Bioethics and the Credibility Crisis, Part I: Diagnosing the Challenges Before Us

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When I first began my higher ed journey in the mid-90s, postmodernism was the topic du jour. Whether one was enamored or repulsed, many a course reading and assignments in my graduate and doctoral studies were spent trying to understand the various aspects of the postmodern critique and to develop constructive responses to its social, cultural, and philosophical implications. At the root of postmodernism, especially in its philosophical and theological variants, was a deep skepticism of knowledge, truth claims, and above all the pursuit of absolute certainty that marked modernism.

From the death of the author, history, grand metanarratives, and meaning to the rise of relativism, deconstruction, and the unmasking of the power plays in language and socio-cultural artifacts, as doctoral students we were tasked with constructing our theological methodologies in the wake of this postmodern critique. Of course, postmodernism, though the bogeyman of the day, was not the first philosophical system to challenge the foundations of knowledge. Precursors in the thought of Friedrich Nietzsche in his assessment of the will to power and reflections of Twilight of the Idols and Gay Science and the Classical Pragmatism as developed by John Dewey, William James, and Charles Pierce had already begun to fracture the armor of certainty sought by the modernist project.[1]

And yet, for all of the fervor and spilled ink, somehow we all moved on. This point was brought home in a recent faculty workshop by an alumni guest speaker. He noted in a passing comment that we were so focused on postmodernism in that decade and a half of education, we missed the thing that was actually transforming society—technology, and more specifically the digital revolution in information and communication technologies. Alan Kirby, writing in 2006 for Philosophy Now, noted something quite similar: “postmodernism is dead and buried. In its place comes a new paradigm of authority and knowledge formed under the pressure of new technologies and contemporary social forces.”[2]

So why the lengthy foray into postmodernism if it evaporated into the academic ether? One key insight that emerged within postmodern philosophy is that facts and values along with meaning and significance are more intimately tied together than we may care to admit. Somewhere along the way in my philosophical education, I learned about the fact-value distinction. Facts were about objective reality—the givens and the hard data that are empirically or rationally verifiable. By contrast, values were characterized by subjective things—to put it simply, the significance something has for us as individuals. In the context of ethics where this cashes out most tangibly, values speak to the prescriptive or normative assessments of that which is good or bad. This is the basis of David Hume’s distinction between descriptive verses prescriptive assessments in ethics. The so-called “Is-Ought” problem or fallacy is that one makes a philosophical category mistake in moving from descriptive statements (effectively “what is in the world”) to conclude something prescriptively (“the way the world ought to be”). While the fact-value distinction is an introduction to philosophy kind of lesson, it is nonetheless a critical tool that one learns working in ethics and bioethics.

A more sophisticated tool that builds off this fact-value distinction is the Potter Box, first developed by Ralph B. Potter, Jr, a social ethicist at Harvard Divinity School. I am not sure precisely when I encountered the Potter Box in my educational journey, and the version I use in my own teaching is a slight modification from Potter’s original. Regardless, the Potter Box visualizes four quadrants through which one moves for moral analysis of an ethical dilemma. Each of the quadrants identify one of four respective categories or dimensions that contribute to moral analysis—definitions, values, principles, and loyalties.[3] For Potter, the definitions are the facts of the dilemma, and the principles are the ethical principles one brings to bear. Whether it is a corruption or an adaptation, the version I have come to use with my students is that ethical decision-making incorporates the four dimensions of facts, beliefs, loyalties, and reason (see figure 1).

Figure 1 – Modified Potter Box

One implication in working with the Potter Box is the realization that individuals can come to ethical agreements and disagreements through a variety of shared or conflicting beliefs, loyalties, and approaches to ethical reasoning. When I began teaching in the early 2000s, I would suggest to students we might disagree about the facts when one or both parties have an incomplete understanding of the facts or when facts are unclear or not well established. Properly understood and fully developed, though, the facts should speak for themselves. Indeed, despite the specter of postmodernism and the accompanying concerns about relativism wreaking havoc in ethics and bioethics, science and medicine remained the bulwark of modernist objectivity. And, given contemporary deference to these domains, up until the last couple of years we could still speak generally about the facts (especially scientific and medical facts) even as the other three areas of the Potter Box fell to the politics of values, beliefs, and significance. Of course, there was always the challenge that some would conflate facts and beliefs by smuggling assumptions about significance and value into their statements of facts.

One common example I would use in class to illustrate this point comes from the so-called stem cell wars of the late 90s and the early part of the 00s when facts about pluripotency and multipotency were assumed to also mean that one had immense (purportedly miraculous) therapeutic use and the other had little or no therapeutic use. While the jury is still out on pluripotent stem cells, multipotent stem cells sources have proven their therapeutic utility many times over. Debates about potential mental health implications or frequency of maternal-fetal conflict cases and their relation to abortion have held similar controversies surrounding the facts. Polarizing issues have often led to challenges in determining the appropriate terms and their precise meaning and establishing the facts as they pertain to ethical discourse. For the most part though, these challenges were confined to a handful of socially and politically charged ethical issues.

