No. 9: September-December 2013

Iain Brassington

Bioethics in the UK

Academic Foresights

How do you analyze the present situation of bioethics in the UK?

One way to answer this question would be to look at the role that that bioethics, broadly conceived, has come to play in the general public discourse.  By this measure, the status of the discipline is quite high.  Ethics committee approval is built into research; the General Medical Council expects that the undergraduate medical curriculum contains an element of ethics teaching; and there are frequently programmes devoted to, or touching on, bioethical issues on the national media (BBC Radio 4’s Inside the Ethics Committee being a good example).  Look beneath the surface, though, we should probably add a couple of qualifications.

For example, ethics committee approval of research can verge towards the formalistic: since – for perfectly good reasons – their membership draws from scientists and members of the public as well as professional bioethicists, not every member of every research committee is familiar with bioethical argument.  Hence, though the question of whether a given proposal is good science in the moral sense implies taking account of whether it’s scientifically sound, the scientific soundness does sometimes eclipse other considerations.  Thus research on animals is sometimes assessed purely on the basis of what the benefits to humans might be; and “benefits to humans” is sometimes interpreted quite narrowly – as narrowly as how many papers will be generated, and in what high-impact journals.  Accordingly, good methodology and the promise of lots of papers does, unavoidably, sometimes get more weight than one might expect.

Medical school ethics teaching often does not go much beyond an emphasis on informed consent and a slightly robotic attachment to Beauchamp and Childress’ “four principles” – the idea that biomedical ethics is reducible to respect for autonomy, beneficence, non-maleficence, and justice, without too much attention paid to what something like justice actually requires or why autonomy almost always is treated as primus inter pares.  On the other hand, we must admit that it’s perhaps unreasonable to expect medical students to become sophisticated philosophers at the same time that they are training to become doctors: they have enough to contend with as it is.  Neither ought it to be forgotten that there is a small but significant appetite among medical undergraduates to take a year out from their studies to intercalate for a degree in medical ethics and law.  Furthermore, there’s a steady stream of qualified medics, nurses, and bench scientists who return to university to complete an MA or PhD in medical ethics and law once their career has got going.  (At Manchester, we’ve got a bit of a habit of convincing people hitherto convinced that they wanted to be doctors that, actually, they want to be medical ethicists or lawyers as well… or instead.).

Within the academy, there is a fairly large number of universities that offer some form of bioethics teaching, either as a degree in its own right, or as part of an applied ethics syllabus.  Bioethics or medical ethics degrees are – with the exception of one or two intercalated programmes that offer degrees at UG level – overwhelmingly postgraduate, and this does present the possibility that student numbers will be squeezed in coming years as recent and projected increases in tuition fees begin to have an impact.  This may mean that it is going to be increasingly difficult for universities to attract large numbers of students – and this, in turn, may mean a reduction in the number of centres offering tuition in bioethics as a stand-alone subject.

In the US, bioethics as a discipline drew significantly in its early years from theology and social activism.  My sense is that the UK was slightly different, inasmuch as that it was more of a branch of philosophy at the start.  However, bioethics does have a tradition of drawing from disciplines other than philosophy.  One trend that has begun to appear over the last few years is an “empirical turn” – bioethics has become very hospitable to work by sociologists and anthropologists.  This does cause a little tension, since the concerns of one discipline are not always the concerns of another, and people whose intellectual backgrounds are different do sometimes talk past each other.  To that extent, it might be claimed that there is a distinction to be drawn between philosophical bioethics and empirical bioethics.  There is something to that, for sure – though it probably oughtn’t to be overplayed.  After all, “philosophical” bioethics is a form of applied philosophy, and so presupposes and requires at least some contact with the real world.

Still: the point stands that a persistent problem across the field of bioethics is that one of its major strengths – its interdisciplinary diversity – is also the seed of one of its major weaknesses.  There is no generally accepted understanding of what a bioethicist is.  On one hand, this means that “bioethics” draws strength from the various insights provided by philosophers, lawyers, sociologists, and the like.  On the other hand, though, there is no mark that one has to have met in order to call oneself a bioethicist; and this does mean that the reputation of the field and, by extension, those working in it is vulnerable, since it’s not always obvious to those not in the know who is and isn’t worth his salt.  More worryingly, there is a slight tendency of some bioethicists to blur the line between academia and advocacy to the extent that the latter informs and directs the former.  This feeds into a perception in some quarters that to be a bioethicist is to be at best a jack-of-all-trades, but a master of none; among philosophers, for example, bioethics does not have the high status of, say, work in the field of mind and language, or even political philosophy.

This sniffiness is not – I have to admit – wholly unwarranted.  But neither is it as pervasive as it was in the recent past.  And for reasons at which I’ll hint below, it may well decrease further.

