by J.S. Blumenthal-Barby, Ph.D.
I begin this blog post with a long quote from Julian Savulescu’s article, “Bioethics: Why Philosophy is Essential for Progress,” just published in Journal of Medical Ethics:
“I left a promising career in medicine to do bioethics because I had done philosophy in 1982 and attended Peter Singer’s lectures in practical ethics. The field was new and exciting and there were original proposals and arguments. Singer, Glover, Lockwood, Parfit and others were breaking new ground, giving new analyses and arguments. Now medical ethics is more like a religion, with positions based on faith not argument, and imperiously imposed in a simple-minded way, often by committees or groups of people with no training in ethics, or even an understanding of the nature of ethics.
What medical ethics needs is more and better philosophy— and a return to the adventurousness and originality of its pioneering days. There have been successes—euthanasia and better treatment of animals to mention just two. But the field has in many ways dried up or become dominated by moralists bent on protecting privacy and confidentiality at great cost and ‘getting consent’, and in other ways ‘protecting basic human rights and dignity’. Medical ethics isn’t sufficiently philosophical, and when it is philosophical, it’s the bad arguments or a narrow range of arguments that often seem to make a difference. And there is the attempted scientification of ethics in empirical ethics, a kind of sociological ethics, surveying people’s opinions and practice. But this can never directly lead to answering the question: what should we do?
Most people working in or talking about medical ethics have never studied ethics….for many people working in bioethics or medical ethics, or formulating guidelines or policy, ethics is a ‘hobby’. They have no formal training in ethics. Imagine that I was to sit on a cardiological research funding panel, or review a paper in cardiology, or stem cell science. It would be laughable. Yet I have 7 years formal training in medicine and research. Many people ‘doing medical ethics’ have nothing like that training or experience.
The trouble with medical ethics is that there is not enough original, good philosophy. Not that you need a philosophy degree to do good philosophy: John Locke was a doctor; Derek Parfit does not have a doctorate and only an undergraduate degree in history; Iain Chalmers is not a philosopher. Yet philosophical thinking is the most important activity in medicine and in life—ethics determines what we should do. Science can only tell us how to do it.”
This is a powerful article, and while I am well aware of my bias, I believe there is quite a bit of truth to its points. Now, certainly there are instances of good philosophy in bioethics, certainly good bioethics requires things other than good philosophy, and certainly one need not be Derek Parfit or have a PhD from a top ranked philosophy program to make solid philosophical contributions to bioethics (as Savulescu notes, trying to ward of criticisms of elitism). But, Savulescu does a good job of pointing out rampant conceptual confusions among practitioners in the field (e.g., “coercion” has become a commonplace label for many instances and practices that do not match most conceptual definitions—nor try to challenge them and defend and create new ones), an appeal to concepts such as “justice” without an understanding of the types, complexities, or histories of such concepts (such that their application becomes incorrect, counter-intuitive when applied correctly, or worse—vacant), and a heavy reliance on professional/legal statements and empirical investigation to do the work of telling us what to do (e.g., as Singer argues, people have a minimal moral obligation to help when doing so is of great benefit to another and small cost to them regardless of whether people think they have this moral obligation—a fact that we might find out about via survey data collection for example).
I’ll add to Savulescu’s reflections by borrowing a distinction from G.A. Cohen. In his recent book, Rescuing Justice and Equality, Cohen makes a distinction between “fundamental normative principles” and “rules of regulation” (in Chapter 7). He criticizes Rawls of a “single disfigurement” whereby he misidentified principles of justice with optimal rules of regulation. Fundamental principles say what justice is—they provide important conceptual content. Rules of regulation (e.g., income tax rules) are things that we create and adopt as a practical task in order to serve fundamental normative principles, and they benefit from transparency, public input, stability, etc. Formation of rules of regulation is important since they (ideally) support the content of our moral beliefs, convictions, and obligations. But a sole or heavy focus on only the rules of regulation risks the loss of precious content.
There is not space in this post to reflect sufficiently on the potential causes of the phenomena that Savulescu discusses, but some reflection on this is important here. Is it because there is no more space for original philosophy in medical ethics? That all of the concepts and arguments have already been mapped out and the task now is merely translational (a task we are also failing at it seems according to Savulescu)? This may in part be true—a lot has been done and it is certainly easier to be more “revolutionary” at the beginning of a field—but new technologies and social changes continue to develop that raise new issues or challenge analysis of old ones. Perhaps it is (in part) the result of the following: many philosophy departments fail to see engagement with “applied” issues (or learners) as philosophy proper (and note the vicious circle here if indeed good philosophy is decreasing in these areas), and many medical centers find it increasingly difficult to support work (or education) that is philosophical in nature given that it is unlikely to be supported by external grant funding or tied directly or immediately to clinical work, and takes a substantial amount of time and energy. These are tough challenges that the field faces, but the first step to addressing them is a recognition and invitation for dialogue, which Savulescu has certainly initiated.