Med Health Care and Philos
DOI 10.1007/s11019-015-9628-7
REVIEW ARTICLE
What is Bioethics?
Nathan Emmerich
 Springer Science+Business Media Dordrecht 2015
Belkin, G.: 2014, Death Before Dying: History, Medicine,
and Brain Death. USA: Oxford University Press, 288
pages, ISBN-13: 978-0199898176, price: 57 USD.
Ferber, S.: 2013, Bioethics in Historical Perspective:
Medicine and Social Morality. UK: Palgrave Macmillan,
248 pages, ISBN-13: 978-1403987242, price: 27 USD.
Wilson, D.: 2014, The Making of British Bioethics.
Manchester, UK. Manchester University Press, 288 pages,
ISBN-13: 978-0719096198, price: 50 USD.
As Powers (2005, p. 306) points out, what bioethics
might be, and the methods with which it is pursued, remain
relatively undefined and highly diverse. We might also
think similarly about ‘ethics’; what it might be and how it
ought to be done is subject to a wide degree of interpre-
tation. Certainly, there are a number of (related) dominant
approaches—formal ethics, philosophical, practical or ap-
plied ethics—there are also a number of other, relatively
mainstream, approaches common to the field of bioethics—
casuistry, principlism, reflective equilibrium—and a num-
ber of ‘alternative’ or otherwise non-mainstream ap-
proaches, some of which are entangled or closely related to
particular bioethical issues—feminist ethics, disability
ethics, and various forms of theological analysis. For ex-
ample, we might note that ethics is not simply a disciplined
academic activity but something pursued in a wide range of
everyday, professional and policy-making contexts. Indeed
one might consider morality—or a moral order—to be a
necessary part of human societies. If so, then the fact that
some concerns are currently addressed as bioethical is a
contingent facet of the contemporary moral order.
N. Emmerich (&)
School of Politics, International Studies and Philosophy,
Queen’s University Belfast, Belfast, UK
e-mail: n.emmerich@qub.ac.uk
Bioethics is not, then, constituted by normative disciplines
(law and philosophical/theological ethics) alone. It is not,
simply, the ethical or ethico-legal analysis of the life sci-
ences, bio-technologies and medical practice. If bioethics is
to be properly understood then it must be seen as part of the
moral order and studied as such. The field must therefore
include historical, sociological and anthropological forms
of analysis.
However, a difficulty remains. What, we might ask, is
distinctive about bioethics? How do we know that we are
studying it, and not something else? It is difficult to think
that what is specific to the advent of bioethics is anything
other than the emergence of applied ethics, first as a mode
of philosophical thought (Collin 2000) and, subsequently,
as something that has become more widespread phe-
nomena. Nevertheless, as Wilson (2012, p. 218) cautions,
we should not equate bioethics with applied ethics; even if
they are strongly associated, bioethics is much more be-
side. Of course, historical epistemology is such that com-
mitting to any definition of ‘Bioethics’ prior to the analysis
is out of the question, as is the idea that a definition of
bioethics is the aim or result of such enquiries. Yet the
conduct of historical enquiry is such that some initial
characterisation is unavoidable and the substantive analysis
will provide further detail. This review essay sets out to
engage with this aspect of the books being considered.
Aiming ‘‘to provide insight into both the history of
bioethics as a social practice, and into the wider history of
medicine in its social context’’ (2013, p. 2) Ferber views
bioethics as something that straddles medical culture and
its socio-political environments. Somewhat amorphously it
is considered to be ‘‘the socially interpretative dimension
of medicine’’ and to encompass ‘‘a wide range of social
conversations’’ (Ferber 2013, p. 3). Whilst Ferber suggests
the term bioethics was coined to ‘‘denote a form of applied
123

philosophical ethics’’ (Ferber 2013, p. 1) she also notes that
bioethics is not just a ‘‘branch of applied ethics’’ (Ferber
2013, p. 5). Instead, it gives ‘‘name to a diverse collection
of public policy concerns about science and medicine’’ and
is something ‘‘we all do’’ (Ferber 2013, p. 1, 165 italics in
original). Yet in this view almost any comment on medi-
cine can count as bioethical and we might wonder how we
can differentiate bioethics from what went before (Baker
2013). Without such differentiation we would be hard
pressed to write a history of bioethics or, as Ferber aims to
do, place it in its historical context.
