EDITORIAL
Pardon my asking: do we need eMinence-based bioethics?
Carlo Petrini
Unità di Bioetica, Presidenza, Istituto Superiore di Sanità, Rome, Italy
"(V)irtue would be neither an inborn quality nor taught, but comes to those who possess it as a gift from the gods which is not accompanied by understanding, unless there is someone among our statesmen who can make another into a statesman. If there was one, he could be said to be among the living as Homer said Tiresias was among the dead, namely, that 'he alone retained his wits while the others flitted about like shadows'. In the same manner such a man would, as far as virtue is concerned, here also be the only true reality compared, as it were, with shadows" [1].
"Prophets are never recognised in their own country; an expert is someone who travels a long distance and brings their own slides" [2].
During the last two months I have attended two congresses and one series of lectures on the ethics of research involving human subjects. Of a total of about twenty speakers, twelve showed a slide with an identical list of seven criteria "to make human research ethical". The criteria were published several years ago by three eminent experts as a "Special communication" in one of the world's most respected medical journals (maximum Impact Factor). It is probably unnecessary to name the journal: both medical researchers and ethicists will probably have recognized it.
The criteria are (unanimously and rightly) recognized as sound. I agree: they summarize the basic ethical requirements that are absolutely necessary in all medical research.
The three authors of the "Special communication" are (unanimously and rightly) recognized as eminent ethicists throughout the world. I agree: they have published excellent works.
However, the repetition of the same slide with the same "Seven Commandments" (my definition) raises at least two questions.
1) What kind of ethics is useful for researchers? The debate on the foundation of ethics is absolutely necessary and cannot be abandoned: we need sound anthropological foundations as a basis for ethical evaluation. Nevertheless, researchers also need practical guidelines.
2) What would have happened if an unknown researcher had submitted the same seven criteria to the same leading journal? The seven criteria are exactly the same that have been repeated in every code, declaration or convention on medical ethics (since Nuremberg) and are the same found in the first chapter of every manual on medical ethics. Let us imagine for a moment that an unknown research student submits the same list of seven criteria to one of the world's leading medical journals. I am not at all sure that the referees would respond in the same way that they responded to the three eminent authors.
Some years ago three scientists ("on behalf of the World Artifexology Group") published a humorous "field guide to experts", with the subtitle "Experts are common but not well understood. This guide introduces novice expert-spotters to the essentials of artifexology - the study of experts" [3]. This "field guide" is part of a substantial body of humorous literature on experts.
Do we need eMinence-based bioethics? Yes and no. "Yes": bioethics is no matter for amateurs. We need experts. It is important that even the simplest values and rules be reaffirmed by authoritative experts: this gives authority to the most straightforward concepts.
Some might answer "no": many basic criteria are self-evident and do not need to be revealed by elaborate analysis. Seen from this angle, experts may be unnecessary. Others might be sceptical (because many questions of right and wrong have been debated throughout human history and still remain unresolved) or suspicious (because individual freedom and the existence of moral plurality might resist any attempts to recognize ethical expertise) [4].
In 1982, in his classical article with the striking title "How medicine saved the life of ethics", Stephen Toulmin claimed that medicine saved ethics by giving the philosophers a positive reality check through medical challenges [5]. The same year Cheryl Noble asked: "Have moral philosophers substituted moral reasoning for moral wisdom?" and concluded that moral philosophers are too theory-bound to provide such wisdom [6]. Nowadays the proliferation of bioethics experts and the success of practical ethics guidelines are a fact from which we can draw many lessons. I would suggest four:
- first: people find bioethicists and guidelines helpful;
- second: expertise in ethics is not only the ability to justify one's moral judgments coherently: it is, most of all, a matter of correct or true judgment;
- third: experts should be able to communicate. There is a difference between possessing a skill (or intellectual know-how) and possessing the ability to communicate that skill to others: having the know-how does not necessarily involve being able to communicate it;
- fourth: some general principles (such as the "Seven Commandments") are fairly simple. Their translation to practical application might be very difficult. This is exactly what St. Thomas Aquinas claimed.
References
1. Plato. Meno. 99e-100a.
2. Ashton JR. Change management: prophets and travelers. J Epidemiol Community Health 2002;56(6):401.
3. Oxman AD, Chalmers I, Liberati A. A field guide to experts. BMJ 2004:329(7480):1460-3.
4. Rasmussen LM. Introduction: In search of ethics expertise. In: Rasmussen LM (Ed.). Ethics expertise. History, contemporary perspectives and applications. Dordrecht: Springer; 2005. p. 1-12.
5. Toulmin S. How medicine saved the life of ethics. Perspect Biol Med 1982;25(4):736-50.
6. Noble C. Ethics experts. Hastings Cent Rep 1982;12(3):7-9.