#19 Emily Largent and Govind Persad: Is bioethics ok?

In this episode, we speak with two leading bioethics scholars about the state of bioethics today. Dr. Emily Largent is the Emanuel and Robert Hart Associate Professor of Medical Ethics and Health Policy and the Chief of the Division of Medical Ethics at the University of Pennsylvania Perelman School of Medicine. Dr. Govind Persad is an Associate Professor at the University of Denver Sturm College of Law and our first returning guest on Bio(un)ethical.

With Emily and Govind, we consider critiques of bioethics coming from inside and outside of the field. In light of our recent survey of US academic bioethicists, we discuss who bioethicists are, how they are trained, and how they can better promote ethical decision-making in medicine, science, and public health.

(00:00) Our introduction

(05:16) Interview begins

(09:27) Who counts as a bioethicist?

(20:18) The credentialing problem

(30:43) Critiques from outside bioethics: Why are people mad?

(42:17) Protectionist vs. progress-oriented bioethics

(53:26) The field’s major wins

(57:31) Critiques from inside bioethics: Variable research quality

(1:03:29) Financial barriers to entry

(1:05:18) Lack of demographic and ideological diversity

(1:11:53) Should bioethicists’ views mirror the public’s?

Used or referenced:

• Leah Pierson et al., “Bioethicists Today: Results of the Views in Bioethics Survey”
• Leah Pierson, “Becoming a bioethicist is expensive. That’s a problem”
• Leah Pierson, “We need to evaluate ethics curricula”
• Tom Chivers, “How many lives has bioethics cost?”

Bio(un)ethical is a bioethics podcast written and edited by Leah Pierson and Sophie Gibert, with production support by Audiolift.co. Our music is written by Nina Khoury and performed by Social Skills. We are supported by a grant from Amplify Creative Grants.

Chapters

• 5:16 Interview begins
• 9:27 Who counts as a bioethicist?
• 20:18 The credentialing problem
• 30:43 Critiques from outside bioethics: Why are people mad?
• 42:17 Protectionist vs. progress-oriented bioethics
• 53:26 The field's major wins
• 57:31 Critiques from inside bioethics: Variable research quality
• 1:03:29 Financial barriers to entry
• 1:05:18 Lack of demographic and ideological diversity
• 1:11:53 Should bioethicists' views mirror the public's?

Transcript

Note: Transcripts are automatically generated using Descript and edited using Claude. They likely contain some errors. 

Sophie: Hi, and welcome to Bio(un)ethical, the podcast where we question existing norms in medicine, science, and public health. I'm Sophie Gibert, a Bursoff Fellow in the Philosophy Department at NYU, soon to be an Assistant Professor at the University of Pennsylvania.

Leah: And I'm Leah Pierson, a final year MD/PhD candidate at Harvard Medical School.

Sophie: Is bioethics in crisis? The field has come under increasing scrutiny in recent years, with critics raising fundamental questions about who bioethicists are, how they're trained, and whether they actually improve ethical decision making in medicine and research.

Leah: There have been several critiques, all of which we'll discuss in this episode. First, some have argued that while most ethical and regulatory barriers are well intentioned and have been designed and implemented in good faith, in practice, these regulations often create barriers to scientific and medical progress, imposing invisible but real costs on our ability to develop new treatments or implement reasonable policies. Some critics have correspondingly argued that the field of bioethics has been net harmful.

Sophie: Others point to more structural concerns. The field lacks a unified methodology and clear standards. Bioethics training varies dramatically across institutions. And there are significant financial barriers to entering the profession, with some master's programs costing nearly six figures for a one year degree.

But even as bioethics training programs have proliferated, as we've discussed in other episodes, it's not obvious what would give someone the moral authority to say what research should be permissible, or what care someone should receive. Bioethicists often have this authority, but it's not always clear they have the expertise to justify it.

Leah: In light of these concerns, we recently conducted the first survey of U.S. academic bioethicists, which cast further light on these issues as well as illuminating new ones. We asked 824 bioethicists about their backgrounds and their beliefs, and our results paint a striking picture. 81 percent of bioethicists identify as white, 87 percent describe themselves as politically liberal, and nearly two thirds have a parent with an advanced degree. These demographics raise further questions for a field meant to guide ethical decision making in medicine and research, domains that directly affect the public. When the field lacks diversity of experience, ideology, and socioeconomic status, how well can its guidance serve the broader public?

Sophie: Our survey also found that bioethicists' views often diverge substantially from public opinion on key issues. For instance, bioethicists are much more likely to support abortion rights, but less likely to support compensating organ donors. They also differ from the public on fundamental questions like when personhood begins.

While most Americans believe life begins at conception, over two thirds of bioethicists place the start of personhood at or after viability. While reasonable people can disagree on these issues, the stark differences between bioethicists and the public they serve merit examination.

Are these differences a product of deeper ethical reasoning? The natural result of professional bioethicists possessing expertise that most members of the public lack? Or do they reflect the field's demographic and ideological homogeneity?

Leah: Today we'll be exploring these questions with two leading bioethics scholars. Emily Largent is the Emanuel and Robert Hart Associate Professor of Medical Ethics and Health Policy and the Chief of the Division of Medical Ethics at the University of Pennsylvania Perelman School of Medicine.

Her work focuses on ethical and regulatory issues in clinical research with a special focus on neurodegenerative diseases.

Sophie: Govind Persad is an associate professor at the University of Denver Sturm College of Law, where his research examines the intersection of health law, bioethics, and justice, with a particular focus on issues of resource allocation in healthcare. Govind is also our first returning guest to BioUnethical, so if you enjoy this episode, consider checking out his interview on episode two.

Both Govind and Emily were also co-authors with us on the survey paper we mentioned, which we'll discuss more in the episode. We start our conversation with Govind and Emily talking about the field of bioethics in general, which may be of particular interest to those considering careers in bioethics. We then branch out into the challenges that the field faces, challenges coming from outside the field and coming from within. If you want to skip straight to the critiques of bioethics, feel free to jump ahead.

As always, our episode notes contain timestamps for the episode, and you can access the papers we reference there or at our website, biounethical.com. You can also submit feedback there or email us at biounethical@gmail.com.

Finally, if you enjoy today's episode, please consider leaving us a rating or review or sharing this episode with a friend.

Leah: Hi, Govind and Emily. Welcome to the podcast.

Emily: Hi, it's good to be here.

Govind: Hi, we're excited to be here.

Sophie: One of our aims in this episode is to help people get a better understanding of the field of bioethics. One thing that makes this challenging is that it's hard to define what makes someone a bioethicist. For instance, while it might be reasonable to say the field of professional academic philosophy consists roughly of people with PhDs in philosophy doing research in well-defined branches like epistemology, ethics or metaphysics, it's not clear that there's an analogous thing for bioethics.

Govind: Nonetheless, let's take a stab at defining bioethics. How would I define the field of bioethics or a bioethicist, whichever is easier? Sure, thanks. So, I think it's easier to define the field than to define who is a bioethicist. And I would actually start with the ethics part, rather than the bio part. So, I would say bioethics is going to be about questions of right and wrong or what individuals should do or what they're permitted, or required or prohibited from doing, that's the ethics part.

That's different from questions we might ask that are scientific questions that describe how the world is.

Govind: To draw this line that people quibble about how to draw it precisely. It's about questions of value rather than questions of descriptive fact. So that's why it's a type of ethics. Now the bio part, the way I would think about it is, these are questions of right and wrong or permission prohibition that arise in biology.

In the life sciences, in the domain of inquiry related to living organisms. People sometimes use the term biomedical ethics, which I think also is useful in that that focuses especially on questions of health and often human health.

But I would actually tend to think of bioethics as opposed to biomedical ethics as also encompassing things like issues of right and wrong that arise with respect to animals or with respect to plants. That's helpful. I hadn't thought about it in exactly those terms, but it helps explain why things like environmental ethics or animal ethics get included under the heading of bioethics.

One worry you might have about the ethics part of that definition would be that it excludes empirical bioethics. How would you square the practice of empirical bioethics with that definition?

Sophie: I do agree there's a tension there. What I would say is that what people call empirical bioethics is often trying to get at questions of right and wrong or value, but trying to get at it using empirical methodology.

Govind: So for instance, if one were to survey a group of individuals, just sort of take a poll of their views on some question of right and wrong, not try to make an argument as to what is right and what is wrong, which is often a lot of what we do and what you might call conceptual bioethics or philosophical bioethics—

That might be a kind of empirical bioethics. I would say it's still connected to ethics because it's about right and wrong, but it's not using a conceptual method or offering its own argument. There are other things that get called empirical bioethics that I struggle a little bit more with.

