This is bioethics bytes with me, David Edmonds and me Nigel Warburton.
Bioethics Bytes is made in association with Vox, which we here are Centre for Practical Ethics and made possible by a grant from the Wellcome Trust.
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Radically new techniques are opening up exciting possibilities for those working in health care.
For psychiatrist Dr. Surgeons, the option to clone human beings to give just one example.
Who should determine what is allowed and what prohibited? And what sort of consent should doctors elicit from patients before treatment?
Is the trend toward detailed consent forms helpful, or should we trust doctors to make good decisions for us?
The philosopher Nora O'Neill, formerly principal of Newnham College Cambridge, has written extensively on the issue of trust.
Trust is vital in most areas of human interaction, but nowhere more so than in health and medicine.
And O'Neill. Welcome to Bioethics Bytes. Hello.
I'm very glad to be here. The topic we're going to focus on is trust.
You've spent a lot of time thinking about trust and mistrust or possibly distrust in the areas of media, ethics and medicine, particularly.
We want to look at it in the area of bioethics. But could you say something, general, about trust?
I think the thing that came to interest me about trust is that this seems to me
to have been a very great change in the way we discuss it in the last 15 years.
It used to be thought of as a matter of trusting relationships.
And of course, it was very close to the sort of implied or implicit consent that people often assumed underlay professional relationships.
It wasn't, of course, merely an attitude that implied consent and trust always involved judgement about what the other person was saying,
what they were committing themselves to do. And it always implied that one took a fairly discriminating view.
One trusted people to do some things and not others.
But then in bioethics, we underwent a great revolution when people began to say, Oh,
trust, particularly trust between patients and doctors, is merely a form of deference.
It doesn't respect what came to be called patient autonomy.
And what we want are much more formalised relationships of explicit, informed consent as the background to any legitimate intervention.
And meanwhile, the discussion of trust went off in a completely different direction,
and people began to focus principally on third party attitudes and reports of third party attitudes.
Now, when you read the polls, that's what they give you generic attitudes towards types of professional politicians,
journalists, doctors, scientists and so on.
We all enjoy it when the politicians and the journalists have a very low score, but the professors and the doctors get a very high school.
But when you think about it, it's only a generic attitude and it's of no practical use.
We don't want to place our trust exactly as others do.
When we have a practical problem, we want to place it with discrimination as we always used to.
Making a judgement, deciding I trust this person for this purpose, but not for that purpose.
It seems to me that when you put faith in something of someone, you don't really have sufficient evidence.
But trust implies that you do have good grounds or you think you have good grounds for that.
Well, all these terms are little bit vague. People sometimes talk about blind trust or unconditional trust.
I know somebody whom I would trust to edit my manuscript, and that's very high trust on my part.
But I wouldn't trust him to post a letter that I had given him to post.
And we make that sort of judgement all the time.
And I think it's a pity that the dominant public discourse about trust assumes now that it's merely a generic attitude.
That's an appropriate sort of investigation if what you're trying to do is to sell a type of product.
You want to know whether your brand of fattening chocolate bar is more trusted than the other brands of fattening chocolate bars.
But it's not very useful for the practical purposes that we all have in real life.
So trustworthiness isn't a universal category.
Usually people are trustworthy in certain respects and institutions are trustworthy in certain respects.
So as people who have to engage with that institution or that individual, what do we do?
How do we judge somebody's trustworthiness? I think it comes down to three things.
Probably we want to know are they competent? Or you employ someone to do something very skilled.
You sort of want to know, can they do it? We want to know, are they honest?
Because that affects everything, including the question of whether the credentials they told you about really exist.
And we want to know whether they're reliable. None of us is perfect in all these respects, but that's roughly what we need.
It's rough, it's ready, and it's essential. When you're talking about trusting somebody to make judgements that affect your own life,
you're to some degree relinquishing autonomy over what happens because you're saying you know better than me about what I should do,
so I'll just go with your judgement. Is that a fair assessment?
I don't think it is quite fair. First of all, we constantly have to rely on other people as sources of information, as sources of expertise.