But something has happened in the last decade, as we now find ourselves in the midst of a crisis of credibility. Facts themselves are under dispute; not because of conflicting data points but rather as Kirby anticipated in his declaration of newly formed paradigms of authority and knowledge that have emerged in the context of our emerging technologies. Perhaps it was the re-emergence of fake news and conspiracy theories now amplified by the power and reach of social media[4] or as Stuart Richie has pointed out the drift in research integrity and the reliability of scientific inquiry.[5] Or, it may be the rise of citizen science and the DIY movement converging alongside what Tom Nichols has referred to as the death of expertise.[6] Another contributing factor could be the politicization of knowledge in the culture wars or the militarization of disinformation between nation states. Regardless, our emerging medtech world has led us to a confidence gap, effectively a crisis of credibility. The once incontrovertible—scientific facts and medical science—are now viewed with skepticism and scorn amidst increasing debates about vaccines, GMOs and other gene therapies and modifications, diet recommendations, the value of preventive care, rising interest in alternative medicine, supplements, and home remedies, and the list goes on.

Yet, even amidst the malaise of this rising culture of skepticism, real scientific discoveries, medical advancements, and technological innovations continue apace. Facts remain the facts even if they are harder to adjudicate than they once were. Medicine and science are not immune to the fallibilities of mistakes, selfishness, deception, and other characteristics and consequences of human depravity. Indeed, bioethics emerged as a discipline precisely because the noble pursuits of medicine and science could be twisted to justify heinous and despicable acts done in the name of science and medicine for the pursuit of the “greater good.” One needs only to peruse the accounts of the Nuremberg trials or Henry Beecher’s 1966 expose of research abuses.[7]

Just as Hippocratism was built on the insights of observational medicine, we too must remain firmly committed to both discerning the facts and being clear about our beliefs and our values. The Potter Box remains a valuable tool in the bioethicist’s toolbox, even as facts have become harder to establish and are not as self-evident to establish in ethical discourse. In a future issue, I will revisit this topic to discuss the Hippocratic commitment to observational medicine and the consequent importance of the integrity of scientific and medical inquiry as part of the advancement of a properly principled and virtuous Christian Hippocratic bioethics. For now, I leave you with the articles of this present issue examining professional integrity, the ethics of uterine transplants, and the moral status of the embryo in the ethical debates over IVF alongside our traditional complement of a clinical case study and book reviews.

REFERENCES

[1] While there are various streams of postmodern philosophical traditions, this particular one culminated in the work of Richard Rorty, a prominent neo-pragmatist of the late 20^th century, who connected the two philosophical movements through his proposal of postmodern bourgeois liberalism. See Richard Rorty, “Postmodern Bourgeois Liberalism,” The Journal of Philosophy 80, no. 10 (1983): 583–89, https://doi.org/10.2307/2026153. Some streams emerged from continental philosophy in the existentialism from Camus and Sartre to Foucault’s critique of existentialism, while yet others developed within apophatic traditions in theology connected to Pseudo-Dionysius. Another prominent stream emerged from the intersection of phenomenology (especially Heidegger) and philosophy of language, resulting in the poststructuralism of Jacques Derrida.

[2] Alan Kirby, “The Death of Postmodernism and Beyond,” Philosophy Now58 (November/December 2006), 34, https://philosophynow.org/issues/58/The_Death_of_Postmodernism_And_Beyond.

[3] For background information an d a discussion of the Potter Box and its use in moral reasoning, see the helpful article by Miguel Franquet-Santos-Silva and Carlos-Aurélio Ventura-Morujão, “The Potter Box Model of Moral Reasoning,” El Profesional de la Información 26, no. 2 (2017): https://revista.profesionaldelainformacion.com/index.php/EPI/article/download/epi.2017.mar.20/34484/168825.

[4] Fake news is not a new phenomenon and has a long legacy in history from the emergence of false reports, hoaxes, propaganda, and disinformation alongside the resilience of conspiracy theories of various sorts. For a contemporary account of the re-emergence of fake news see Mike Wendling, “The (Almost) Complete History of ‘Fake News,’” BBC January 21, 2018, https://www.bbc.com/news/blogs-trending-42724320. See also, Julie Posetti and Alice Matthews, “A Short Guide to the History of ‘Fake News’ and Disinformation: A New ICFJ Learning Module,” International Center for Journalists (2018), https://www.icfj.org/sites/default/files/2018-07/A%20Short%20Guide%20to%20History%20of%20Fake%20News%20and%20Disinformation_ICFJ%20Final.pdf.

[5] Richie blames a variety of factors that have contributed to this drift in research integrity, specifically identifying grant processes that reward hype and sensationalism, mistakes in statistical evaluation, misrepresentation of data through p-hacking, fabricated data sets, and flaws in peer review processes and publication biases against null result and replication studies, among a variety of other issues and concerns. Stuart Richie, Science Fictions: How Fraud, Bias, Negligence, and Hype Undermine the Search for Truth (Metropolitan Books, 2020).

[6] For a discussion of this see Tom Nichols, The Death of Expertise: The Campaign Against Established Knowledge and Why It Matters (Oxford University Press, 2017), especially chapter 4.

[7] Henry K. Beecher, “Ethics and Clinical Research,” The New England Journal of Medicine 274, no. 24 (1966): 1354–60, https://pmc.ncbi.nlm.nih.gov/articles/instance/2566401/pdf/11368058.pdf.

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