Sophie: For instance, there's going to be a broad range of things that have to do with implementing recommendations, and there are some aspects of implementation that are very practical, are certainly about sort of making it possible to do the right thing, but to the extent that really they are important.

Govind: Sort of entirely in a technical domain. So say that you created, for instance, a—you know, there's this controversy in bioethics about the permissibility of an organ transplantation procedure called normothermic regional perfusion. And if you developed as, say, a biologist or a transplant surgeon, some procedure that made it easier to do some part of that or that obviated some ethical problem that would otherwise arise. That's a very ethically valuable innovation. But I'm not sure that I would say that it's a kind of bioethics.

It's a very important thing to do, maybe more important than a lot of bioethics, but I'm not sure I would say that's bioethics.

Emily: Okay, so we've spoken now about the field of bioethics, but you mentioned that it's harder to define a bioethicist. So let's just get into some of the difficulties that arise with doing that.

I think one of the clearest things is that there's just no single credential that makes somebody a bioethicist, right? If somebody says they're a lawyer, we know they went to law school, we know that they have a JD, we know that they likely passed the bar exam. And when I was, you know, early on talking to mentors and I said, "Hey, I would love to be a bioethicist. That's what I want to do with my career." That was one of the things I was told is that nobody knows what a bioethicist is, but they know what a lawyer is. And that's probably why I went to law school, because law gives tools that are useful in bioethics.

And when I tell somebody, "Hey, I have legal training," they understand what that is in a way that they maybe don't understand when I say that I'm a bioethicist. So, I think in some ways it's great that there's no gatekeeping as to who is a bioethicist. I think that it helps that it's a multidisciplinary field and we have perspectives from philosophy and theology, from law, from policy, lots of different backgrounds coming together.

But it also raises some challenges I'm sure we'll talk about around things like judging the quality of work or coming up with a set of methods that would define bioethics.

Govind: Yeah, the only thing I would add is I think, because it's a discipline oriented around questions of value, one of the things that's nice but also challenging is that I think questions of value are the sort of topic about which individuals can have opinions and insight without necessarily having the type of documented expertise that would be needed for, say, some very technical questions in tax law.

And I think that the challenge is that it doesn't necessarily seem like everybody who has an opinion about a question of right and wrong in the life sciences is going to, by virtue of that, count as a bioethicist. So, otherwise, all patients and all physicians, for instance, would probably end up counting as bioethicists.

Sophie: And so I think that makes the line-drawing problem a little bit trickier than—obviously, it's easier to identify who's a physician. We hadn't planned to talk about this, but I do feel like it's relevant here.

One place that we obviously had to draw some lines with respect to who counts as a bioethicist was in coming up with a population to survey for our project. And that was actually one place in which we got pushback from commentators who suggested that maybe our sample was skewed toward academic bioethicists.

Our method was to look at presenters from a large bioethics conference and also people affiliated with bioethics programs. And we were forthcoming about the fact that we were surveying academic bioethicists primarily. One suggestion I think someone made in the commentaries was something like going to LinkedIn and typing in "bioethicist" as an alternative sampling strategy. So maybe we could just speak to our rationale for identifying bioethicists.

Leah: Wait, I need to just interject. I'm sorry. I have to just say something quickly, which is that I have tried to do a LinkedIn-based population survey, and it is just impossible. You cannot do that. It is not a practical suggestion because people's contact information is not on LinkedIn, and people don't respond to LinkedIn messages.

So, I think my reaction is like, whenever you are doing a survey, you need to be pragmatic about the trade-offs that are involved in defining the set of people who you're trying to sample. And I think a really critical trade-off is, the broader you go, the more loosely you define who a bioethicist is, the worse quality of contact information you have for them, the fewer people are going to respond.

And I think one of the real strengths of our survey is that nearly half of the people we sent it to responded. And I think this is probably the most common type of response bias that we see in surveys is non-response bias, and so I mean, yes, I think in an ideal world, it would be amazing to be able to get a 100 percent response rate from everybody who self-identifies as a bioethicist.

I think practically speaking, there are real unavoidable trade-offs here.

Govind: Yeah, the thing I would say actually about self-identification and bioethics that I think is tricky is that—I wish I'd said this earlier—what we might be trying to sort of get at is what makes somebody a professional bioethicist.

And often we think, to be a professional, being a professional is not just a matter of self-identification. Self-identification might be necessary, but it's probably not going to be sufficient.

Almost certainly it's not going to be sufficient to count as a professional bioethicist. And then because there's not the same kind of universally recognized single credential, or at least small subset of credentials as there is for—and even for lawyers, right?

You could have JDs, you could have lawyers from other countries who have LLBs. For physicians, you could have MDs, you could have DOs. But I think a particular challenge for defining bioethicists even if—and I think that there are really good reasons in a survey to sort of limit it to the set of individuals that we would say are professional bioethicists, as opposed to anybody who, you know, puts the word bioethics in their LinkedIn—

I think there still remains this sort of greater challenge, both with people who might plausibly be identified as professional bioethicists or might self-identify but really don't meet those criteria. And then also the people who might really be talking about questions of value and ethics and might be, say, philosophers or lawyers, but they might not themselves identify as a bioethicist, often for the kinds of reasons that Emily was suggesting, which is that they maybe are hesitant to think that it's a field that they would want to identify their work with.

Leah: Okay, so as we've alluded to already, there are several things that seem to make bioethics importantly different from other academic disciplines, like say philosophy or economics. First, it's a lot younger. The word bioethics was coined less than a century ago. Second, as we've been talking about, there's no unique methodology attached to bioethics in the way that there is for statistics say, there's also no core area of inquiry since bioethical issues arise in medicine, philosophy, law, and the sciences, among other disciplines.

And, in addition to this, while there are a lot of bioethicists who are academic researchers, many bioethicists aren't, instead they serve on IRBs or do clinical ethics consultation or teach ethics to medical students or do something else. So given the breadth of the things that bioethicists work on, the methods they use, the types of work they do, does it make sense to have a unifying discipline called bioethics?

And why? Emily, let's start with you.

Emily: So I think it does make sense to have that as an umbrella term that we use. I think Govind set us up with a very nice definition at the start that this is really about questions of value or what people ought to do in the fields of biosciences. What I think of as an analogy is that oftentimes we can think of the practice of medicine, but within medicine people work in a lot of different settings and they have many different specializations.

So, within bioethics, we have people who would identify as doing clinical ethics work. We have people who would say, I do research ethics, right? They study the ethics of human subjects research. People who do neuroethics, people who focus on reproductive ethics, environmental ethics, food ethics, public health ethics.

So I think that if we think of bioethics as an umbrella term, that's useful. But I think it's really generally not enough to understand what somebody does. You want to dive a little bit deeper.

Understanding if somebody is primarily using legal methods, philosophical methods, empirical methods, that's an important sort of second piece of helping people situate themselves within the field.

Leah: Govind, what are your thoughts?

Govind: My thoughts, I think, are very similar. The discipline I was thinking of was actually public health. So I used to teach in a school of health before where I teach now in a law school, and in a school of public health you'll have people who are trained as economists, sociologists, physicians, as nurses, as epidemiologists.

A variety of forms of training, but share a common interest in the same topic. In some ways, I think, the challenge with bioethics is that it in some ways blurs the line between a field or a set of highly similar methods of inquiry, which is the kind of thing you might have in maybe a field like sociology or psychology, although even there, right, think of psychology, you have quite a bit of difference between, say, people who are doing fMRI research and Freudian psychologists, but I think bioethics is like that, but maybe even to a greater degree.

Yeah, thanks. That's helpful. I think one question that raises is why is it useful to have this umbrella term? Cause for example, in medicine we can think, well, you know, it might be useful because all doctors have the same four years of medical school training, even though they go on to subsequently differentiate.

Leah: But you would never have a conference that was just like a "medicine conference." The analogy to public health is maybe a little different in that I actually do think that public health practitioners have more varied training. A public health department might have economists, it might have epidemiologists and so on.

But even still, I do think there probably is some core assumed knowledge, or maybe the problems that people are working on are sort of more tightly defined. So what is the value out of having this umbrella concept of bioethics?

Govind: I mean, similar to public health, I guess I would say, I think a couple advantages of the umbrella are that if you have plenary conferences or journals or discussions, you can have people who have different methodological approaches to the same topic be more easily in conversation with each other. So you could think of it as sort of akin to a kind of hashtag.

The other advantage might be a kind of branding advantage, which is that it makes it seem, and maybe makes it without the scene, more of a recognized and serious profession. So, it allows people to say that they are, in public health, a public health professional, in a way that you can't really be a professional in, just a hashtag. The other analogy, actually, that is coming to mind for me in terms of a discipline that's kind of similar again would be business schools are a little bit like this. I don't know, Sophie, if you have thoughts on this in that, they similarly will contain people whose disciplinary training and approach vary quite a bit.

