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This is bioethics bytes with me, David Edmonds and me Nigel Warburton.

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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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For more information about bioethics bytes go to WW W Docs Practical Ethics, dot oecs docs ac UK or to i-Tunes u.

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Radically new techniques are opening up exciting possibilities for those working in health care.

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For psychiatrist Dr. Surgeons, the option to clone human beings to give just one example.

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Who should determine what is allowed and what prohibited? And what sort of consent should doctors elicit from patients before treatment?

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Is the trend toward detailed consent forms helpful, or should we trust doctors to make good decisions for us?

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The philosopher Nora O'Neill, formerly principal of Newnham College Cambridge, has written extensively on the issue of trust.

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Trust is vital in most areas of human interaction, but nowhere more so than in health and medicine.

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And O'Neill. Welcome to Bioethics Bytes. Hello.

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I'm very glad to be here. The topic we're going to focus on is trust.

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You've spent a lot of time thinking about trust and mistrust or possibly distrust in the areas of media, ethics and medicine, particularly.

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We want to look at it in the area of bioethics. But could you say something, general, about trust?

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I think the thing that came to interest me about trust is that this seems to me

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to have been a very great change in the way we discuss it in the last 15 years.

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It used to be thought of as a matter of trusting relationships.

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And of course, it was very close to the sort of implied or implicit consent that people often assumed underlay professional relationships.

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It wasn't, of course, merely an attitude that implied consent and trust always involved judgement about what the other person was saying,

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what they were committing themselves to do. And it always implied that one took a fairly discriminating view.

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One trusted people to do some things and not others.

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But then in bioethics, we underwent a great revolution when people began to say, Oh,

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trust, particularly trust between patients and doctors, is merely a form of deference.

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It doesn't respect what came to be called patient autonomy.

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And what we want are much more formalised relationships of explicit, informed consent as the background to any legitimate intervention.

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And meanwhile, the discussion of trust went off in a completely different direction,

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and people began to focus principally on third party attitudes and reports of third party attitudes.

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Now, when you read the polls, that's what they give you generic attitudes towards types of professional politicians,

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journalists, doctors, scientists and so on.

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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.

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But when you think about it, it's only a generic attitude and it's of no practical use.

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We don't want to place our trust exactly as others do.

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When we have a practical problem, we want to place it with discrimination as we always used to.

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Making a judgement, deciding I trust this person for this purpose, but not for that purpose.

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It seems to me that when you put faith in something of someone, you don't really have sufficient evidence.

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But trust implies that you do have good grounds or you think you have good grounds for that.

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Well, all these terms are little bit vague. People sometimes talk about blind trust or unconditional trust.

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I know somebody whom I would trust to edit my manuscript, and that's very high trust on my part.

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But I wouldn't trust him to post a letter that I had given him to post.

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And we make that sort of judgement all the time.

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And I think it's a pity that the dominant public discourse about trust assumes now that it's merely a generic attitude.

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That's an appropriate sort of investigation if what you're trying to do is to sell a type of product.

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You want to know whether your brand of fattening chocolate bar is more trusted than the other brands of fattening chocolate bars.

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But it's not very useful for the practical purposes that we all have in real life.

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So trustworthiness isn't a universal category.

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Usually people are trustworthy in certain respects and institutions are trustworthy in certain respects.

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So as people who have to engage with that institution or that individual, what do we do?

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How do we judge somebody's trustworthiness? I think it comes down to three things.

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Probably we want to know are they competent? Or you employ someone to do something very skilled.

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You sort of want to know, can they do it? We want to know, are they honest?

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Because that affects everything, including the question of whether the credentials they told you about really exist.

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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.

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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,

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you're to some degree relinquishing autonomy over what happens because you're saying you know better than me about what I should do,

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so I'll just go with your judgement. Is that a fair assessment?

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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.

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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.

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We in the first place rely much more on some informants than on others for very good reasons.

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And we derive people who say, to quote a well-known phrase, I read it in the tabloids, so it must be true.

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But I think making judgements where communication is mediated is inevitably much more complicated.

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And what we have to find is some way in which to judge our source, the intermediary.

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Making sure that there are available ways of checking and challenging is very important

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if people are to place trust in complicated matters where they rely on intermediaries.

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Does that mean there should be all these forms that doctors and other people involved

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in medical ethics have to fill in to prove that they're following procedure?

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Do you think those forms prove any such thing?

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What has happened is that informed consent procedures where there is some particular procedure or transaction, have superseded trust.

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Informed consent is highly structured, as you say,

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and people have to demonstrate that they've informed people of all sorts of complicated matters, which they probably can't understand.

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This, I believe, is what has brought a lot of informed consent into some disrepute.

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You've probably met the moment in the sitcom American sitcom, and it wafts across the emergency room.

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Doctor, have you consented? And that gives the game away, doesn't it?

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The consenting is a process done for institutional and professional purposes, and it doesn't really always inform the patient or the research subject.

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I can see how we might go about judging competency, honesty and reliability in an accountant, for instance.

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But in the area of bioethics, what sort of criteria can you possibly use?

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Imagine that there's a drug available which increases children's IQ.

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And the question is, should we as parents give that drug to our children who could possibly be an expert there?

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I'm not myself very much in favour of trying to answer hypothetical questions.

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If one invents a hypothetical product that increases IQ.

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My first question would be, okay, tell me about this hypothetical product.

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What are its side effects? How expensive is it?

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Is it reliable? Who produces it? Is it on prescription?

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There are a lot of things I'd want to know before I start dosing a child.

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And these are pretty commonsensical things. But I believe that bioethics has, of all fields of ethics,

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been most prone to people who have come in inventing counterfactual scenarios and asked people to take a view on them.

