Cogito

Locking horns over bioethics: The challenge from Steven Pinker

Locked in combat no retreat.

In a recent op-ed in the Boston Globe, high-profile psychologist and author Steven Pinker strongly criticized the profession, or academic field, of bioethics. Pinker’s article suggests that the main imperative for bioethicists right now is to “get out of the way” of potentially valuable research.

This has prompted numerous defences of bioethics, including one from my Cogito colleague Matthew Beard. I will take a different tack, because I believe Pinker is largely correct. I do, however, agree with Matthew Beard’s comment that Pinker is, himself, making moral presuppositions. We all do that, and we must face up to it.

Indeed, a problem with disputes such as this - including a vast range of debate over moral, philosophical, political, and cultural issues - is that they are not empirically tractable. Often, the disputants are relying, at a deep level, on different presuppositions. At that level, there may not be even an approximate and tacit consensus. Disputants lock their philosophical horns, with no realistic prospect of reaching agreement, because they don’t accept each other’s basic premises. I’ll return to this.

A modest defence of bioethics

I might seem an obvious person to argue the toss with Pinker: to offer a defence of bioethics.

My formal qualifications include a Masters degree in bioethics from Monash University, and I hold a Ph.D in philosophy from the same institution, where I wrote a dissertation grounded in philosophical bioethics and legal/political philosophy. A considerably revised version of this has since (2014) been published by MIT Press under the title Humanity Enhanced: Genetic Choice and the Challenge for Liberal Democracies.

Much of my published work - both academic publications and more popular ones - fits comfortably within bioethics, and I have taught bioethics to undergraduate students. In particular, I’ve acted in the past as the lecturer and coordinator at Monash for its subject “Ethics, Genetics and the Law”.

Given all that background, it’s unlikely that I’d oppose the academic field of bioethics, and of course I don’t. On the contrary, I count as a bioethicist in good standing, though notably a philosophical bioethicist.

More specifically, I support intellectually rigorous investigation of what laws and ethical guidelines should apply to medical practice and biomedical research. As individuals, and as a society, we have an interest in regulating these practices. Perhaps most obviously, we want some assurance that doctors will be focused on helping us with our individual problems, rather than on secretly using us to test pet theories about treatment regimes. Again, we want to know that our own values will prevail when we accept risky treatments, and that the values of our doctors won’t be imposed on us. It follows that we seek assurance that risks will be explained to us accurately, and that we won’t be channelled into accepting treatments without first being given disclosure of possible side effects.

These sorts of fears and concerns are perfectly reasonable. They can be elaborated, sub-divided, and further divided at indefinite length, but the general idea is easy to understand. Once identified, fears and concerns such as these give support to key bioethical principles such as those of respecting patient autonomy and obtaining informed consent to treatment. There must also be exceptions, such as when consent cannot be obtained in an emergency or if a patient is too immature or intellectually impaired to understand the situation.

All of this is important for at least three reasons. First, the grave consequences of many medical choices. Second, the imbalance - often a dramatic one - between the power and knowledge of a patient (or a research subject) and the power and knowledge of a medical practitioner (or a research scientist). Third, the shocking history of (many) practitioners and researchers abusing their superior power and knowledge. I’m sure we could add other important aspects.

We need to set rules, we need to adapt them to new situations as they arise, and we need to teach the rules to professionals who’ll be expected to follow them (such as doctors and scientists) or enforce them (such as lawyers). In developing regulatory policy in a fraught area like this, we inevitably encounter conflicting values that must be balanced in some way. All of this inevitably leads to a field such as bioethics. It has a history and a crucial social role. Bioethics is, and (I submit) should be, a thriving field for research, teaching, and practical implementation.

In summary, the field of bioethics is legitimate and important - and I’ll continue to contribute to it.

Why Pinker and I can agree

I don’t, however, believe that Pinker would seriously deny any of the above. At least, nothing that he states in his Boston Globe article commits him to doing so.

The view that he has stated, admittedly in a polemical way, is a perfectly respectable one within the field of bioethics. In fact, as a philosophical bioethicist I have a great deal of sympathy for it. Pinker claims - and I agree - that many of the current rules, and the practices through which they are interpreted and applied, have swung too far in the direction of constraining research. At the very least, that’s a legitimate viewpoint.

Alas, the established rules and practices - and the deeper principles appealed to in order to support them - can outrun the reasons why we needed rules in the first place.

It is one thing to establish a rule that forbids a doctor from prescribing a drug without warning about its known and significant side effects. There’s an obvious reason why I might fear that happening to me as a patient, and there is, unfortunately, a history of many doctors making high-handed decisions. Sometimes they’ve acted from a paternalistic attitude that they know what is best for the patient. Sometimes they have used patients as mere guinea pigs. Rules that forbid these forms of professional arrogance serve a real and obvious need. Well-crafted rules help allay commonsense, and reasonably uncontroversial, fears and concerns.

But it’s another thing entirely if some form of treatment or research is forbidden because it violates a nebulous - and highly controversial - value such as “dignity”, “sacredness”, or “social justice”. It is not even obvious that there is such as thing as dignity in the relevant (perhaps Kantian) sense, let alone sacredness. Various meanings can be given to the term “social justice”, but its content is, at best, furiously contested. Even if two political philosophers can agree on its meaning at a highly abstract level, they are likely to give it dramatically different concrete content.

Accordingly, I agree with Pinker’s decision to place all these expressions in scare quotes. It might not mean that he is merely sneering at them, but he is certainly distancing himself. And rightly so. The scare quotes convey that these expressions cannot be taken for granted as transparent or useful, or as referring to things that exist in the real world.