Some come in with a lot of experiences, people who are practitioners, some come in—and again as economists, some are psychologists, some are philosophers. And, again, it's a little challenging to figure out what exactly the core is and why we would need to, say, have a business school as opposed to having, you know, people who work specifically on economics of business or psychology of business in those schools in an academic setting or similarly in professional or non-governmental settings.

But I assume some of the same advantages would apply to having a single bioethics discipline as well as might be true for public health or the example of business.

Sophie: So in our survey, we found that bioethicists have different educational backgrounds. That 63 percent have a PhD, 25 percent have a medical or nursing degree, 12 percent have a legal degree, and 38 percent have a master's. This could be seen as a feature of bioethics, in that people are bringing different expertise to the table.

Or it could be seen as a bug, in that it may make it impossible to establish some baseline knowledge or ability that all bioethicists should have. We've been talking about this credentialing problem. Emily, let's start with you. How big of a problem do you think this is?

Emily: I actually think it's a pretty big problem. You know, we've given examples before about law or medicine, and if somebody has gone to medical school or they've gone to law school, we can assume that there is some core set of knowledge that they should share. You know, you gave the example of tax law. I never took tax law when I was in law school, but you know, we all share that we've taken certain constitutional law classes and thought about regulation and the administrative state, for example. So in bioethics, it is, it's very hard. I think it's a quality control issue because we can't assume that people have a core area of knowledge.

And we also really don't have any way of assessing their skills and how good they are, but they do.

Govind: Yeah, I agree. It's more of a challenge in bioethics. I would be interested to know empirically actually, whether there is say in public health or in other kind of cross-disciplinary areas, more frequently a common shared core than there is in bioethics. So whether, for instance, what proportion of people who work in some capacity in a school of public health or a public health department have at least an MPH or some public health degree. I actually didn't at the time I taught in a public health school. So maybe I was part of the problem in that respect for that discipline. But I think, a big challenge, as Emily is saying, is just, currently, at least, and at least within the US, the lack of there being any defined core means that somebody could be seen as a bioethics professional and not have any at all of the same training as some other individual has, and maybe not have any formal training at all that you might say is training in that discipline, and that is very different from lawyers, similarly in medicine, there's going to be more specialization, but there are certain basic things with which every physician is going to have some familiarity and that's just not true I think in bioethics.

I think it is problematic.

Emily: I do think one way we get around this is that we then have job-specific requirements. So to be a professor of bioethics, they might require that you have a PhD or that you have an MD. Similarly, if you're going to be a clinical ethics consultant, people might want to make sure that you have completed a master's in bioethics and MBE. So there are ways that we can do it with jobs. I think where this becomes even more of a challenge is sort of in places like community hospitals, where maybe there's somebody who's interested in ethics and they become the ethics consultant and the person that people go to when they have questions.

But to Govind's point, they might not have any training. It's a very sincere interest. They might do some reading on the side, but that doesn't mean that they truly have ethics training. And so I think in places we can use job criteria or other things to address some of the challenges, but there are places where there's less control.

Leah: In light of some of the challenges we've been discussing, there have been efforts in the past few decades to try to come up with licensing or credentialing programs for bioethicists. These include, for instance, the development of the Healthcare Ethics Consultation Certification Program and the emergence of many Masters of Bioethics programs.

Govind, to what extent do you think these programs have addressed the challenges we've been discussing?

Govind: So, I think, my verdict would be mixed, there are both advantages and disadvantages of having these credentialing programs, and I think part of the challenge is that bioethicists are going to be playing a variety of different roles.

And so for instance, the healthcare ethics consultation credentials that I'm familiar with might be relevant to certain kinds of clinical ethics consultation that one might do in a medical care delivery setting, but would not, I think, be appropriate preparation for providing ethical advice on, say, ethics of clinical research with human subjects.

And it might not prepare you for that at all. I don't think it would prepare you necessarily for producing high quality scholarship in bioethics and there might be people who might produce valuable scholarly research in bioethics who I don't think would need or benefit from that type of credentialing.

So because of these different roles, I don't think it's going to make sense to have one credential. In terms of a common core of knowledge, I could say I think we'll see more of a case for that. I think there's a sort of optimistic vision of Masters of Bioethics programs where they could serve as kind of equivalent to that core that you see in other professional disciplines like the medical sciences or like law. I think there are two challenges. One is that there are individuals who have other forms of fairly deep disciplinary training that I don't think you would then want them to additionally have to have a master's in bioethics. So here I speak in a conflicted way because I have this degree, but it would be somewhat surprising to me if someone said, well, you have a PhD in philosophy with a specialization in ethics and applied ethics, but you don't have a master's of bioethics, so it's not really clear that you're qualified to speak about bioethical questions.

And the other is that, maybe this is a question we'll get to later, there are financial and other burdens associated with a master's in bioethics program that I'm not sure would be appropriate to put on all individuals who would appropriately be credentialed as bioethicists. I don't know if my mind would change about that second thing if there were some sort of better agreed upon core and the where there is for law. Actually, maybe I can ask you all. I don't know. We have your thoughts about this. Like for medicine, there has to be some common language that not only physicians but other health professionals who do not have as expensive a form of training like physician assistants are still all able to have a common core to be able to talk to one another about matters of patient care.

Maybe this is too optimistic of me to think that—I don't know whether it's possible to generate something like that that is reasonably and affordably accessible and can create a kind of common language for discussion among bioethicists without necessarily creating the financial burdens of, say, everybody has to have a master's of bioethics to be a bioethicist.

Leah: Yeah, I mean, I think the analogy to physician's assistants is interesting because I take it that the standard model in medicine had historically been that all doctors are going to learn basic things about renal physiology, oncology, neurology, whatever, like everyone's going to graduate from medical school having done like six, at least six weeks, four weeks, whatever focused study in this thing. And the model of physician assistants and, and, you know, to be clear, I really don't know much about PA education, but I do know about sort of the environments that PAs work in. Tends to be like, we're going to have you be an oncology PA, or we're going to have you be a breast surgery PA or psychiatry PA.

And they will have really exceptional knowledge about that specific thing, but they are going to have less depth across many of the other things that doctors would have. And so, to some extent, the model of a PA is kind of eroding this standard approach to medicine of like everybody's going to kind of have some relatively deep level of understanding about all aspects of medicine.

And I think that is one of the things that is controversial about the emergence of this model.

Sophie: Yeah, that's interesting. I did just want to add in response to Govind.

I do think it matters a lot where you get your degree in philosophy or whatever it may be as far as how well that prepares you to do high quality research in bioethics. I mean, I can only speak to my own experience, but there's a lot of variation between programs in terms of whether they have faculty who are actually doing applied ethics work.

That wasn't something I was really looking for when I went to my PhD program, I was looking for people doing more abstract work in ethics, meta-ethics. I knew at the time that it would be really important to co-author with bioethicists, lean on the training I got at NIH in order to be able to do bioethics research.

So just, you know, not every PhD in philosophy focused on ethics is going to give you that skill set in particular, and so you might need something else in addition.

Sophie: But it wouldn't necessarily be an MBE. You might do a postdoctoral fellowship in bioethics, or other sorts of kind of apprenticeship models. So I think the degree is still not perhaps the thing that we want to have as the standard.

Leah: Yeah, Emily, you haven't gotten to weigh in explicitly on this question yet, but to what extent do you think that the credentialing programs we've talked about have addressed the challenges that we've been discussing?

Emily: So I teach in a Master of Bioethics program and I see a lot of really great students come through that program. I know that for many of them that's not actually their terminal degree. They're often using that to say, either complement another degree that they're already getting, so maybe they're graduating from law school and they intend to practice as lawyers, but they're interested in healthcare law, or they'd like to do things around food and drug regulation and they feel like there's a nice complementarity there.

We also see that we have some medical students and dental students who feel like they'd like to be abreast of these issues and so they're doing that as part of their degree program. The other model I see is that people are using an MBE almost daily to burnish their credentials to then apply to medical school.

They see it as a stepping stone. And I think that it's great that we're seeding bioethical knowledge across these fields. I think that the more people who have been exposed to the idea of these bioethical issues, they have some framework for thinking about the issues. That's really great. But I don't think that by itself the MBE can be the degree for the field. I think that for many people, you know, say if you're working in an IRB, it's great, but if you would like to do scholarship, I do think that there's going to be something beyond an MBE that people need. So it gets us part of the way to have an MBE program.

And I think that similarly for some areas, that having your healthcare ethics consultant credential is useful, but, you know, we do need to think more broadly given all the ways people operate in the field.