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I just don't take a view on them.

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I want to know whether they are scenarios that are actually arising for people, and then I might do a little homework.

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What about one of these new technologies that very recent have thrown up all kinds of ethical questions like cloning?

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What would you say there? I'm not entirely certain whether cloning of human beings has been achieved,

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although I think it's been reported quite often, which is a slightly different matter.

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Now, being a clone would not be a bad fate.

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Identical twins are natural clones, and as we know, they're very different person.

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So there's nothing intrinsically wrong with being someone else's clone.

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However, I think that there might be difficulties in the typical situation in which people might desire to clone somebody.

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Whom do you wish to clone?

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Do you wish to clone a celeb or do you wish to clone one of the parents because of reproductive difficulties for that parent?

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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.

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The spitting image of whomever the long faded celeb who existed a while ago.

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If it's a relative, I think that's a quite a different set of complications,

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which we would need to think through very carefully, namely that it distorts all the family relationships in certain ways.

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If I am the clone of my mother, does my father have different feelings towards me,

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more appropriate to the feelings towards a spouse than the feelings towards a child?

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People have difficulty enough in sensing themselves to be too like a parent as they grow up and as it were,

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in differentiating themselves sometimes, of course, madly irritating for the parent.

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But how would that be if you really were genetically identical?

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Now I can see how those are all relevant and interesting issues that will be thrown up by this sort of case.

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But some legal decision making would have to occur.

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Who should we trust to make those sorts of decisions? What kind of competence is there in ethics?

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I don't think it's just in ethics. I think it's much more broadly spread in the population.

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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.

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They are never party politicised. And ever since the Warnock report of the 1980s led to the first legislation regulating IVF, in vitro fertilisation.

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Ever since then, it's been done very slow motion with very widespread consultation with many interested parties and

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certainly patient groups and parent groups taking a very active part in the debate about such legislation.

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So I would say a Democratic debate, but not a party politicised debate is the way to move towards legislation in this area.

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And I think that bioethics makes an excellent contribution there by helping to clarify and set out the arguments.

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And I think sometimes where such a procedure has not been followed, for example, on legislation,

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on the use of human tissues, we don't have anything like such good legislation.

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Often, at least in Britain, when there are committees which decide biomedical issues,

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they're quite heavily populated by people from particular religious standpoints.

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And yet many of the people for whom they're legislating don't share those religious standpoints.

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Why should we trust those people to make judgements for us?

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In my experience, it's not been true that they're particularly heavily populated,

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but I would say this they're quite heavily populated by people of a secular standpoint.

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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,

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and you can't kick off people because you don't like their basic orientation.

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Does that mean that we should be including homeopaths and astrologers on committees that decide these issues?

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Homeopaths and astrologers make a different sort of claim that they don't make a claim to have a sort of world view.

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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.

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Now, we've been talking about trust, which you've demonstrated is actually central to human relations, I think.

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And we haven't mentioned the philosopher's name at all yet lurking behind all this.

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I know there has to be at least one philosopher.

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Well, of course, in my case, the philosopher on whose work I've spent most time and given most attention is Immanuel Kant.

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And Kant is very well known for putting a conception of autonomy very central in his arguments.

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And I think I first really became alert to what was going on in bioethics,

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where I realised that the conceptions of individual autonomy that had been debated in the political philosophy in the

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seventies and eighties had become mainstream in bioethics and were in certain very demanding conceptions of informed consent,

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were being promoted as ways of securing that individual autonomy.

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But what struck me suddenly was these people are claiming that the position they're taking has Kantian ancestry and authority.

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I knew quite well by then that Kant's conception of autonomy was a conception that had nothing to do with individual autonomy.

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It was a conception of certain principles, was said to be autonomous if they were the sort of principle that everybody could adopt.

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So it was part of his argument for morality. And I think.

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That conflation between autonomy and morality, which we often see in contemporary bioethics and more broadly in contemporary ethics,

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is simply a failure to realise that if you're talking about individual autonomy,

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meaning individual capacities to choose, you haven't yet begun to talk about how those capacities ought to be used.

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You're not yet talking about ethics.

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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.

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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.

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I suspect the deeper problem is that they're using a very large range of different conceptions of individual

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autonomy so that we have very thin conceptions where individual autonomy is a matter of mere choice,

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doesn't matter whether it's reason, choice or unreason choice.

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And then we have a whole range of conceptions where people say, no, no.

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By individual autonomy, I don't mean just any old choice, I mean an autonomous choice.

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And that's something much grander. It is an informed choice or it is a rational choice or reflective choice.

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And that, I think, has led to quite a lot of confusion.

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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,

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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?

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Now we know from empirical studies by sociologists that people don't understand all the stuff to which they ostensibly give consent.

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So there's a sort of pretence, a pretence that what we've got is informed or even supposedly fully informed consent.

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And we don't have that. People are busy. They have different areas of expertise.

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They can't follow it all. They've had to rely heavily on other people's information.

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They may have been feeling terribly ill, confused the rest of it.

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So one has to ask what's informed consent really for why is it got such a prominent part in our culture?

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And I think the answer is it is for the service providers, not the service users.

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It's about laying off liability. It's not really about ensuring that everything's understood, but it is legally effective.

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If you do the operation having got consent, you haven't committed an offence of assault.

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And that's very fundamental for surgeons, for hospitals and for all of us.

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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.

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And or. Neal, thank you very much. I've enjoyed talking about it.

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Thanks a lot. For more information about bioethics bites, go to WW dot practical ethics, dot oecs dot AC Dot UK or iTunes U.