COMMENTARY
Medicine saved ethics. Has ethics harmed medicine?
Carlo PetriniI; Enrico AllevaII
IUnità di Bioetica, Presidenza, Istituto Superiore di Sanità, Rome, Italy
IIDipartimento di Biologia Cellulare e Neuroscienze, Istituto Superiore di Sanità, Rome, Italy
ABSTRACT
In an article in The Boston Globe, Steven Pinker holds that the primary moral good of bioethics should be to "get out of the way". The accusation that bioethics is an obstacle to research because it calls attention to basic principles such as personal dignity and justice is clearly contradicted by the facts. There are, nonetheless, other ways in which bioethics can stand in the way of science, two of which, bureaucratisation and the loss of cultural vivacity, are worth addressing. Ethics committees provide a framework for evaluating problems and determining an appropriate course of action.
Key words: bioethics, ethics committees, human experimentation
Every so often, over the last ten years or so, some more or less well known author has caused a - usually brief - uproar by bringing serious charges against bioethics. In a famous intervention in 2008 Steven Pinker maintained "the stupidity of dignity" [1]. Now his target is the whole bioethical discourse: in a recent opinion piece in The Boston Globe, Steven Pinker makes the suggestion that the primary moral goal of today's bioethics should be to "get out of the way": Pinker adds that: "a truly ethical bioethics should not bog down research in red tape, moratoria, or threats of prosecution based on nebulous but sweeping principles such as 'dignity', 'sacredness' or 'social justice'. Nor should it thwart research that has likely benefits now or in the near future by sowing panic about speculative harms in the distant future. These include perverse analogies with nuclear weapons and Nazi atrocities, science-fiction dystopias like 'Brave New World' and 'Gattaca' and freak-show scenarios like armies of cloned Hitlers" [2].
Steven Pinker is a controversially debated Harvard psychologist. His "The blank slate: The modern denial of human nature" [3] caused widespread disputing at the international level. For example, his public debate with an anti-reductionist antagonist, the neuroscientist Steven Rose [4], has raised important questions about Pinker's approach while considering hotly-debated scientific issues. This latter possibly may well be inserted in a long series of shots he shows a tendency to display with the general public. It may be worth mentioning that he was a finalist for the Pulitzer prize, given his capability to produce bestselling books at a quite regular pace.
The article in The Boston Globe [2] triggered a flood of comments not only on a variety of blogs and other social media but also in scientific journals of every kind. The controversy even prompted a summary report in Nature [5].
Jonathan Baron's 2006 book Against bioethics [6] had a similar effect, and was followed in 2012 by, among others, Tom Koch's Thieves of virtue. When bioethics stole medicine [7]. In 1982 the noted essayist Stephen Toulmin claimed that bioethics, which over the preceding decade had set itself apart as a separate discipline [8], had saved ethics [9]. Recent advances in medicine had, according to Toulmin, forced ethicists to tackle concrete problems and, by abandoning fruitless abstract speculation, to find practical solutions. Today we might ask ourselves if ethics has returned the favour. Pinker and other authors who criticise bioethicists suggest the answer is negative: bioethics is an obstacle that stifles biomedicine and prevents its progress.
Pinker's assertion echoes the thoughts of many scientists whose research requires the approval of an ethics committee before starting. Nevertheless, it is not difficult to defend the committee's role: numerous examples could be cited of research studies that, in the total absence of any ethical assessment, have seriously violated human rights [10]. The accusation that bioethics is an obstacle to research because it calls attention to basic principles such as personal dignity and justice is clearly contradicted by the facts.
There are, nonetheless, other ways in which bioethics can stand in the way of science, two of which, bureaucratisation and the loss of cultural vivacity, are worth addressing.