Sophie: To what extent do you worry that credentialing programs in bioethics might be counterproductive? In the sense that because it's such a difficult thing to credential well, meaning that we have a hard time figuring out exactly what you're supposed to put in a credentialing program,

Govind: We might risk conferring legitimacy on people whose training hasn't actually conferred expertise. I mean, I guess I'd say, I agree with that. The status quo, however, is that people get called bioethicists without any evidence of any training, but sometimes just because the reporter interviewing them or the community hospital that needs somebody has reason to want to call them that.

So I agree with the problem you're identifying, Sophie. I think the status quo is also. So I think the question is basically whether introducing credentialing helps with that problem but also maybe keeps us from getting to the very most optimal answer in terms of figuring out who has expertise. It's a kind of trade-off.

Leah: So we will now move to section two, Critiques from Outside of Bioethics. It was interesting when we posted the Twitter thread of our survey results a lot of people got mad. And what this indicated to me is that a lot of people outside the bioethics community don't hold bioethics or bioethicists in high regard.

To illustrate this, I will read some of the representative quote tweets from our tweet thread that included the results of our survey of bioethicists. One tweet with nearly 1,000 likes says, quote, "Reminder that the entire point of bioethics is to claim as evil what future generations will consider normal," end quote.

A tweet with a hundred likes says, quote, "I'm sticking with my adage that bioethics is to ethics as astrology is to astronomy," end quote. I could keep going. I don't think I need to, but these aren't cherry-picked examples, though obviously the group of people who write angry quote tweets about bioethics surveys are probably not representative of the general population.

Still, I doubt we would be seeing this outpouring of anger if you posted a survey of economists views on economic issues or philosophers views on philosophical issues. So we're curious to hear your thoughts on why a small but vocal minority of people are so frustrated with bioethicists. Govind, let's start with you.

Govind: So this is actually a topic that I would like to see more empirical investigation of, in that I'm actually not totally convinced, especially about the case of economists, who often people get very mad at. So I see, maybe this is more of a thing you would see on Twitter, but people will call economists "ghouls" when they say things like, you know, maybe there are trade-offs if we just keep raising the minimum wage or if we had a hundred percent tax on rich people, or if they're like, maybe there's an importance of having health insurance, so to deal with moral hazard and people would, I think people would be very mad.

So, I would be interested to know whether, when weighing in on topics that are controversial, bioethicists arouse more ire from the public than other professions when they weigh in on topics that are similarly controversial. I think what might get bioethicists into hot water more often than perhaps economists or philosophers is that they may more often weigh in on topics that are of importance to a lot of people and where it might seem a lot of people like you can have a relevant opinion on a topic that's not highly technical.

You know, if bioethicists end up having, for instance, opinions on some high profile case of whether some families should be allowed to remove a loved one from life support or if bioethicists are involved in deciding, you know, what public health measures should be taken in a flu outbreak.

That's the kind of thing that I can imagine there being a lot more public opinion having about than also important questions, but that might seem more technical, like, what exactly should the, I don't know, optimal rate be for the 30-year treasury security. And so that might be one reason why bioethicists may tend to get into hot water more often.

So yeah, empirically, I would actually love to do or see someone do a survey of, you know, is it the questions that are upsetting folks?

Or is it the methodology being used by bioethicists in answering those questions? That's just a preliminary thought.

Leah: Emily, what do you think?

Emily: I think my thoughts really echo Govind's and it's that we all live it. We all live bioethics questions, whether we're a patient ourselves or, you know, COVID's a great example, we all lived through a pandemic and suddenly bioethical issues affected all of our lives, decisions to reopen schools or decisions about who should be first to get a vaccine or how we should allocate ventilators.

I mean, these are all questions that suddenly became very prominent in everybody's minds and directly affected them. And so when somebody comes out with a strong opinion, you know, I think that the bioethics opinions can then be in conflict with what people have as their intuitive sense of right and wrong, as what their own values tell them, and so I would suspect that there is probably more frustration with bioethics, particularly public-facing bioethics, where you're really trying to engage with people and with policymakers, just because people are going to have opinions about things that directly touch their lives and few things are more personal than our health and well-being, which is an area that bioethics often covers.

Sophie: Yeah, that all sounds right to me. I mean, I think one thing that also seems like it might be going on is that because the field is not that well defined, people understandably conflate bioethicist views with what are standard practices around things that have bioethical valence, so like, whether you can altruistically donate an organ and like how hard it is to do that, or whether you can participate in a challenge trial.

Leah: And people may see policies around those things that they don't like or that they disagree with and draw a causal link between bioethicists hold a view on this that matches that policy, and I don't like that policy, thus bioethicists are to blame, and I'm mad. You know, if bioethicists endorse bad policies, then that might be a separate issue.

But I think that there's often an assumption that bioethicists have more responsibility for practices than they in fact do.

Govind: Can I actually say something about this with the economists? Because I thought of a couple of examples where and these are actually, in my understanding, pretty technical questions, but also ones that people immediately have reactions to, where they do sometimes tend to get mad at economists.

So, I think economists in general have been against the home mortgage interest deduction in the United States, that you can deduct your interest if you have a mortgage on your taxes. And economists have consistently lost that battle when the economists are like, yeah, we should get rid of this deduction.

The public is like, we hate this. We like to have lower taxes. We like to be able to buy houses that are nicer and we think this policy helps us do that. We don't really care what economists think. You see similar phenomenon where economists are saying that we should have carbon taxes.

Economists often tend to like carbon taxes as a way of addressing climate change. Both people on the left and the right often get mad at economists and say that they don't like that. And there's a famous battle in health insurance where economists overwhelmingly thought and I think wrote a letter saying that people should be taxed on the economic value of their health insurance.

Economists love this. They think it would be a very sensible policy, just like you're taxed on your wages. You shouldn't have a distortion by having a different or non-existent tax on your health insurance. Everybody else seems to not like this policy and again, people with different political valences sort of got together and wanted to get rid of this tax on health insurance.

Either because they didn't like taxes in general or thought that health insurance is the kind of thing that we shouldn't tax. And so for all the sort of Nobel Prize economists saying, this tax is distortionary and encourages employers to pay people in the form of health insurance instead of wages that they could use more productively to do things that might actually improve their health, like be able to afford a more walkable commute or something.

People just didn't care what the expert economists had to say about this or even if they cared, they just ignored them. So I wonder if it has to do with not only is there expertise, but is it a question where people immediately have a reaction?

To what extent do you think that the frustration people have with bioethics is well informed? In other words, if people outside of bioethics attended major bioethics conferences or read top bioethics journals regularly or had long conversations with a bunch of bioethicists, do you think that their feelings would become more positive or more negative?

Govind: I think we should study this empirically. Actually, I think we should do a survey where we get—I don't know, Emily, if you think this would pass IRB approval, I hope that it would—you recruited some people, I don't know what their risk of harm and so on would be and have them go to a bioethics conference and maybe do a pre-survey of what their views are and questions their views of bioethicists as well, and see if it changes.

I think we should totally do this.

Leah: Sounds awesome.

Emily: I mean, I've definitely seen in other areas there's been interest in bringing patients into academic conferences so they can be exposed to cutting edge research and then seeing how they feel at the end of the conference. So I think that there would be good reason to try that in bioethics. I think that for all the things we've discussed, the quality of bioethics work can be quite uneven.

I think this is true in journals. I think this is true at conferences. I don't feel confident that somebody attending a conference, depending on which sessions they went to, would necessarily feel better about bioethics at the end. I think that some of it too is that you know, we talked in ethics about people having reasonable disagreements since a lot of these are questions of values and the weight that people put on different things.

And so some of the examples that really hit the mainstream, like when Peter Singer promotes infanticide, there are articles in mainstream newspapers and magazines about how dangerous Peter Singer is. And can you believe this? And when those are the examples that become the most salient when people see that kind of scholarship in the popular media, I don't think that's reflective of where most bioethicists stand on these issues, but I certainly think that it diminishes public confidence in bioethics, and I think that there's probably part of a larger trend right and questioning expertise and other things that are happening that I'm not sure that showing people sort of where we generate our expertise is going to make people feel better about bioethics just because of skepticism about expertise generally.

Leah: Yeah, that seems right to me. I mean, as we're talking about this, like one thing I'm thinking about is that a lot of the people who are like quote tweeting the survey were people who have thought really deeply about some of these issues and who have relatively informed—you know, maybe they're not views that bioethicists overall would agree with, but they are like informed and have thought deeply about these issues.

But they don't have the credential that would allow themselves to be called a bioethicist. And so then when someone else has a credential and they have the legitimacy of having the status of bioethicist conferred upon them to the extent that confers legitimacy, they probably feel frustrated because they're like, this person has a bad take.

