Having received only a short introduction to empirical bioethics as a student almost a decade ago, I found myself happily picking up this edited volume as I become increasingly aware of the need to closely reflect upon my own developing approach to global bioethics, as well as my skills in teaching bioethics to those new to the field. My hope was to find enough inspiration to situate my own identity in the field, to gain a deeper understanding of the nuances of empirical approaches and, along the way, to pick up key messages that I could somehow impart to my own students. I have not been disappointed on any of these fronts.

This edited volume is divided in two parts, as its subtitle suggests. Each part consists of six chapters, preceded by an introduction by the editors, which highlight the central questions addressed by the various authors, as well as how these questions relate to the theoretical and methodological tensions discussed in the preface. Early on in the preface, the editors carve out a space for this volume in the bioethics literature by illustrating the key tensions between philosophically-informed and social science-oriented approaches to bioethics. They do this by situating their vision for the book in contrast with other approaches to empirical bioethics (e.g. those that do not aim to generate solutions to normative questions); [1] by hinting at the variety of approaches that come under the umbrella of empirical bioethics; and by positing three conditions (veridical, realist and pragmatic), any of which can be met in order for bioethics to have so-called “real-world purchase.”[2]

The chapters that follow can therefore be seen, to a certain extent, as illustrations of various ways of doing bioethics that would have real-life purchase, and the challenges and obstacles such approaches—and bioethics—must overcome in the process. In the chapter immediately following the introduction to theoretical perspectives, John McMillan (Chapter 2) pinpoints one of the core tensions between normative and empirical approaches: the fact/value distinction, which he goes on to argue is perhaps far less distinct than methodological purists might want it to be. Mark Sheehan (Chapter 3) then tackles one of the most frequent sources of tensions between normative and empirical methodology: the difference, for example, between “what are taken to be legitimate social norms and practices and what they should be.”[3] This provides the background to explore a charge often levelled at empirical approaches—that of moral relativism—a charge and concept to which Sheehan offers an alternative: a “moderate objectivist” position to ground empirical methodology.

Moving away from these core theoretical chapters, the next three chapters consider bioethics in relation to other practices. Kyle Edwards and Zuzana Deans (Chapter 4) consider the arena of policy-making and Richard Huxtable (Chapter 6) reflects on law, with each chapter examining, albeit in very different ways, the legitimacy and authority of bioethical practice and enquiry when compared to law and policy-making, and its relationship to real-world questions. Between these two chapters, Ilina Singh (Chapter 5) turns the table by asking how empirical approaches to bioethics might engage with substantial theoretical challenges. She explores the value-laden nature of empirical work and the need for those engaged in empirical methodologies to understand that specific theoretical perspectives will necessarily inform the questions asked and the tools used for empirical work (a task which Jackie Leach Scully to a great extent addresses head-on in her feminist take on empirical bioethics in the second part of the book). In a final chapter that almost comes around to the issues explored early on in the book, Alan Cribb and John Owens (Chapter 7) tackle the obstacle of interdisciplinary conflict (especially between philosophy and social science) by making a moderate plea for open-mindedness and toleration in approaching both moral practice and moral knowledge and in answering that eternal question at the heart of ethics: “how ought we to live”?[4]

The second part of the volume shifts to the question of how empirical bioethics research should be conducted, to a certain extent building on the theoretical and conceptual perspectives gained in the first part. Four illustrative methodologies have been chosen, which speak, in various degrees, to either a consultative approach (researchers consult the data, conducting a normative analysis separately), or a dialogical approach (researchers and participants co-develop understandings of and solutions to moral questions). This second part is also prefaced by the editors, who conclude the introductory chapter (Chapter 8) with a set of questions to enable bioethicists to select the type of methodology best suited to their own work.[5]

The first of these practice-oriented chapters, by Elleke Landeweer, Bert Molewijk and Guy Widdershoven (Chapter 9), explores the dialogical method in empirical bioethics which “seeks to produce moral learning and direct improvement to practice by involving stakeholders in a process of reflection and dialogue on moral issues in practice.”[6] In contrast, Ghislain van Thiel and Johannes van Delden (Chapter 10) take a more philosophically-informed take on empirical methodology by developing John Rawls’ famous reflective equilibrium (which can be broadly seen as a philosophical methodology to achieve coherence in moral thought) to include the moral intuitions and considerations of agents other than the researcher-thinker, as well empirical research on moral intuitions and morally relevant facts. Also inspired by political philosophy, and using the question of adults with dementia as research participants, Scott Kim (Chapter 11) considers deliberative democracy as a methodology in promoting the legitimacy of governance in bioethics as well as providing justification for policies. The fourth area addressed is that of feminist approaches to empirical bioethics. Here, Jackie Leach Scully (Chapter 12) reminds us that the feminist turn in bioethics arose out of a need to counter traditional ways of doing bioethics, which were too often blind to power and oppression. Feminist empirical methods in bioethics, as with feminist philosophy and feminist scholarship in general, are therefore unashamedly rooted in a commitment towards equality-based norms and practices.