The inescapable conclusion is that bioethics must, in
some way, be orientated around the academic and philo-
sophical endeavour of applied ethics. Ferber contrasts
‘mainstream’ and ‘feminist’ bioethics with the former be-
ing described as claiming a ‘procedural neutrality’ whilst
the latter ‘‘admits a political point of view’’ (Ferber 2013,
p. 23). Furthermore, in Chapter 2—‘Bioethics as Scholar-
ship’—Ferber focuses on the academic tension that exists
between the field’s domains. This primarily concerns
questions about the relationship between applied ethics and
other forms of bioethical enquiry. In particular she high-
lights the ‘hyper-rationalism’ of the philosophically trained
ethicist and the endeavours of social scientists (anthro-
pologists, sociologists and, one might add, historians) as
well as those of theologians and healthcare professionals.
She also suggests that moral philosophy—the discipline
that applied philosophical bioethics claims as its inspiration
and intellectual home—remains ambivalent about its most
infamous offspring. Indeed we might read her as suggest-
ing that applied bioethics inhabits a space between re-
spectable philosophy and political agitation. Whilst they
may not necessarily be mutually exclusive, it is common to
find calls for bioethics to exhibit greater philosophical
rigour (Cf. Savulescu 2015) as well as to become more
involved with clinical practice, public debate, policy-
making and political activism outright.1 As a result it may
be that the applied ethicist’s need for philosophical
validation means that bioethicists ‘proper’ will be more
comfortable not only actively engaging with others, but
doing so on equal terms.
Indeed, such calls are often expressed simultaneously, at
least in the sense of being presented side-by-side.2 Nev-
ertheless, one does not have to look far to find discussions
of the way(s) in which the respective imperatives of these
activities exist in tension and may have occasion to conflict
(cf. Brock 1987; Benjamin 1990; Momeyer 1990; Toulmin
1
On this latter activity see Impact Ethics: http://impactethics.ca/
[Accessed 22nd Febuary 2015].
2 Kennedy’s Reith Lectures in 1980 there was some degree
For example see the 40th anniversary issue of the Journal of
Medical Ethics containing various articles discussing ‘good medical
ethics’.
123
N. Emmerich
1981). Inevitably this promotes further ‘boundary-work’
with the result that ‘‘[q]uestions of politics have shaded
into questions of methodology’’ (Ferber 2013, p. 36) and
vice versa. Whether philosophical or methodological, any
attempt at ‘semantic assent’ or reflexive analysis does not,
by itself, guarantee the absence of ethico-political interests.
Rather, such strategies should be seen as providing ‘‘a
politically safer ground to carry on arguments with serious,
but largely implicit, value implications’’ (Fuller 2000,
p. 249). As a result political ‘‘questions of whose authority
carries weight’’ (Ferber 2013, p. 36) are never far from the
surface in bioethical scholarship and we can extend Fer-
ber’s thoughts about the use of language in medical culture
to its use in bioethical culture(s):
‘‘Every choice about the language to be employed in
medical culture has a political and ethical dimension,
broadly speaking, as every statement explicitly or
tacitly expresses a preference about what should be
and about the shape that decisions should take’’
(Ferber 2013, p. 38 italics in original).
The various domains of bioethics are, at least in part,
constituted by the situated and contextual rhetoric associ-
ated with them. As such statements produced within each
of these domains are not only marked out by different
vocabularies but by the fact that they ‘‘arise within some
kind of social matrix’’ (Ferber 2013, p. 39). These social
matrices are the various disciplinary approaches to
bioethics and the different traditions of social, cultural and
political discourse, including that of law, that, taken to-
gether, are constitutive of the moral order. Indeed, one
might say that academic disciplines are themselves tradi-
tions, albeit it more, less or differently, reflexive traditions
of intellectual inquiry. Nevertheless, in this light, they can
be characterised as having their own internal moral order
and their discourses can, thereby, be related to those of the
moral order more generally. Indeed, one might take this as
Ferber’s stated task: the examination of bioethics in his-
torical perspective.