And they get to say they have expertise, but like, I actually have expertise and I have the correct take.

Sophie: Leah, do you have in mind people in the rationalist community or the effective altruism community?

Leah: Yes.

I mean, I've just, I remember that there's this like podcast that Maddy Glacius did with Julia Galef on Rationally Speaking where they were both critical of bioethicists because they were like, what entitles them to have views on these issues. I forget exactly what they were talking about.

It might have been kidney donation. I'm not sure. But I would think of both of those people as people who have thought really seriously about a lot of issues that bioethicists are engaged in and like, they definitely clear the bar that a lot of bioethicists are clearing.

Emily: I would point, too, to the patient advocacy community as one of these groups that gets very frustrated. I think that there have been, you know, understandably and appropriately a lot of pushes to involve the patient voice more fully. Say in drug development and drug approval processes. There are questions, I think, about how to do that correctly or right.

But that there's become an expectation of patient engagement, and I think oftentimes they would claim that they have particular insight into what it is to be a patient that bioethicists don't bring to the table, and they can feel like, as a matter of, like, epistemic justice, that their voice is drowned out and that people should be listening to them and giving credence to what they're saying about how they're affected by some of these decisions.

Leah: Yeah. Yeah, so this is like somewhat of a transition, but in a lot of ways, the field of bioethics grew out of a history of atrocities. Nazi's experiments on imprisoned people in concentration camps, the U.S. Public Health Service's study of syphilis in Tuskegee, among many, many other examples of unethical research.

And given this background, it's easy to understand why the field has a protectionist orientation. And this orientation seems to persist in modern times, as evidenced by the fact that in our survey, 71 percent of respondents said that they feel that IRB protections, as they exist now, are appropriate. And 15 percent responded that they think they're insufficiently protective, with only 14 percent responding that they think that IRB protections and the status quo are too protective.

Govind, were you surprised by these results?

Govind: Not really. Here's what I would say actually, and I think this connects back to what we were talking about before is, I think, of the people that were surveyed in the survey, a lot of these folks are working as bioethics professionals, within the IRB system. And I think often are not going to think the status quo is a disaster.

I think the way I want to connect it back to what we were saying before is, IRBs are one area different from a lot of these other topics where bioethicists may not only have opinions, but may have a kind of authority. They may have authority to say, can you do a study or not? And I think where some people may get frustrated, certainly with say IRBs, is if they don't perceive that authority as being legitimate.

If they think that bioethicists—and of course, not everybody on IRBs are bioethicists. There may be some conflation between IRBs and bioethicists. But whether sort of bioethics promoted rules or bioethicists themselves are asserting authority over things they don't have the proper basis for authority in, and are doing so in ways that cause harm or that prevent benefit from being realized.

And I think, you know, frankly, in having sat in an IRB, I can see why there might be times when people might feel like IRBs are exercising authority to adopt rules that might not be well justified.

Leah: Yeah. Emily, what do you think?

Emily: When I think about research ethics in particular, I think that we have a scandal and reform dynamic where something bad happens and then we put protections into place, and it tends to really be a one-way ratchet, right? We have more and more and more protections piled on, and so I think that there are places where we have been overly protectionist, but where I think it's difficult is that it's something like institutional review board quality is very hard to assess because we don't know the counterfactual.

If we loosen things up, would we see more harm to participants? Would we see more injuries or poor quality science? And so, I actually think that it's hard to say definitively that it's too protectionist. I think there are places where it does have that tendency. I've argued that in my own work, for example, that we're way too cautious about paying people to participate in research because people sort of misunderstood some of the concerns related to the effects of payment on people's thinking.

But overall, I think it's actually very hard to gauge whether it's too protectionist.

Sophie: Even if we grant that U.S. practices in medicine and research are often quite protectionist, it's not clear that bioethicists are to blame for this situation. For instance, a lot of the red tape might derive from concerns about malpractice suits and the general culture of litigiousness in the U.S. Emily, let's start with you. To what extent do you think bioethicists deserve blame for the areas where there do seem to be excessively protectionist practices around medicine and research in the U.S.?

Emily: Well, sometimes when I give talks, I feel like the ethics talk often comes at the end of a panel, right? You have people who talk about the science and people who talk about where things are going in the field, and then the ethicist comes in at the end. And I'll sometimes joke that I'm just a professional killjoy.

I come at the end and I'm like, well, what she said, there's a lot of great stuff there. But we have to think about all of these other questions that are being raised by the work that you're doing. And so I do think that there's sometimes, you know, people talk about the ethics police, or they sort of groan when the ethicist stands up because they perceive ethicists as really getting in the way of doing things that people want.

But I think both that ethicists can be an important break, right? We, it's great if we can do something, but it's important to ask, should we do something? And I also think that we have to realize that many times bioethicists, we don't actually have that much direct control over what's happening.

Recommendations are made and then they're put into place through policies. There are mediators in between, whether it's institutional policy or federal regulations that govern human subjects research. And so while they're ethically informed, I think it gives ethicists far too much credit to say that they have, you know, single-handedly put into place all of these protectionist policies.

Govind: Yeah, I think I would want to know empirically, you know, what are areas in which bioethicists are exerting actual authority either directly or indirectly? And I think, you know, around things like research ethics rules, there might well be genuine authority exerted by bioethicists.

I think, and you know, you all can speak to this better than I, and Leah certainly. It's not clear to me that protectionism in medical practice or defensive medicine, that much if any of that is attributable to the conduct of bioethicists.

The other thing I would say about protectionism is that one thing I would like to see more of sometimes is, there's a bioethicist whose work I like a lot who, I think in her bio somewhere says, sometimes it's unethical not to do a study, right? So the question is, I think this is Michelle Meyer, who's the bioethicist at Geisinger.

And the idea is that as Emily says, it's often, here's this new technology or innovation, then you put the ethicist, you know, last. You don't often have a panel about the status quo where somebody points out what was ethically problematic about the status quo in part because there's not a social structure of like what are the ethical and social implications of the status quo of like not having research in this area. And so I would I think often ethics would counsel in favor of for instance doing a study of a variety of different status quo practices say in medicine that lack obvious justification and there might be one that's generally inferior to others, but it hasn't been rigorously studied.

So I think there are areas where actually, ethics might be seen as sort of calling for innovation as opposed to stifling innovation. And I feel like actually I've seen that somewhat more in other areas of bioethics, like in maybe an environmental or other context where you'll see people saying, you know, look at this stuff going on in animal agriculture.

It's really problematic. We should look for a different way. We think the status quo in animal agriculture is not okay. You know, the river is turning into a dead zone full of algae because of this current agricultural practice. And so I think the takeaway would be, I would be really interested in sort of ways that ethics might be more more critical of the status quo and more committed to sort of promoting innovation by way of research and improving on that, as opposed to sort of being brought in to be as Emily is saying, saying, "Oh, well, this has problematic aspects about only new deviations from the status quo."

Leah: Yeah, no, that sounds totally right to me. And I'm just thinking of like a label for this, we might call it like progress-oriented bioethics, sort of like, instead of focusing on like, okay, what could we nitpick with potential solutions people are proposing instead of saying, we have this problem we need to solve, what are the most practical ways that we can solve it?

And of those potential solutions, which one is the best? I'm wondering, like, how do we actually make that happen?

Govind: I mean, I have an answer with respect to funding, which is that the way that a lot of funding works—and this is not, I think, unique to bioethics—it's often funding for innovation. So a lot of bioethics is getting funded through, for instance, what are called these ethical, legal and social implications programs for say genomics or neuroscience.

And I think these panels often tend to have exactly the kind of structure that Emily is describing. And that's in part because policymakers and maybe the public are interested in funding new things. Whereas Leah and I were recently corresponding about medical errors and, like, when patients are discharged from hospitals and that they don't, they're not told when they're going to be discharged and there's not, like, a big push for funding on the ethics of, certainly that second topic and probably much less for medical errors than there is for, you know, genomics or the brain initiative or something.

So I think part of this is that we tend to want to fund the shiny new stuff as opposed to funding things just to sort of research ways in which the status quo might be bad.

Emily: I think there might also be a little bit of a publication bias that happens there. It's one thing to write about a novel or emerging issue. But there's some enduring issues that really do continue to deserve scholarship, but they can be harder to publish on or to convince people that there are real issues because when the practice is so ingrained, people are less open either to questioning it or they feel a little bit more pessimistic that anything can change.

And that's an issue at the journal editor level, right? It's like, what are people willing to accept and publish?

