Ethical issues are rife in medicine. Arguments about abortion, organ donation and euthanasia regularly take their turn in the headlines, normally prompted by media scare-stories or an arising controversy. Should people be paid to donate their organs, for example, or should people be allowed to end their life if they consider it to not be worth living? These are complex and controversial questions, and are often literally matters of life and death.
It might be reassuring to know that there are people out there who have the formal training to provide answers to these difficult questions, taking their reasoning from a diverse range of fields including philosophy, law and the social sciences. Step forward the bioethicists – academics that can now be found in many universities.
Although approaches may vary (some bioethicists work using only moral or legal theory, whereas others prefer a more “hands on” approach including focus groups or interviews with interested parties), we spend our working lives carefully analysing the ethical issues that arise within medicine and beyond and use this to establish what is the right or wrong thing to do in a given situation.
But despite this pool of expertise – both widely published and presented at conferences – when it comes to influencing people who make policy, our work largely falls on deaf ears; most recommendations are completely ignored by those who make decisions in public life, and the result is that this expertise rarely has any effect outside of academic circles.
Poor reasoning also kills
But if well-reasoned guidance on the right course of action is ignored, or if flawed moral reasoning is used to maintain the status quo, then the wrong course of action is likely to follow.
The philosopher Janet Radcliffe Richards made this point clearly when she said: “If you die through mistakes in moral reasoning, you are as dead as if you die through mistakes in medicine”.
We need only look at something like organ donation to see this in action. Many bioethicists have endorsed opt-out organ donation systems, or carefully controlled marketplaces for organs, which would probably increase donation rates. Although these suggestions have been around for decades, Wales is only now transitioning to opt-out. The rest of the UK currently has no plans to follow.
But clinging to the frankly bizarre idea that the only ethically acceptable donation system is opt-in and “altruistic” has limited the number of transplanted organs. And as a result, people die from the shortage. If people were dying or being harmed because doctors were making mistakes in patient treatment there would be an outcry, but when it happens because of flaws in ethical reasoning it goes largely unnoticed.
In other scenarios, people are wrongly prevented from dying against their will. The case of Tony Nicklinson recently brought assisted dying back into the spotlight, and highlighted the difficult plight of a man with locked-in syndrome. Although undeniably a complex situation, many bioethicists have presented convincing arguments in favour of assisted dying, yet ultimately legislation has not changed to allow what seems to be the right outcome.
Everyone feels qualified
That limited attention is often paid to bioethicists’ recommendations may reflect a particular view of the work that we undertake. If I wanted to know about aerodynamics, I would speak to an aerodynamicist and trust their expertise on the issue. If they said something that conflicted with my own understanding, I wouldn’t feel qualified to disagree with them. In contrast, if I voice an opinion on a bioethical issue, everyone feels qualified to disagree with me.
The idea of moral expertise has been discussed in academic literature, but you certainly do not need a PhD in philosophy to know that some things are right or wrong. Bioethicists, despite their extensive training, do not have exclusive or special access to the answers to moral questions. Why, then should bioethicists be listened to?
What good ethicists do well is to think through situations methodically, rationally, and objectively. This sometimes results in conclusions that are controversial and truly challenging to accept. Australian researchers recently argued in favour of after-birth abortion (the killing of young babies) – which was hugely controversial – and Peter Singer has been telling us for years that we ought to give a substantial proportion of our income to charity. Bioethics, and ethics more generally, can tell us things that are sometimes uncomfortable and that we do not want to hear.
Breaking the stalemate
Bioethicists disagree on many things, and good arguments were put forward both for and against after-birth abortion for example. This clearly suggests it isn’t always as simple as there being a single right answer to moral problems. And it would be wrong to make bioethicists the final arbiters of right and wrong: where several bioethicists disagree (as they often do), whose argument would you accept as being right anyway?
But the role of bioethics shouldn’t be to simply tell people what to do, but instead to lay out the relevant well-formulated arguments (including arguments with hard-to-swallow conclusions, such as after-birth abortion) and dismiss the arguments that are clearly flawed. How to choose the “right” option from the remaining arguments is open to debate, but bioethics can at least ensure that obviously wrong options are excluded.
Looking at arguments rationally and impartially with fresh eyes may, in cases such as assisted dying, help to break apparent stalemates, and prevent the flaws in moral reasoning that can be so costly to those affected by them.