But it doesn't mean that we lie back in an infantile way and simply say anything goes or whatever you say, guv, we don't do that.
We in the first place rely much more on some informants than on others for very good reasons.
And we derive people who say, to quote a well-known phrase, I read it in the tabloids, so it must be true.
But I think making judgements where communication is mediated is inevitably much more complicated.
And what we have to find is some way in which to judge our source, the intermediary.
Making sure that there are available ways of checking and challenging is very important
if people are to place trust in complicated matters where they rely on intermediaries.
Does that mean there should be all these forms that doctors and other people involved
in medical ethics have to fill in to prove that they're following procedure?
Do you think those forms prove any such thing?
What has happened is that informed consent procedures where there is some particular procedure or transaction, have superseded trust.
Informed consent is highly structured, as you say,
and people have to demonstrate that they've informed people of all sorts of complicated matters, which they probably can't understand.
This, I believe, is what has brought a lot of informed consent into some disrepute.
You've probably met the moment in the sitcom American sitcom, and it wafts across the emergency room.
Doctor, have you consented? And that gives the game away, doesn't it?
The consenting is a process done for institutional and professional purposes, and it doesn't really always inform the patient or the research subject.
I can see how we might go about judging competency, honesty and reliability in an accountant, for instance.
But in the area of bioethics, what sort of criteria can you possibly use?
Imagine that there's a drug available which increases children's IQ.
And the question is, should we as parents give that drug to our children who could possibly be an expert there?
I'm not myself very much in favour of trying to answer hypothetical questions.
If one invents a hypothetical product that increases IQ.
My first question would be, okay, tell me about this hypothetical product.
What are its side effects? How expensive is it?
Is it reliable? Who produces it? Is it on prescription?
There are a lot of things I'd want to know before I start dosing a child.
And these are pretty commonsensical things. But I believe that bioethics has, of all fields of ethics,
been most prone to people who have come in inventing counterfactual scenarios and asked people to take a view on them.
I just don't take a view on them.
I want to know whether they are scenarios that are actually arising for people, and then I might do a little homework.
What about one of these new technologies that very recent have thrown up all kinds of ethical questions like cloning?
What would you say there? I'm not entirely certain whether cloning of human beings has been achieved,
although I think it's been reported quite often, which is a slightly different matter.
Now, being a clone would not be a bad fate.
Identical twins are natural clones, and as we know, they're very different person.
So there's nothing intrinsically wrong with being someone else's clone.
However, I think that there might be difficulties in the typical situation in which people might desire to clone somebody.
Whom do you wish to clone?
Do you wish to clone a celeb or do you wish to clone one of the parents because of reproductive difficulties for that parent?
If you clone a celeb, I think we can see that this is quite burdensome for a child to know that they were had to.
The spitting image of whomever the long faded celeb who existed a while ago.
If it's a relative, I think that's a quite a different set of complications,
which we would need to think through very carefully, namely that it distorts all the family relationships in certain ways.
If I am the clone of my mother, does my father have different feelings towards me,
more appropriate to the feelings towards a spouse than the feelings towards a child?
People have difficulty enough in sensing themselves to be too like a parent as they grow up and as it were,
in differentiating themselves sometimes, of course, madly irritating for the parent.
But how would that be if you really were genetically identical?
Now I can see how those are all relevant and interesting issues that will be thrown up by this sort of case.
But some legal decision making would have to occur.
Who should we trust to make those sorts of decisions? What kind of competence is there in ethics?
I don't think it's just in ethics. I think it's much more broadly spread in the population.
And if you look how these decisions have been made in the UK, they are of course ultimately parliamentary decisions, but they are made on a free vote.
They are never party politicised. And ever since the Warnock report of the 1980s led to the first legislation regulating IVF, in vitro fertilisation.
Ever since then, it's been done very slow motion with very widespread consultation with many interested parties and
certainly patient groups and parent groups taking a very active part in the debate about such legislation.
So I would say a Democratic debate, but not a party politicised debate is the way to move towards legislation in this area.
And I think that bioethics makes an excellent contribution there by helping to clarify and set out the arguments.