Sophie: It might also just be harder to say something new and interesting about a practice that everyone sort of already accepts is bad or at least maybe all bioethicists already accept as bad in various ways. I mean, it probably just takes a lot more on the empirical side to do that,

Because, yeah, we can sit and conceptually point out the problems with factory farming or something like that. But to actually do useful research in that area, you would need to be pointing to ways that we could get out of that situation and evaluate them ethically, but to do the first part of that you need a lot of training that maybe a lot of bioethicists don't have.

Emily: You know, I agree about the empirical research point, but I think in many of those cases you have entrenched stakeholders who are invested in the status quo. So I recently went and I gave a talk to a group of surgeons and the thesis of my talk was the communication between surgeons and patients is incredibly poor.

That that was my thesis. I felt like I had it backed up with both empirical evidence and also with anecdote, and personal experience, and at the end, the reception that I had was one of the angriest, and I think it's because the people in the room are professionals.

They pride themselves on doing a good job. They measure their outcomes in terms of the success of the surgery, and they were not very receptive to having their soft skills, you know, or how they talked about things criticized.

Leah: Right. No, that makes sense. I think there's like a related thing which is people can say, there's this problem in the status quo, and here's what I think is the solution to it, but oftentimes the solution doesn't fully understand the shape of the problem. And so then when people who are, like, sort of participating in the status quo and have, like, really first hand understanding of the problem, then they get frustrated when someone who's, like, a relative outsider is telling them an impractical solution or something like that.

Govind: Not that I'm saying that's what you were doing in your talk, but I think that that is a thing that happens. So I mean, we've been critiquing bioethics, but we are kind of curious if you guys have thoughts on what are some big wins that we can credit bioethics with that would not have occurred, but for the existence of the field.

So let me say something about the different domains. In scholarship, Sophie will correct me if I'm wrong, but I think the probably the most widely assigned article in like philosophy undergraduate classes, is an article in bioethics about the ethics of abortion.

This is probably the article that, like, if you're a philosophy major, you would have read most often. So I think in terms of scholarship, it's easy for me to say that this is an article that probably wouldn't have existed if people hadn't been thinking about bioethical questions. It's a little bit of a puzzle because I don't think the author of that article, Judy Thompson necessarily would have identified herself as a bioethicist, Sophie I think probably has met her and might be able to say whether she identified that way.

Her work certainly was very influential in bioethics. For things like the wins from consultation or from research ethics or from policy, I think it's very, very hard to say. And I'd be very interested in Emily's thoughts because it's hard to know the counterfactual. It's hard to know, say, what the rules for ethical review of clinical research or the rules around organ allocation or around organ procurement would have looked like absent a field of bioethics.

I think that's really, really difficult to know, and in some ways it's hard for me to envision having those rules without having some kind of field of bioethics, the question to me is sort of how the field would look as opposed to whether there would be one and I tend to think, you know, despite the fact that there are flaws in these existing rules, some of the alternatives to having sort of bioethically informed rules for things like organ allocation or IRBs to say, for instance, have pure researcher or, you know, transplant surgeon self-regulation, I think would be a lot worse, would be very, very bad.

So, if the counterfactual is pure self-regulation, then I think it's a win for having some form of bioethical influence.

Leah: Emily, what do you think?

Emily: I think we can point to a lot of small wins that collectively are a big win. So I think having clinical ethics consultation or research ethics consultation in many cases, although those consultants often are not prescriptive, but lay out a range of acceptable options that we have seen improvements in care and research because consultants are routinely made available. So I think that, you know, while in any individual patient's experience, it might be a smaller win, that collectively that's big. I would also point to some areas that I think have really developed often in parallel with the law, but I think informed consent in this area where bioethics has had a lot to say in conjunction with case law that has moved that forward.

And I think similarly, when we look at something like our current human subjects research regulations in the U.S. Those really reflect the principles laid out in the Belmont report, which was these ethical principles that now are quite foundational to how we think about research ethics. And, so, I think that would be another area I would point to as a big win.

Leah: Yeah. Yeah, I mean, I feel like clinical ethics consultation is not something that probably most people have a lot of experience with and I, as a medical student, I actually don't have much experience with this either. But I will say that just my experiences with clinical ethics consultants have basically universally been positive in that I think they are very solutions-oriented and when you get a clinical ethics consult, very rarely are they like, "Oh, you thought you could do a bunch of things? You can't. They're unethical." It's, it's usually the opposite. It's usually like the team is like, "we feel paralyzed because we don't know what we're allowed to do here." And the ethics consultants say, "well, you know, you actually have a number of options. Here they are. Here are the pros and cons of each." And so I think people sometimes get frustrated that the consults aren't more directive, but they definitely do, I think, open the space of possibilities, whereas I think bioethicists are oftentimes seen as sort of closing that space.

And so I think that that is a real example of a place where people may not see this, but it actually can be very helpful for clinicians and practice. So we also now want to transition to section three, which is critiques from inside bioethics. And we've been talking about this a bit, but I've heard many bioethicists critique bioethics for the variable quality of scholarship.

Frankly, I think this critique is fair. I don't know how different bioethics is from other academic disciplines in this regard, but there are reasons to suspect bioethics could be especially hard. First, at baseline, it's really hard to do good interdisciplinary work because you need to have expertise across multiple areas for the same reason.

It can be really hard to peer review interdisciplinary work. And separately, bioethics is viewed by many philosophers as being a less rigorous and prestigious discipline. And I think even within disciplines like public health, health policy, and medicine, people sometimes see ethics scholarship as being less rigorous, less important, or both.

This can drive star students away, or it can lead to students having insufficient mentorship, resources, or support in conducting bioethics research, all of which can undermine the quality of scholarship. So, starting with you, Govind, do you agree with the charge that the quality of bioethics scholarship is more variable than the quality of work in other disciplines, and if so, do you have thoughts on why?

Govind: So, I used to, but I actually I'm not sure that I do now, part because I feel like I've seen work in legal scholarship, but I think there's a lot of variability and quality there as well. And I thought the same thing about scholarship and public health.

I think the same thing, actually, when I look at, I get the table of contents for JAMA and JAMA internal medicine, I have to say, I see I think the same thing, at least about the scholarship that has aspects that I can evaluate, that are sort of not highly technical. And even in highly technical areas, I think there are similarly challenges in sort of replicability and other things for empirical topics as well.

So for psychology or biology, or even some of the hard sciences. So I think the lesson really for me is that, I think it is hard to have high quality research. I think there is a variety of pressures, pressures to publish more quickly, challenges in the fact that reviewers are typically not compensated financially.

So getting publications reviewed quickly and competently, I think is challenging. A different question, though, I would answer yes to, which is, is there more variability than there should be? And I think that there should be higher and more consistent quality in bioethics.

I just don't think it's unique to bioethics as a discipline.

Leah: I mean, just to follow up on the last thing you said, Govind, there's more variability than there should be. How would we go about eliminating some of that variability. Do either of you guys have thoughts or suggestions?

Emily: I mean, I suspect in part, this is an issue that there are just too many journals. You know, as there has been more pressure to publish, I think we've seen more and more and more journals open. I think it both dilutes the pool of people who are willing to peer review and work that, you know, I certainly don't want to gatekeep and say that if you can't publish and say the top 10 journals, you shouldn't be publishing at all.

But, I think that you can have lesser quality work be accepted at some of these journals not just the predatory ones where you basically are paying to just get your work out there. But, you know, I think that constricting the field might actually be helpful in some ways for quality control.

Govind: I mean, this again seems to be like a question that I would love to see studied empirically. And part of the challenge is knowing what would be a metric for high quality and variability and I grant that in bioethics and I think here I think it has in common with legal scholarship, a field that I read in a lot now, you know, there may not be sort of common standards for what is high quality scholarship, but basically, I'm curious if there are areas where we have reason to think there have been material, say improvements in quality or in reducing variability, with that help. So I know like in some other fields, for instance, they pay reviewers or they may have more consistent standardization.

In my experience reviewing for journals, I've had some journals that were more willing to give you more clear guidance in what a helpful review would be. And actually, this sounds like a very small change, but I actually think that might be helpful, because I've had widely variable qualities of review come back for papers that I've published.

The other thing, the last thing I'll say about this, and I think this may segue into something we'll talk about later, is that, I worry a little bit that it could sometimes be too easy to publish things where the conclusion is probably right, but the argument for the conclusion doesn't make any sense, but the conclusion is probably right ethically and, like, not controversial.

Whereas if you're trying to publish something that is defending a conclusion that is likely to be highly controversial or, maybe, most people might think is wrong. People might be likely to reject that paper just based on the conclusion, even if the arguments are quite nicely done.

And so I sometimes worry, I'll see papers that defensively that I think, you know, sure, that conclusion is probably right, but they'll say something like, yeah, we should have more community consultation and governance in bioethics. And I'm like, yeah, you know, sure.