The final two chapters of the book take yet another step towards practical considerations, by exploring important advice and notes of caution for researchers in the field and by offering further thoughts on what the editors call a “central requirement of research conduct in empirical bioethics”, which is “an explicit and continual reflexive stance to be adopted when engaged in one’s research activities.”[7] Bobbie Farsides and Clare Williams (Chapter 13) reflect on the multitudes of practical difficulties faced by researchers involved in interdisciplinary empirical work, including justifying novel methods to institutions, funders and research committees, based on their own experience of conducting mixed-method bioethics research. Lucy Frith and Heather Draper (Chapter 14) explore the difficulties that might follow data gathering and analysis, for example by illustrating the challenges inherent to quality reporting and publishing.

In a volume filled with scholars who are widely considered experts in their fields, it is difficult to do each chapter justice, if only because of the sheer richness and experience covered within each short chapter. However, I was pleasantly surprised by how much was contained within the two thoughtful introductory pieces by the editors. These chapters not only provide the reader a short overview of the contributions, but they also frame the parts by pointing the reader to the key tensions and motivations behind each part, and the book in general. They provide important anchors to a volume that ranges from metaethical and conceptual reflections to extremely practical considerations, and that could have easily lost focus. Early on, the editors speak about ways of “approaching knowledge” rather than of a conflict of methodologies, and this is key in setting the tone for the book and one of its central motivations.  This is not to say that those looking for methodological reflection will be disappointed: Part II provides a variety of tasters from the methodological menu, along with Singh’s more theoretical reflections on methodology in Part I.

Importantly, however, the editors carve out a space for this volume by presenting it as a challenge to philosophically-inclined normative bioethics, which has been guilty of treating empirical bioethics as a “handmaiden” rather than a partner.[8] This is also a challenge to the status quo, that is, keeping normative and empirical lenses quite distinct and separate. The challenge from empirical bioethics (which in this case takes a step farther than the “empirical turn” known to bioethics so far) is both a territorial one and a theoretical one. This is no easy task. According to the editors, bioethics has to “take seriously, and combine, both normative and empirical epistemologies.”[9] For this,

…a great deal of intellectual legwork is required in order to be able to tell a coherent theoretical story about how one can combine the empirical and normative, and how one can obtain both empirically informed and useful normative conclusions that are appropriately justified.[10]

The goal is to find “sufficient common ground and a sufficiently common language” to create something that “stands alone.”[11] As much as this is appealing, there are a few things that remain problematic as to the role the editors seem to propose here. First, it is not entirely clear what form of bioethics empirical ethics is placed in conflict with. According to the editors: “a bioethics that is dominated by theoretical philosophical approaches is ill-suited to the job of engaging with, and prescribing about, complex ethical dilemmas.”[12] While the real world is indeed extremely complex, any student of bioethics will bear witness to the fact that ethical theories and thought experiments can be equally mind-bogglingly complex.

Perhaps the problem then is not about complexity, but rather that traditional approaches to bioethics have, as mentioned earlier, less real-life purchase. After all, an “approach to ethics that focuses wholly on argument and consistency risks ignoring the human element and sanitising what is, essentially, a very messy, social and human phenomenon.”[13] However, several theoretical strands in bioethics will attest to the fact that even deeply philosophical approaches have long shed the abstract nature of philosophical thought and of straightforward application of ethics.[14] Various versions of non-deal theory (see, for example, Powers and Faden,[15] Wertheimer,[16] and Millum and Emanuel[17]), among other approaches, demonstrate that it there is extensive use of empirical scholarship in any serious attempt to find solutions to a multitude of real-life, complex moral questions, especially in global and health ethics.