Bureaucratisation is a real problem. According to data collected from 51 of 56 facilities participating in a multicentre trial in one European country in 1993, the assessment procedures demanded by local ethics committees called for 25296 pieces of paper and 62 hours of photocopying [11]. In today's world informatics has lightened the paper load and cut time requirements, and such an episode would no longer be compatible with European regulations [12], although in many European nations the administrative workload is one of the main causes of bottlenecks in the procedures for obtaining ethical approval.
The second risk - loss of the ability to stimulate, which bioethics should possess - was highlighted already in 1999 by Albert R. Jonsen in a lecture he gave at the Lifetime Achievement Award Ceremony at the American Society for Bioethics and the Humanities. The lecture spawned a delightful article entitled "Why has bioethics become so boring?" [13], which suggested several reasons to explain the phenomenon. One of these "is that bioethics has become a respected part of the world of medical, scientific and social policy and, like anything that becomes respectable, loses a bit of its rough edge and some of its rudeness. Thirty years ago, all ethicists (if we may in retrospect call them such) were outsiders, strangers, engaged in criticism of the establishment. Their ways of talking were foreign, their academic credentials odd" [13].
So what is to become of the principles of bioethics? Some general principles are very simple, but their translation might be very difficult. This is why regulation of research has a positive balance of benefits over costs. The main reason why ethics committee approval of a project is required is that neither researchers nor research subjects are always knowledgeable and objective enough to determine whether a project is scientifically and ethically appropriate. Researchers need to demonstrate to an impartial expert committee that the project is worthwhile, that they are competent to conduct it, and that potential research subjects will be protected against harm to the greatest extent possible [14]. Ethics committees provide a framework for evaluating problems and determining an appropriate course of action.
REFERENCES
1. Pinker S. The stupidity of dignity. Human Life Review 2008;34:75.
2. Pinker S. The moral imperative for bioethics. The Boston Globe; 1 August 2015. Available from: www.bostonglobe.com/opinion/2015/07/31/the-moral-imperative-for-bioethics/JmEkoyzlTAu9oQV76JrK9N/story.html.
3. Pinker S. The blank slate: The modern denial of human nature. London: Penguin Books; 2002.
4. Blackmore S. The two Steves - Pinker vs. Rose - A debate (Part I). 2013. Available from: http://edge.org/3rd_culture/pinker_rose/pinker_rose_p2.html.
5. Madhusoodanan J. Bioethics accused of doing more harm than good. Opinion piece that calls for bioethics to "get out of the way" prompts self-reflection among ethicists. Nature 2015:524(7564):139.
6. Baron J. Against bioethics. Cambridge, MA: MIT Press; 2006.
7. Koch T. Thieves of virtue. When bioethics stole medicine. Cambridge, MA: MIT Press; 2012.
8. Bioethics: the science of survival. Perspect Biol Med 1970;14(1):127-53.
9. Toulmin S. How medicine saved the life of ethics. Perspect Biol Med 1982;25(4):736-50.
10. Lafleur WR, Böhme G, Shimazono S (Ed.). Dark medicine. Rationalizing unethical medical research. Bloomington, USA: Indiana University Press; 2007.
11. Maskell NA, Jones EL, Davies RJO. Variations in experience in obtaining local ethical approval for participation in a multi-centre study. Q J Med 2003;96(4):395-7.
12. European Parliament, Council of the European Union. Regulation (EU) 536/2014 of the European Parliament and of the Council of 16 April 2014 on clinical trials on medicinal products for human use, and repealing Directive 2001/20/EC. Official Journal of the European Union 27 May 2014;L158:1-76.
13. Jonsen A. Why has bioethics become so boring? J Med Philos 2000;25(6):689-99.
14. World Medical Association. Medical ethics manual. Ferney-Voltaire: World Medical Association; 2009.
Address for correspondence:
Carlo Petrini
Unità di Bioetica, Presidenza, Istituto Superiore di Sanità
Via Giano della Bella 34
00162 Rome, Italy
E-mail: carlo.petrini@iss.it.
Accepted on 4 September 2015.