In your opinion, how will the situation likely evolve over the next five years?

As mentioned above, bioethics has become much more welcoming of empirical and social scientific input over the last few years, and it is unlikely that this will change in the near future. Another trend that we’re likely to see continuing is input from people whose background is not within the mainstream Western philosophical tradition.  Journals like the Journal of Medical Ethics are already receptive to papers explaining, say, an Islamic perspective on such-and-such an issue.  Such contributions are particularly useful in the context of clinical ethics: it rewards medics treating patients from a range of backgrounds to understand why certain things might be a concern, and therefore papers that can explain a given cultural take on an issue ought to be welcomed.

The caveat to this is that the trends will turn out to be of merely anthropological interest rather than being “ethics” in any particularly full-blooded sense unless bioethics’ attempt to understand those traditions is accompanied by a critical engagement with them.  I would hope that we see more of this in the coming years.

Indeed, I think that there is a growing appetite for more “proper” philosophy within bioethics (I myself have argued that bioethics is nothing without a sound foundation in philosophy) and rather less catechistic Principlism, and much less of the kind of fluffy, uncritical approaches to clinical ethics in particular that Birmingham’s Angus Dawson has labelled “jazz poetry”.  This may lead to more squabbling about not only how to spot and solve moral dilemmas in medicine and the biosciences, but about what bioethics is to begin with (my implication that anthropological claims about ethics are not bioethics in the full sense in the previous paragraphs is exactly the sort of claim that’d ruffle feathers).  Yet I don’t think that this ought to be too big a worry – it might be a sign of healthy self-examination.

Public health will probably prove to be an area of growing interest.  Concerns about public health are already causing some disruption to the rather conservative principlism of medical-school bioethics: after all, effective public health measures (such as mandatory vaccination, tight regulation of tobacco sales, and so on) are in tension with the classic liberal individualism, insisting on personal sovereignty, that informs most interpretations of “respect for autonomy”.  Public health ethics is likely to be a subdiscipline that both informs public policy, and helps shape bioethics tout court.

Another area in which we’ll see continued interest is genetics.  With genetic testing becoming ever cheaper, ever faster, and ever more accessible, how we can regulate the spread of genetic information will pose ever-greater problems for policymakers.  Should insurers have access to genetic information?  Employers?  Biobanks?  Partners and family members?  How much, and on what grounds?  Synthetic biology has begun to attract bioethical attention, though I suspect that this area of research will turn out to raise no significant unique questions – with one proviso: given the very real possibility that it will be possible for enthusiastic amateurs to synthesise, say, polio, how should we regulate the dissemination of scientific insights?  Nevertheless, owing to the fact that synthetic biology and genetic manipulation is likely to play a part in curing disease, feeding the world, and providing biofuels, there will be public policy debates to which bioethicists are likely to be able to make significant contributions.

Additionally, an increase in open-access publishing across the board will – hopefully – make it easier for bioethicists from less economically developed nations to make an impact on debates.  That one of the problems with biofuels is the amount of land needed for them, and the knock-on effects on food production, this may be very good timing indeed.

Finally, it’s tempting to replace predictions about the coming 5 years with a proposal for what they should (or shouldn’t) bring: I have a colleague who has suggested that there should be a five-year moratorium on papers about assisted dying, or at least a strong presumption against publication, on the grounds that original insight is very rare and tends to be eclipsed by a kind of trench warfare in which neither side does anything much except reassert their prior position.  I may be guilty of contributing to this situation, but I’m tempted to endorse that idea.

What are the structural long-term perspectives?

This is difficult to predict in anything but the broadest terms.  For as long as there is bioscience, there will be problems that bioethicists can address. And though policymakers may occasionally pay little more than lip-service to bioethical concerns, they do at least do that – and, in all fairness, bioethicists’ input does tend to be taken seriously.  While I think it’s reasonable to expect a slight fall in student numbers in coming years, there will still be a significant number.

Bioethics as a discipline in the UK is somewhere between 30 and 40 years old.  It is a discipline reaching maturity and consolidation; it needs to find a way to increase and maintain both its diversity and its intellectual rigour – but this can, and will, be done.

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Iain Brassington is a philosopher based in the Centre for Social Ethics and Policy in the School of Law at the University of Manchester.  He is director of the MA, LLM and MSc programmes in Healthcare Ethics and Law, and teaches Jurisprudence on the undergraduate law curriculum.  His research interests are in the ethics of genetics, end-of-life issues, and moral theory; his latest book, Bioscience and the Good Life, will be published by Bloomsbury in November.  He is also an editor of, and contributor to, the Journal of Medical Ethics’ blog:

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