But there's not really an argument here as to why this probably true conclusion is true.

Emily: I think it's a nice point. I think that again, going back to this idea that there can be reasonable disagreement about these things that you often can't critique an article based purely on the conclusion. I think it has to be really on the basis of how it's been argued. And so if there were to be a core skill set in bioethics that people should pursue, I think it is about rigorous argumentation.

You know, as a peer reviewer, I try to focus, like, do we logically and rigorously get to our conclusion, not do I agree or disagree with what you're ultimately saying.

Sophie: I wonder how much this problem has to do with people seeing bioethics as not just research but almost activism sometimes. Like, they see very clearly that the conclusion of a bioethics paper might have practical implications, and so they think like it matters more what the conclusion is than what the argument is, but that might be kind of dangerous.

So, earlier we talked about how bioethics has moved toward creating formal training programs. One problem with these kinds of programs is that they can be very expensive, creating barriers to entry for many students. For instance, the tuition for a one-year master's of bioethics at two programs that shall go unnamed are $74,000 a year and $92,000 a year, and this doesn't include cost of living or health insurance. Although some students will be eligible for financial aid, it's going to be hard for a lot of people to justify taking on anywhere near this much debt to do a one-year master's that won't guarantee them a job in the field or provide clear financial benefits.

Emily, what are the implications for bioethics of having high financial barriers to entry?

Emily: I mean, certainly I think it creates privilege in who has access to this kind of education. I don't know that I would solely focus on Masters of Bioethics programs, although I think there's reason to, given that that is sort of an entry point for a lot of people, a reason to think about it. But there are opportunity costs of course, also to doing something like getting a PhD or going to law school, other paths to becoming a bioethicist.

And you know, we know that there are also many hurdles for people to get over to get into those sorts of programs. So I think that we do need to think about ways to make it more accessible if we are going to have a more diverse field. And when I think about diversity and issue, we'll talk about more, right?

It's not just demographic diversity, but it's viewpoint diversity. It's, there are many potential axes that we would be interested in. And so, some barriers to entry I think are useful for quality control and the things that we've talked about. But again, it's these trade-offs where we are then limiting the voices that can come into the field when we make it financially infeasible for people.

Sophie: One issue that has been top of mind for the bioethics community in recent years is the lack of diversity among bioethicists. In our survey, we found that there's both a lack of demographic and viewpoint diversity in bioethics.

Leah: For instance, we found that 81 percent of academic bioethicists are white and nearly two-thirds have a parent with a postgraduate degree. Meanwhile, 87 percent are liberal, while just 4 percent are conservative. There are also other kinds of diversity we might aspire to, including methodological and topical inclusiveness, i.e. ensuring bioethicists work on a wide range of problems using a wide range of approaches. What kinds of inclusiveness do you think bioethics should aim to address for its own sake? For instance, because it is intrinsically better to have more diversity. And what kinds do you think bioethics should address because this will provide instrumental benefit?

For instance, if bioethics had more religious diversity, maybe clinical ethicists would be better equipped to support patients from more religious backgrounds. Govind, let's start with you.

Govind: Thanks. Yeah, so it actually challenges the premise a little bit in that instead of saying kinds of inclusiveness we should value for intrinsic versus instrumental reasons. I would instead talk about, for the sake of people who want to be bioethicists or participate in bioethics, and then for the sake of those who might benefit from the product of bioethics, say, bioethics scholarship or bioethics consultation. And for the first one, fairness to people who might want to participate, I think the case for certain forms of demographic inclusiveness strikes me as very, very strong. That we would want to try to make sure that people's chances of being participants in the process of developing bioethics scholarship or becoming bioethics teachers or consultants, isn't limited by circumstances like economic disadvantage or bias against people from specific racial groups. We wouldn't want those kinds of factors to limit the opportunity to participate in bioethics.

The second question about the products of bioethics, I think, strikes me as really a question for kind of social scientific empirical studies. So you mentioned the question of, you know, would having more religious bioethics make bioethics consultation more beneficial or helpful to maybe religious patients or religious settings. I would be really interested in understanding empirically the extent to which that is true. So we have some evidence that concordance between medical providers and patients may have some benefits. I think we have more actually evidence about that for some ethno-racial concordance than we have for religious concordance, but it'd be interesting to know whether that is true.

And even if that is true, there would then still be tradeoffs we have to wrestle with, because if it is true that including more religious bioethicists improves [the outputs], there's still a tradeoff between that interest and the interest of fair access, say, for bioethicists who are not religious, or who are members of minority religions that might not have many shared adherents, and so where you wouldn't get that same instrumental benefit to others, but you might worry about whether it's really fair to people who are non-religious or members of minority religious groups to have their participation opportunities constrained or limited because of their religion.

And you could imagine very similar questions coming up for issues around, say, ethno-racial concordance that actually has been talked about in that literature.

The other thing, that I would really want to emphasize is not mixing up or confusing these different forms of inclusiveness because often people will start out by wanting to talk about a form of inclusiveness, which I think the case is quite strong and then it will transmogrify into something that might be much more debatable. So I think whether sort of every methodology of inquiry should be equally included or would equally sort of conduce to really good scholarship, really good consultation. A, that's an empirical question. The challenging thing is to want to know what are the standards by which you would assess what is a higher quality output. And B, the answer to that might be very different than the answer for the demographic question. So one thing we take up in the survey, right? Is, you know, some people said in response, we should want more of this, somewhat abstruse in my view theorists' scholarship, being engaged with by bioethicists. And I think empirically I'd be curious about would that actually make the scholarship more accessible, higher quality, better at helping to do whatever it is we think bioethics should be doing. And I have my own doubts about whether that is true, but it's also important to make sure that we don't conflate sort of including that theorist's views with including, you know, poor or marginalized people as bioethicists, which I think is a quite different question.

Sophie: Okay, so it sounds like there's a background thought there that certain kinds of group membership, like race or gender or maybe economic class, are the kinds of things that it can be unfair to exclude on the basis of, but other ones like methodology you use, or viewpoint are not the kinds of things that we should be worried about on the fairness side.

Govind: Yes, in the sense that, like, this gets put this way in legal discussions and I think it's imprecise, but I guess it's something people find intuitively easier to understand, this gets put in terms of, like, immutability or something you can't be expected to change. It wouldn't be reasonable to expect somebody to like quit being their race in order to be a bioethicist.

A, it's not really possible, it'd be really offensive. By contrast, if somebody is using, you know, take the case—go back to the case I talked about—Freudian psychologists. It might be that Freudian psychology is not the most useful method of providing a psychological lens on some bioethical question because of like methodological problems at the modern day rigor of Freudianism compared to other psychological schools. And that's not really, in my mind, a form of unfairness to Freudians because being a Freudian is not akin to being part of some immutable category. I think religion is a tricky case for this because religion is not, you know, factually immutable. We know of many people who shift over time in how they identify or not with respect to religions. But I think we may at the same time feel like there is a fairness consideration present with respect to inclusion of different religious views that goes beyond just outputs, but goes to whether there's fairness to people who want to participate as well.

Leah: One thing that we found in our survey is that bioethicists are different from the general American public in multiple respects.

In contrast to the 87 percent of U.S. bioethicists who consider themselves liberal, just 25 percent of Americans do. Bioethicists also hail from more advantaged backgrounds, are whiter and are less religious. It's perhaps not that surprising then that bioethicists views on ethical issues are quite different from Americans. For instance, bioethicists are much more likely than members of the U.S. public to think abortion is ethically permissible. Conversely, bioethicists are much less likely to think that compensating organ donors is ethically permissible. Starting with Emily, to what extent should the field of bioethics mirror the US population and where should we expect or aspire to divergences?

Emily: So I don't think that we're necessarily thinking that there's an objective truth oftentimes that we're trying to achieve. And so the fact that there isn't a convergence of viewpoints is perhaps not concerning. And especially if we think that because bioethicists sit and reflect on some of these issues, study them empirically, think about them at length and reflect, you know, it might be that those views are just more, you know, informed or thoughtful than somebody's sort of intuitive idea about whether or not we should say pay an organ donor or whether or not abortion should be permissible. But where it does, I think, come into conflict is if bioethicists are acting in capacities like providing ethics consultation or they are informing policy, then the divergence in views might be more concerning because there might be perceived as some illegitimacy of the offering of a viewpoint that doesn't cohere with what's mainstream or broadly held amongst the public. And so there it's really, I think, a question of which areas, you know, if we think, for example, the common view in bioethics consultation is that an ethics consultant can come in and really be an objective party and they can offer neutral recommendations. But there are some people who challenge that and say, actually, it's a fallacy to think that somebody can really come in and be a neutral party. And that ethics consultants are not offering that despite this prevalent view that they are. And so instead we need to raise concerns about values and position in a pluralistic society. And maybe ethics consultants need to have a different toolkit available to them.