To take another example, examining the concept of exploitation in global bioethics (including the fact that people engage in what may arguably be labelled exploitative practice, such as selling one’s organs or commercial surrogacy for financial reasons) crucially depends on describing and understanding real-life situations, whether we then go on to use or critique liberal, Marxist, feminist, structural theoretical perspectives on exploitation. A thorough examination of the concept would be severely lacking if it did not also, for example, take into account (either directly through empirical work, or indirectly by reporting the empirical work done by others) the lived realities of those who are (arguably) exploited. Here as well, those who invoke the term “exploitation”, both in designing the empirical research and in analysing it to make normative claims, should be aware of the existing—sometimes conflicting—theoretical frameworks behind the concept. The awareness of the theoretical underpinning of empirical work is something several authors discuss in the volume, but it also points to the fact that rigour in argumentation is perhaps closer to the messiness of the real-world than sometimes suggested in this book. Indeed, any bioethical enquiry that aims to say something important about the real world should be in conversation with a variety of disciplines, and perhaps even in a form of reflective equilibrium (or as van Thiel and van Delden might say, in normative-empirical reflective equilibrium) among many lenses, intuitions, arguments and principles. To go back to the example of exploitation, the moral intuitions about exploitation of those actors engaging in organ markets or global commercial surrogacy might also be tempered by conceptual and theoretical frameworks related to coercion, commodification, relational autonomy, adaptive preference, agency, and so on.

To a certain extent, I am not entirely convinced that a case can be made on the basis that the fact/value distinction is partly an illusion. While several illustrations are given, notably by McMillan as to the porous nature of this dividing line, the ability to recognise a factual versus a value-based claim remains central to recognising the hidden normativity in empirical methods that several authors in the volume point to. Indeed, I would argue that the “ethnographic turn” in some of the discourse around global bioethics (for example, in the context of surrogacy) suffers from “moral absenteeism”,[18] if not moral relativism, due to a methodological motivation to remain silent on normative considerations.

As I see it, this volume presents several challenges to the status quo in bioethics. The first, and simplest message, is perhaps that those of us who are considering empirical research as part of our work in bioethics, must consider both the theoretical and normative underpinnings seriously, as well as choose our methodological tools carefully. A second category of challenge is based on the idea that pure theory and argumentative rigour cannot possibly be the only tools (or even the best tools) to address real-world problems. I am troubled, however, by the fact that the theoretical overhaul posited by the editors at the beginning might ultimately become a foe to another important virtue that all the authors uphold—namely that of quality. It is perhaps not simply an “academic division of labour” as Cribb and Owens describe it.[19] Instead, it suggests that those of us who do not necessarily come from one of these “parent” disciplines are better served, and will better serve the field, if we continue to hone our skills within a limited number of areas in the discipline. Having now read this contribution from scholars who have spent decades perfecting the skills that come across in these pages, I remain convinced that the strongest challenge is a territorial one, rather than the need to truly “suspend disciplinary assumption”[20] with a view to achieving harmony. Bioethics is not the purview of one discipline (nor is it even an integrated one, I would argue); rather, it is best served by conceding territory to all relevant disciplines, in a dialogue that is charitably critical and genuinely open to a variety of knowledges and experiences.

[1]     Jonathan Ives, Michael Dunn, and Alan Cribb (eds.), Empirical Bioethics: Theoretical and Practical Perspectives (Cambridge: CUP, 2017), p. x.

[2]     Ibid.

[3]     Mark Sheehan, “Metaethics, Relativism and Empirical Bioethics” in Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, pp. 33-50, at 36-37.

[4]     Alan Cribb and John Owens, “Embracing Diversity in Empirical Bioethics” in Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, pp. 103-122, at 107.

[5]     Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, pp. 132-133.

[6]     Elleke Landeweer, Bert Molewijk, and Guy Widdershoven, “Moral Improvement through Interactive Research: A Practice Example of Dialogical Empirical Bioethics” in Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, pp. 139-149, at 139.

[7]     Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, p. 134.

[8]     Ibid., p. 6.

[9]     Ibid., p. 5.

[10]    Ibid.

[11]    Ibid., p. 10.

[12]    Ibid., p. ix.

[13]    Ibid.

[14]    John Arras, “Theory and Bioethics” (Stanford Encyclopedia of Philosophy, 2010) available at

https://plato.stanford.edu/entries/theory-bioethics/ (accessed 1 June 2017).

[15]    Madison Powers and Ruth Faden, Social Justice: The Moral Foundations of Public Health and Health Policy (Oxford: OUP, 2008).

[16]    Alan Wertheimer, Rethinking the Ethics of Clinical Research: Widening the Lens (Oxford: OUP, 2010).

[17]    Joseph Millum and Ezekiel Emanuel, Global Justice and Bioethics (Oxford: OUP, 2012).

[18]    Alison Bailey, “Reconceiving Surrogacy: Toward a Reproductive Justice Account of Indian Surrogacy” (2011) 26(4) Hypatia 715-741, p. 716.

[19]    Cribb and Owens, supra n. 4, p. 108.

[20]    Ives, Dunn, and Cribb (eds.), Empirical Bioethics, supra n. 1, p. 10.