Wilson’s approach is somewhat different. Rather than
placing bioethical issues in context he traces ‘The Making
of British Bioethics.’ In the first chapter Wilson examines
club regulation in the UK medical profession. As form of
self-governance, club regulation was naturally aligned with
the notion that ethical concerns were considered internal
matters. Since the nature of medicine existed beyond the
understanding and, perhaps most crucially, experience of
non-professionals they were not in a position to consider
issues of ethical importance properly. Whilst this ethos
persisted within the UK medical profession at least until
of outside influence. It is obvious, for example, that the
1967 Abortion Act was not merely a matter of the medical
What is Bioethics?
profession setting a legislative agenda and exerting its in-
fluencing over parliament. Furthermore, credit for creating
the London Medical Group (LMG) can be awarded to Rev,
later Very Rev., Edward Shotter (Wilson 2014, p. 74).
Nevertheless, we should not take Shotter’s claim that LMG
meetings were open to the public with too much serious-
ness as relatively little, if anything, was done made to make
‘the public’ aware of the meetings.
Thus, whilst we can accept Dunstan’s claim, made in
1987 at a joint Anglo-American conference on Biomedical
Ethics hosted by the Hastings Centre and co-sponsored by
the Royal Society of Medicine, that going by ‘‘the in-
volvement of churchmen and philosophers in medical
ethics, we in the United Kingdom were about 10 years
ahead of you in the United States’’ (1988, p. 5) we should
not conclude to much from it; this involvement was not a
challenge to club regulation but part of it. Whilst those in
the Church of England who sought to engage the UK
medical profession on matters of ethics were outsiders in
the strict sense, they cannot realistically be seen as any-
thing other than part of the club and, therefore, likely to
inhabit a ethos consistent with that of the medical profes-
sion. That said, whilst UK theologians who engaged with
the medical profession about ethical issues ‘‘positioned
themselves as ancillaries to doctors’’ and maintained the
orthodoxy that ‘‘ethical issues were largely professional
concerns’’ (Wilson 2014, p. 93), there was also some
recognition that the multiplicity of ethical views in a newly
pluralist society must be taken into account. Certainly this
is clear in Wilson’s account of Ian Ramsey and his trans-
disciplinary medical ethics (2014, chap. 2).
If the correct notion of ‘bioethics’ is of something
strongly associated with applied ethics and, therefore, the
opening up of debates about medical ethics to non-club
members, at least in principle, it cannot realistically be
seen in the UK until at least the 1980s. Whilst the Centre
for Medical Ethics and Law at King’s College London
opened in 1978, bioethics as an academic endeavour
gathered pace in the UK throughout the 1980s (Wilson
2014, chap. 3). Indeed it was not until Tomorrow’s Doctors
was published in 1993 that ethics became a formally
mandated part of the undergraduate medical curricula
(Emmerich 2013).
Discussing their public and political impact, as well as
their more academic endeavours, Wilson examines the
careers of Ian Kennedy and Mary Warnock as major fig-
ures in the UK’s slow ‘transition from medical ethics to
bioethics’ (Wilson 2014, p. 95; Ashcroft 2001). In this
context it is, I think, interesting to consider precisely when
it was that Mary Warnock become a bioethicist and what
this might tell us. Whilst one might suppose that Warnock
was asked to chair the Committee of Inquiry into Human
Fertilisation and Embryology because she was a bioethicist
this is not supported by the facts. Certainly Warnock’s
interest in the application of philosophical ethics to con-
crete moral problems predated her appointment, this was
not the reason for it. Furthermore, she had not previously
given serious consideration to any bioethical issues. War-
nock become a bioethicist because of her appointment and
subsequent activities. Indeed, given her social status and
previous involvement in government inquiries, her ap-
pointment should not be seen as a rejection of club-
regulation; she was hardly an outsider and, in any event, a
‘true’ outsider would never be appointed to chair such an
inquiry.
One result of the Warnock Report, Kennedy’s Reith
lectures and other developments was that the ethical con-
cerns of medicine were no longer matters reserved for
professional consideration but increasingly subject to
public and political debate. The shift from ethics being an
internal concern of the medical profession to being a matter
for wider discussion may well have been an important part
of the making of bioethics in the UK but it is, one might
suggest, also inherent in the ethos of applied (bio)ethics.