Maybe they should be trained more in conflict management than in offering normative recommendations. So I think it becomes very context specific where we might be concerned that there's a real gap and how we bridge the gap is sort of another question. Is it that we try to educate and bring people to our side? Is that we try to arbitrate between the viewpoints? You know, is it how we frame our arguments to make them more palatable? I think there are many ways we can do this. And in some ways it circles very nicely back to where we started, which is the sort of is-ought distinction. You know, how does empirical bioethics inform conceptual? We can think similarly about the fact of a difference. You know, what should we do with that? And there might be different things we should do in different circumstances.

Leah: Yeah, just to follow up on what you were saying about the goal of clinical ethics consultation to be offering this sort of like neutral perspective. I mean, I get that maybe that's not your view, and so it's a little unfair to ask you to sort of explain or defend that view. But it seems a little weird to me in that we might think that sort of baked into the very existence of ethics consultation is this assumption that there are better and worse ways to resolve various ethical dilemmas.

And so it would then be odd to sort of suggest that the people who are brought in to provide expertise in those consultations should not weigh in or push towards the better options and to pull away from the worse options and I guess how do you reconcile that kind of thing with this position of neutrality?

Emily: So it's not an area of my particular research. And I'm sure there are different ways we might address that. I think that, you know, oftentimes there is a premise when you do an ethics consultation, and this is true in the research ethics as well as the clinical ethics consultation, is that you are not trying to be prescriptive and tell people what they ought to do, but you're really there to lay out a range of things that people might do. And I think the hope is that if you have somebody who can take that approach, you know, who is truly objective that they might lay out options, you know, a variety of things to make sure that they're palatable to all stakeholders.

Sophie: Yeah, I mean the idea that you're just purely a mediator here strikes me as deeply implausible. Like in fact, you might think there are cases where putting more options on the table is actively bad, right? Like if clinicians are considering, "Oh, you know, should we intubate this person over their objections or not?"

Leah: Then maybe you want to restrict the scope of potential paths to intubating them or not, and not sort of add things like, "Oh, but we could also do CPR to them over their objection." You know, like there's times when it actually is good to take options off the table. And I take it that one of the goals of an ethics consultant should be appropriately removing options that seem bad, and also helping sort of rank the options that remain.

Again, I know this isn't the area that you work on, but I just, this does feel like it's a tension that we've kind of unearthed here.

Sophie: Govind, did you want to weigh in at all on this?

Govind: My thoughts, I think, go back more to the initial question of when is it okay or not okay for bioethicists to look different from the public in various ways. And my initial thought, which seems sort of the obvious is, you know, well, that should be dependent on whether there's a good reason for them to look like or not like the public. And then I think there are some cases that are going to be easier and some that are going to be harder that goes back to this question of inclusiveness. So, there are going to be some ways that like, you know, you mentioned differences, for instance, in wealth and education, and you might want to have a world where people didn't have differential access to opportunities to have the educational resources that are needed.

That's a good question. You might expect that, for instance, it would be challenging to participate fully in bioethics without some level of university education. And the question is, should that be something that we're trying to fix by getting rid of that educational barrier to bioethics or by making education more accessible?

You know, there are other demographic groups that I think like, you know, I have a six-year-old. I don't think really six-year-olds are going to be, you know, ever reliably the same kinds of bioethics participants that adults are. And so, including their voices in the same way, just if it looks different because six-year-olds demographically do look different from, you know, the population of the U.S. to say, 50, which actually does look really different, that's not necessarily something we should be concerned about in the same way. So the hard questions are when you know, if you look at surveys of the public, you'll find that around 10 percent of the public will say things like, yes, the earth is flat. And around another 10 percent will say, well, we're not sure we're uncertain. And my guess is that it will probably look lower among bioethicists than among the public. And one of the, I think, hard questions is when it comes to views, as opposed to just sort of these demographic characteristics, which of these views should be kind of all right, in bounds in bioethics, we should be concerned if they're disproportionately excluded. And which of those views, it's actually not a problem if they're disproportionately excluded, because what they're highly correlated with is not being disposed to engage in the kind of critical assessment of evidence and argument that is going to be core to sort of any useful model of bioethics.

And I think that's a question that can be a tricky one is sort of which views we want to rule as kind of out of bounds. I think many folks might be able to agree that something like akin to the flat earth example in civil life sciences should be like that, but they're going to be other cases that are going to be really more controversial where I think some people are going to want to say that say, some views about disputes among religions about evolution might be inbounds or out of bounds.

And I think those are going to be some of the issues. Again, trickier questions.

Sophie: Mm-hmm. So then just to summarize here and let me know if this sort of picks up what both of you are getting at in answering this question. It seems like whether or not we should worry about the mismatch between bioethicists views and the public's views depends on why bioethicists think what they do and why the public thinks what they do and whether bioethicists are having their opinion because of some kind of relevant expertise that they have relative to the public.

Leah: So we like to close by asking our guests what is one rule or norm broadly related to what we've been talking about today that you would change if you could, and why. We can start with Govind.

Govind: Yeah, so the norm that I would change, and I think may actually be responsible for some of the frustration the public feels with bioethicists, is that I think it would be valuable to be more disciplined about how we talk about normative questions, questions of value versus questions of fact.

And maybe this is self-serving having just been involved in doing this survey, but I think it can be really valuable to do empirical surveys when you're trying to answer a question, as well as doing normative analysis. And bioethicists should be clearer about which they're doing when they're talking.

Are they talking with normative expertise or are they talking with empirical expertise? An area where I saw this come up a lot, I think during COVID, is a common form of argument in bioethics is like, sure, there's this thing that we might think about permitting or requiring or implementing as a policy, but we should be nervous about this because if we allowed it, it could jeopardize public trust. This came up, I think we'll all be familiar with this from, like, debates about challenge trials. People were like, well, we shouldn't let people voluntarily infect themselves with the disease in order to test a countermeasure like, antiviral or something, because that could jeopardize public trust in public trust. And now there are both normative arguments why you might not want to allow that and there are arguments about public trust. But the claim public trust, that's an empirical claim. That's a claim about what would actually happen in the world. The ethical sort of argument cousin of that claim would be saying something like that should jeopardize public trust or it would create the conditions that the public would be justified in distrusting. But often people slip from that into the claim that it actually would jeopardize public trust. And you see that not just for that example, but for things like, you know, should we allow some new procedure, you know, normothermic perfusion for organ donation or whatnot. You often see this refrain about public trust offered by bioethicists. Often I see it offered without necessarily an empirical survey of whether the public's trust actually would be affected, how much, and in the ways that bioethicists describe. So I think public trust is one example of this trend that I would like to see change, where I really would like us in bioethics to be clearer about when we have descriptive warrant for a claim about how the real world would change if something happens, as opposed to we're making a claim about what people should do or what they would be justified in doing, regardless of whether they actually would do it.

Emily: So in thinking about this in advance, I think I actually arrived at a place that's complementary to what Govind just said, which is that I think we really need to resist ethics by soundbites. So it's the case that oftentimes when bioethicists are quoted in the lay press, you get these very, you know, these snippets of things that can be very provocative. But I think that they do two things. One is that it sort of gives the impression sometimes that it's an overly simple answer and doesn't really take into account the nuance that I think good bioethics scholarship often does have to take into account. And the other thing it does is I think it promotes this idea that bioethicists are really just giving opinions.

Whereas I think that, you know, hopefully it's come out in this discussion that there is, there's a methodology, people have training, there can be rigor. And while all of those things are challenges in the field, as in all fields to achieve, ideally we do have those sorts of things. And so when you have quotes that come out, they're like, well, that's just obviously wrong, which I've seen something very similar to that in the New York Times recently in an article about informed consent for a clinical trial. I think it really misses or elides the nuance that was going on in the larger context. And so you saw in the responses to the New York Times article, people who were, you know, I think either offended by sort of the simplicity of that quote, or they used it to point out some of these critiques we've talked about earlier, or like, oh, bioethicists are just hacks that, you know, that you would just say that without a bigger opinion. Now, I can imagine pushback being that, well, journalists are the ones who pick these quotes. But I think that there's also a tendency to go to very quotable ethicists and, you know, they are people who can often issue these, these sort of sound bites.

But in a society that I think is pulling away from nuance oftentimes, I think we have to be very careful in communicating bioethics research that we do it with nuance.

Sophie: All right. Well, we've come to the end of our time, so we'll close there. Thank you both so much for coming on the podcast. We really enjoyed this conversation.

Govind: Great. Thank you Leah and Sophie.

Emily: Thank you.