The empirical turn in bioethics

4.3.1. Medical practicalities

Bioethics has traditionally been quite theoretically loaded, drawing upon more general theories from philosophy and ethics. It is commonly described as a branch of applied ethics, which implies the use of general philosophical ethics in the practical field of medicine. Applying the general moral rule that you should not lie, would, in medicine, mean that doctors must tell the truth to their patients. With the development of new technologies and cumulative biomedical knowledge, medicine continued to produce new moral questions which had not really been answered or tested before. In this way, it provided the field of ethics with ever more dilemmas to resolve, as Toulmin pointed out in his much cited article “How medicine saved the life of ethics” (1982).

The field of medicine, in becoming ever more complex, has also made bioethical discourse more complicated, meaning that moral questions were often firmly embedded in the clinical setting. In addition, the juridical aspects of medical decisions have been constantly scrutinised, particularly in the United States, and the development of law and bioethics has gone hand in hand. This required more specialist knowledge in difficult medical areas, such as knowledge of medicine, law and bioethics, and has paved the way for a new group of experts: clinical ethicists.

Clinical ethics is the branch of ethics that is occupied with the moral questions that are embedded in actual clinical practice: could we terminate nutrition support to this unconscious, vegetative patient? Should the parents be allowed to decide that their daughter should not undergo surgical intervention which could prolong her life? The term clinical ethics is now mainly used within the context of clinical ethics’

consultations. In other words, it is concerned with the provision of consultation services on ethics by the growing profession of ethics’ consultants. Such consultation services involve not only moral issues, but also questions of group psychology, conflict resolution, power inequality and so forth.

Recently, another branch of bioethics has also emerged, due to the growing number of empirical studies undertaken in the field. As we described in the introduction, these studies cover matters like interviews with health care personnel, observations of medical departments, and questionnaires relating to the moral grounds for medical decisions. Recently, these endeavours have been gathered under the new term, empirical ethics, and there has been much discussion about what this entails and what purpose it actually serves (Molewijk et al, 2004; Musschenga, 2005). Many of the empirical studies in question are descriptive, recounting matters like the arguments of doctors or nurses or describing a particular medical practice. Traditionally, moral philosophy has had a rather constrained attitude towards descriptive research, referring to the fundamental gap between is and ought, which originates from David Hume (Hume, 1978). The thesis says that describing how the world is cannot tell us how we ought to behave. Even if 90% of all of the doctors in a study consider it to be morally right to not reveal the full truth about their prognosis to dying patients, in order to protect them from severe depression, they may still all be wrong. Our accepted moral practices, like slavery once was, can always turn out to be morally wrong. There is no logical way to infer what ought to be done from what is actually the case. The “ought” and “is” statements belong to two fundamentally different classes: normative and descriptive statements.

4.3.2. Empirical ethics

Why do we need empirical research into ethics then? We ought to distinguish here between (at least) two different types of research on ethics. A common way of empirically exploring the field of medical ethics is to study the moral attitudes of health care personnel. Even if you cannot infer what is morally right from what the participants in a study believe, their comments can inform medical ethics about the kinds of arguments that are prevailing and how health care personnel assess the moral values involved in different settings. This knowledge could enable the field of medical ethics to target its moral arguments in such a way that they have an impact

on how medical decisions are made. Exploring these attitudes is also often used to reveal cases of malpractice and to target areas in which the moral standards of health care personnel need to be improved.

Another way to conduct empirical ethics is to describe actual medical practice. This approach can inform medical ethics about the organisation and practice of health care by illustrating how and what kinds of situations arise. This is perhaps the most important contribution made by the discipline. If ought-statements from moral philosophy should have any implications for actual medical practice, then they must relate to what medical practice is really like. A crucial role of empirical ethics is to display the particularities of medical practice in order to understand what the practice implies in ethical terms. If most doctors believe that it is morally right to deceive a dying patient, the interesting question is why they think that this is morally defensible. We might discover that the answer is not moral negligence or a lack of moral sensitivity that needs to be corrected; there may be other, overriding moral considerations that we have not yet discerned. Indeed, the peculiarities of the situation may have moral implications that are not as easily detectable by outsiders, but are nevertheless sensed by the participants. When people behave immorally, seemingly for no good reason, or seem to be immune to moral correction, it might be appropriate to ask if there are aspects of the situation that we have not properly understood. This seems to be relevant to medicine, given doctors’ fairly modest interest in bioethics.

In particular, empirical ethics has the potential to contribute to a fuller understanding of the premises of health care and the medical profession. All too often, bioethical discussions seem to be so stuck on the theoretical arguments that they remain blind to obvious practical circumstances that limit their relevance. This is not chiefly a problem of how to apply moral demands in medical practice; it is instead a question of how the practical arrangements of the medical profession form the ethical decisions that are involved therein. Many practical conditions limit the freedom of action of the participants. Some are obvious in health care, like resources and time, while others are perhaps more hidden, but they all curb the possibilities of moral choice. It might not be philosophically legitimate to infer what ought to be done from what is the case, but what ought to be done nevertheless rests upon what it is possible

to do. This normative aspect of empirical ethics has been addressed by several ethicists, exploring how empirical ethics bridges the gap between facts and values (de Wries & Gordijn, 2009; Kon, 2009).