Perhaps most obviously, it seems to me, as to many others (doubtless including Pinker), that nothing is genuinely and literally sacred. Even if something does possess the mysterious property of sacredness, or sanctity, it is highly doubtful that contested ideas about that should have any role in shaping regulatory policy in secular liberal democracies.

In the upshot, Pinker and I can agree because it is possible to come to conclusions similar to his from within the field of bioethics, and without denying the field’s practical necessity. Indeed, a large proportion of philosophical bioethicists are suspicious of the same expressions that Pinker places in scare quotes. My impression is that many of us also share his view that some current laws and other rules are unnecessary, illiberal, perhaps even irrational.

How to be a sceptical bioethicist

It is possible to study bioethics from a rather sceptical viewpoint. That is, we can be sceptical about much of the supposed wisdom in the field, including the use by some bioethicists of noble-sounding appeals to “human dignity”, “the sanctity of human life”, and so on. As I’ve shown above, the field of bioethics does not need any such expressions or concepts to justify its important role.

My own work in philosophical bioethics takes a markedly sceptical approach, in this sense; and that, in turn, meshes well with my general approach to philosophy. Much of my research involves disputing the authority of social institutions - such as morality, religion, and the law - that purport to tell us how to live our lives.

I don’t suggest that we can do without all these institutions. I certainly don’t imagine that we could get by without the institution of law (religion is another matter, though; I’d be happy to do away with it).

When confronted by these powerful institutions, we can subject their various claims to rational scrutiny. (I am not a “cultural Marxist”, but this is a kind of critique of domination!)

Returning specifically to bioethics, it seems clear enough that we do need laws and ethical guidelines to give us some protection from the power - and its possible abuses - held by doctors and medical researchers. Something similar could be said about the need for rules restricting abuses of power by lawyers and journalists. But that does not tell us, in itself, which rules we should have or whether the current ones are, overall, too restrictive, too lax, or about right.

Although Pinker is not a professional bioethicist, that in itself should not prevent him from having an informed opinion about the current laws, guidelines, etc., applying to medical practice and research. Indeed, all citizens are affected by regulatory policy in these areas, and I encourage my readers, regardless of their backgrounds, to inform themselves as well as they can.

It doesn’t seem that Pinker wants to do away with all the rules, or with the rigorous investigation of which rules best serve us. He appears to believe that the current rules are about right when it comes to protecting individual patients and research subjects, but that they are too restrictive in other ways. Whether or not he is too sanguine about the former, the latter is very likely true.

To some extent, that is an empirical question: it requires detailed study of exactly which research has been hindered over recent decades. But there’s more to it than that.

Locking horns forever?

As I mentioned at the outset, bioethical debates can involve persistent and intractable disagreement, much like other moral, philosophical, cultural, and political controversies. To some extent, that is because of difficulty in obtaining relevant empirical data. It is, however, also because of deep-seated disagreements in presuppositions.

Debates within the physical and biological sciences often converge on agreement. That is possible because there is already an approximate (often tacit) agreement on what counts as evidence, what standards of evidence apply, and what forms of reasoning from observations to theoretical conclusions are cogent.

Debate about questions of what is morally right or wrong, what regulatory policies we should develop and apply, or what is a good life - or even what is a good book - are more often characterised by persistent, emotionally charged failure to achieve consensus. Whereas scientific theories can be overthrown relatively rapidly if they are contradicted by too many observational anomalies, religious worldviews, moral theories, political ideologies and viewpoints, and conceptions of living well display great resistance to criticism or falsification. When some go out of fashion, or survive only by changing radically, it may require social upheaval, the use of force, or the passage of a long period of time.

Although there is much agreement within the field of bioethics - for example, no one seriously doubts that there is an important role for patient autonomy - there is also much scope for persistent dissensus. To some extent, the the field is riven by different conceptions of why we need bioethics at all.

My earlier explanation of why we need bioethics would be contested by some bioethicists as shallow or reductive, or perhaps as scientistic. There may, for example, be no way that I can reach agreement with an opponent who insists that the purpose of bioethics is to protect “human dignity” rather than to allay ordinary fears of abuses. Even a bioethics based on the latter can become complex, given the varied and difficult situations that can arise; however, it will look very different from a bioethics based on radically different concepts and perhaps an entirely different worldview.

Under those circumstances, consensus may be out of reach unless - and until - general social values change.

Conclusion

In summary, I can agree with Pinker’s main points from within the field of bioethics and without in any way deprecating its legitimacy or importance. I hope that Pinker would acknowledge this much.

Pinker may or may not be a utilitarian at the level of theoretical normative ethics. I don’t consider myself to be a utilitarian, but he and I would probably agree that bioethics is best justified as serving various commonsensical and secular interests. He speaks of the need for safeguards of safety and informed consent, and I agree that this is central.

We might both have a problem reaching agreement with those bioethicists (Margaret Somerville, Leon Kass, and many others) who have fundamentally different conceptions of what values bioethics should protect - perhaps grounded in fundamentally different worldviews.

I doubt that those differences can be settled - at least quickly - but it is open to me, or to Pinker, to make a case to the wider public that bioethics should be tied to a relatively narrow and prosaic purpose. Further, we can argue for considerable freeing up of existing principles, laws, guidelines, interpretations, and practices. We can argue for an increased priority to be placed on greenlighting (rather than impeding) biomedical research.

That case may require more detail, and more engagement with objections, than in Pinker’s relatively short Boston Globe article. I hope he will develop his views at greater length.

Meanwhile, many people - doctors, scientists, administrators, lawyers, and ordinary citizens from every walk of life who may become patients or research subjects - have a stake in bioethical controversies. Formal training in philosophical bioethics can help in coming to grips with the issues, and in not reinventing wheels or going down known false paths. At the same time, we all need to think about policy in this area. Bioethics is too important to be left to professional bioethicists.

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