeneutic approaches, this framework is designed not to come up with definitive judgements about what is right or wrong, but to explore where lived experiences fall ‘on spectrums of right-wrong, good-bad or just unjust’, thereby generating insights which can point to, albeit not guarantee, richer and more nuanced ethical understanding. Examples of qualitative research projects undertaken by the authors illustrate how this approach can fruitfully bring out positive as well as negative aspects of people's moral experience in healthcare settings.
Some less positive aspects of healthcare, by contrast, are brought out in Agledahl and colleagues' qualitative study of 101 patient consultations in a Norwegian hospital (see page 650). Illustrated by telling vignettes, it demonstrates how these doctors ‘actively directed the focus away from their patients’ existential concerns onto the medical facts and rarely addressed the personal aspects of a patient's condition'. This did not mean that these doctors were cold or ‘clinical’ in their dealings with their patients: on the contrary, they ‘attended to their patients with courteousness, displaying a polite and friendly attitude and emphasising the relationship between them’. Nevertheless, the authors argue, by disregarding ‘patients’ personal accounts’ the doctors not only risked ‘missing information that is clinically important’, but even more seriously, disregarded ‘their patients’ humanity, which is a moral offence that is often perceived negatively’. The authors have no ready remedy for this: ‘it is uncertain’ they write, ‘whether it is possible for doctors to care for patients existentially while also attending to their clinical responsibilities which require them to apply a depersonalised medical science’. The most that may be possible is for the doctor to attend to the patient's ‘humanity as far as possible within the medical setting, and apologise when unable to address personal issues’, although the authors qualify this by adding that their study included ‘only hospital doctors… and it is possible that general practitioners attend more to their patients as people.’
A closely related aspect of hospital medicine is discussed in Australian author McDougall's paper on a junior doctor's ‘role virtue conflict’ when seniors, appearing to neglect or disregard not just the existential but also some clinical aspects of a patient's condition, propose to carry out what the junior believes to be futile and burdensome invasive treatment (see page 646). Questioning the judgement of those with more experience, the author agrees, is problematic ethically and practically, but it may be morally required and, depending on how it is done, morally appropriate: guidance on how to do this, she argues, can be generated by reflecting on the respective virtues of the junior as a doctor, as a team member and as a medical learner. Respectful questions about the rationale for seniors' decisions may be sufficient, but if not, it is better for the junior to be open with their seniors about the ethical difficulty and, if that does not resolve the issue, by ‘taking concerns outside the team or refusing to participate in treatment’. Clearly this is not going to be easy, and the author emphasises the need for medical schools to prepare their students for such possible difficulties by training in effective and appropriate communication not only with patients but also with colleagues.
Communication questions of a more intriguingly theoretical kind, albeit with practical implications, are raised in Cohen's paper on ‘The Gettier Problem in informed consent’ (see page 642). Do competent patients really give informed consent to medical treatment when their ‘choices, through free, are not the result of the medical information they received from their doctors’, but of some intervening, unrelated or even accidental experience which made them change their initial decision not to consent? Relating this to a classic problem (raised by Edmund Gettier) in epistemology, the author suggests that the standard justification of informed consent with reference to the principle of respect for patient autonomy (which in practice ‘necessarily involves some consideration of the relevant information’) may need to be rethought.
Autonomy also appears, but in the less familiar context of the public understanding of science, in Pickersgill's paper on ‘Research, engagement and public bioethics’ (see page 698). Against the background of a significant shift in emphasis, by British scientific and medical research funding bodies, from ‘science communication’ and ‘public understanding of science’ towards ‘public engagement with science’, and based on the author's own research on the social and ethical dimensions of neuroscience, the paper argues for ‘a fresh emphasis on public understandings of research’. ‘To address these issues’, the author argues, ‘the onus is on…science educators to ensure that the messy realities of scientific life are embedded within communication of biomedical knowledge’, not least in order to ensure that ‘individuals and social groups… unfamiliar with some of the specifics of certain modes of research and ethical frameworks’ do not ‘have their autonomy compromised when they come to participate in studies’.