And I think sometimes where such a procedure has not been followed, for example, on legislation,
on the use of human tissues, we don't have anything like such good legislation.
Often, at least in Britain, when there are committees which decide biomedical issues,
they're quite heavily populated by people from particular religious standpoints.
And yet many of the people for whom they're legislating don't share those religious standpoints.
Why should we trust those people to make judgements for us?
In my experience, it's not been true that they're particularly heavily populated,
but I would say this they're quite heavily populated by people of a secular standpoint.
Why should religious people trust them? If you believe in democracy, you have to have a range of your fellow citizens with a diversity of views,
and you can't kick off people because you don't like their basic orientation.
Does that mean that we should be including homeopaths and astrologers on committees that decide these issues?
Homeopaths and astrologers make a different sort of claim that they don't make a claim to have a sort of world view.
They make a claim to have an area of practical or theoretical expertise which as far as it can be judged, they don't have.
Now, we've been talking about trust, which you've demonstrated is actually central to human relations, I think.
And we haven't mentioned the philosopher's name at all yet lurking behind all this.
I know there has to be at least one philosopher.
Well, of course, in my case, the philosopher on whose work I've spent most time and given most attention is Immanuel Kant.
And Kant is very well known for putting a conception of autonomy very central in his arguments.
And I think I first really became alert to what was going on in bioethics,
where I realised that the conceptions of individual autonomy that had been debated in the political philosophy in the
seventies and eighties had become mainstream in bioethics and were in certain very demanding conceptions of informed consent,
were being promoted as ways of securing that individual autonomy.
But what struck me suddenly was these people are claiming that the position they're taking has Kantian ancestry and authority.
I knew quite well by then that Kant's conception of autonomy was a conception that had nothing to do with individual autonomy.
It was a conception of certain principles, was said to be autonomous if they were the sort of principle that everybody could adopt.
So it was part of his argument for morality. And I think.
That conflation between autonomy and morality, which we often see in contemporary bioethics and more broadly in contemporary ethics,
is simply a failure to realise that if you're talking about individual autonomy,
meaning individual capacities to choose, you haven't yet begun to talk about how those capacities ought to be used.
You're not yet talking about ethics.
So are you saying that what's gone wrong is that some people in the area of bioethics are using the word autonomy, claiming it's a Kantian use.
There just isn't a Kantian use. If it were just that, I think it would be pretty simple if it was just so to speak, a mistake of interpretation.
I suspect the deeper problem is that they're using a very large range of different conceptions of individual
autonomy so that we have very thin conceptions where individual autonomy is a matter of mere choice,
doesn't matter whether it's reason, choice or unreason choice.
And then we have a whole range of conceptions where people say, no, no.
By individual autonomy, I don't mean just any old choice, I mean an autonomous choice.
And that's something much grander. It is an informed choice or it is a rational choice or reflective choice.
And that, I think, has led to quite a lot of confusion.
And one of the difficulties is that when we're talking about clinical ethics, where someone's having a serious operation and they have to consent,
do we mean merely that they have to say, well, I agree, or do we mean that they've got to understand all this stuff?
Now we know from empirical studies by sociologists that people don't understand all the stuff to which they ostensibly give consent.
So there's a sort of pretence, a pretence that what we've got is informed or even supposedly fully informed consent.
And we don't have that. People are busy. They have different areas of expertise.
They can't follow it all. They've had to rely heavily on other people's information.
They may have been feeling terribly ill, confused the rest of it.
So one has to ask what's informed consent really for why is it got such a prominent part in our culture?
And I think the answer is it is for the service providers, not the service users.
It's about laying off liability. It's not really about ensuring that everything's understood, but it is legally effective.
If you do the operation having got consent, you haven't committed an offence of assault.
And that's very fundamental for surgeons, for hospitals and for all of us.
But we ought to be clear that that's what it's about. And to call all this patient autonomy is at the very least inflationary and I think misleading.
And or. Neal, thank you very much. I've enjoyed talking about it.
Thanks a lot. For more information about bioethics bites, go to WW dot practical ethics, dot oecs dot AC Dot UK or iTunes U.