Is bioethics a bully?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5802 (Published 03 September 2012) Cite this as: BMJ 2012;345:e5802
- Daniel K Sokol, barrister and honorary senior lecturer in medical ethics, Imperial College London, UK
When I worked with hospital ethicists in the United States, we would tell clinicians that we were not the “ethics police.” Just as the very existence of the Hippocratic oath makes one wonder about the ethics of ancient Greek physicians, the need for this reassuring remark suggests a problem with the perception of the ethics team by clinicians.
For years, I was immersed in bioethics. I lectured, researched, published, sat on committees, and visited medical establishments as an ethicist. The subject filled my working life. When I encountered resistance to my efforts, I assumed the problem lay with those who were objecting. They were the ones who misunderstood or were pig headed, not me, for who in their right mind could object to the value of bioethics? Now, I spend more days in court than in the lecture theatre. This newfound distance from ground zero has illuminated aspects of bioethics that I had missed, ignored, or taken for granted. Were the objectors right? Is bioethics a bully?
Bioethics is a hotchpotch of disciplines, ranging from sociology to law. Although there is infighting about the dominant discipline within bioethics, philosophy is, arguably, king. The inclination of philosophy is towards abstraction. Aristotle, Hume, Kant, Mill, Heidegger, and other lesser known philosophers populate the pages of academic articles in bioethics. Modern medicine, on the other hand, is a pragmatic discipline. Abstraction is rare. This contrast between the theoretical and the concrete, coupled with the ever present temptation for academics to appear clever, creates a danger for bioethics: through the use of theories and esoteric language, bioethicists can obfuscate, confuse, intimidate, or antagonise the very clinicians and patients they seek to help.
Members of research ethics committees often complain that a researcher’s “participant information sheet,” replete with medical jargon, is incomprehensible to its intended readers. The same criticism applies to much bioethical prose. If the writing is aimed at ordinary clinicians, then it should be understandable to them. In the words of Raanan Gillon, one of the fathers of modern medical ethics, “ethics should be basically simple for it is there to be used by everyone, not just by people with PhDs in philosophy or theology.”1
Clinicians are told (or possibly “advised”) what to do by bioethicists, in research and clinical ethics committees, lectures in medical schools and elsewhere, and books and articles. These instructions are given at a safe distance from the nitty gritty of practice. The emphasis is on legal and ethical barriers, medical errors, violations of this or that guideline or principle. The tone is negative, and a whiff of disapproval fills the air. It is not surprising that bioethicists are seen by some as so called ethics police, disempowering or threatening the medical profession with a barrage of criticisms.
To make matters worse, most professional bioethicists are not clinicians, so these bitter instructions are usually given by people with no medical qualifications. They are removed from the pressures of everyday practice, issuing commands like generals far from the battlefield. But unlike military generals, bioethicists have not fought their way to the top, rising up the ranks. They cannot say, “I’ve been there.”
In law, much care is taken in choosing medical experts but what makes a bioethics expert? If you need a bioethicist for a lecture or a report, where should you turn? There is no Royal College of Bioethics, no MRCB (bioethics) exam, and an MSc or PhD in the subject is no guarantee of knowledge or quality. The Institute of Medical Ethics, which describes itself as “a charitable organisation dedicated to improving education and debate in medical ethics,” has no role in the regulation or standard setting of the increasing number of bioethicists in the United Kingdom.
I have long believed that a good bioethicist should get his or her boots dirty by spending time in the muddy trenches, but I have no doubt that I too have been guilty of sounding like the ethics police, or using pretentious language, in this very column.
Bioethics, in its current form, has bullying tendencies. Ironically, it often adopts a paternalistic attitude towards clinicians, treating them as an ethically deficient species. Although bioethics should not shy away from pointing out ethical concerns in medical practice, sometimes forcefully, it must not give way to negativism or, worse still, to a zeal to condemn. Clinicians are easy targets and, without a command of the fancy theories and language of the accusers, possess few means to respond formally.
Of course, the difficulties in the tense relationship between clinicians and ethicists are by no means created by the latter group alone. Some clinicians are unreasonably resistant to the integration of bioethics in medicine. Further, there are myriad voices within the broad church of bioethics that do not fall foul of the criticisms above.
Without a standard exam or curriculum, there is no guarantee that individual bioethicists will take an inward look at their practice. It is not a natural instinct. A greater awareness of anthropological or sociological critiques of bioethics, a better appreciation of the challenges of practising medicine (perhaps through some immersion in the relevant setting), and more collaborations between practitioners of bioethics and medicine should lead to greater professional harmony, and more relevant, nuanced, and practicable solutions to ethical problems in medicine.
Cite this as: BMJ 2012;345:e5802