The discipline of applied ethics considers ethics to be an
autonomous domain of individual reflection. It decouples
ethics from particular practices (like medicine), modes of
social life (like professions), and considers the idea of
‘tradition’ to lack moral significance. The analytics—or
what Ferber calls rhetoric—of applied ethics is such that it
paradoxically ‘‘embeds the practice of disembedding’’
(Anderson 2005, p. 178), removing issues from the con-
texts in which they arise, (re)presenting them as decon-
textualized puzzles about which we must make intellectual
and procedurally objective decisions. This methodological
facet of applied ethics can be considered inherently po-
litical. Furthermore, it is consistent with the way modern
liberal thought accommodates morality and the way that,
today, procedural processes are used to not only guarantee
democracy but transparency and accountability.
Wilson’s argument establishes a connection between the
success of bioethics and the rise of ‘neo-liberal’ forms of
governance, especially New Public Management, the pro-
motion of an ‘audit culture’ and the valorisation of indi-
vidual choice. Certainly neither applied ethics nor bioethics
more generally provides the intellectual foundation for
these broader socio-political developments. Rather, it is the
case that these developments have facilitated the success of
applied (bio)ethics. However, this is largely because ap-
plied ethics is positioned as prior to politics and therefore
conducted in an apolitical manner. Nevertheless, bioethics
may not be entirely devoid of the tools required to engage
in broader forms of socio-political critique. Ferber suggests
that what distinguishes the applied ethicist from the moral
philosopher is the degree to which each is willing to be
involved in providing normative advice (2013, p. 26). In
123

this light whether or not an academic bioethicist’s is will-
ing to contribute to the public debate by critically engaging
with the socio-political dimension of healthcare, and of
bioethical issues more generally, may primarily be a matter
of professional and disciplinary inclination or ‘ethos.’ If so
we might want to reflect on the academic training of ex-
isting and future bioethicists.
Belkin’s account of the history of brain death and, in
particular, of the Ad Hoc Committee of the Harvard
Medical School to Examine the Definition of Brain
Death—the body that developed the initial, and still in-
fluential, criteria that defines brain death—reinforces the
‘apolitical’ inclinations of applied (bio)ethics. However,
his approach differs significantly from that of Ferber and
Wilson in that he does not consider bioethics to name an
expansive set of disciplinary and political practices or-
ganised around particular concerns. Rather, at least in the
context of his research into brain death, he considers
bioethics to be a moralised form of conceptual and philo-
sophical analysis (Belkin 2014, p. 212). In contrast to the
way Wilson treats the Warnock Report, Belkin does not
consider the Harvard Report to be a bioethical document;
its production is not presented as a bioethical endeavour.
Indeed, part of Belkin’s purpose is to challenge ‘bioethical’
criticism of the Report as ‘‘ethically unsophisticated,
problematically focused on transplantation, and lacking
conceptual justification and empirical basis for this way of
understanding and defining death’’ (Belkin 2014, p. xv).3
To this end he criticises bioethics for not taking the en-
tanglement of fact and value sufficiently seriously as,
whilst it began by pointing out this entanglement, its sub-
sequent strategy has been quixotically misguided. Rather
than embrace the complexity of medicine, bioethics has
sought to conceptual sanitise medical knowledge and, as a
result, to purify its practices (Belkin 2014, pp. 212–219).
Bioethics assumes the possibility and utility of disentan-
gling fact from value (Belkin 2014, p. xvii) and, as part of
the Enlightenment Project (Belkin 2014, p. 228), it pri-
oritises the philosophically determined meanings of a
concept instead of examining how it is used in practice. As
Belkin puts it in the context of his research: ‘‘Rather than
focus on the ontology of medicine, bioethics instead fo-
cused on describing and debating the ontology of death’’
(Belkin 2014, p. 212).
Belkin’s account traces the way ‘‘conditions of work and
knowledge production changed’’ (2014, p. 29) in the years
3
Interestingly such criticism can be considered as having parallels
with those leveled at the Warnock Report. Furthermore, both reports
can be characterized as ‘pragmatic’ or as exhibiting pragmatic
elements (Belkin 2014, p. xviii; Wilson 2014, p. 161) whilst their
longevity belies the strength of such ethico-conceptual or applied
(bio)ethical critiques. Or, perhaps merely their importance and
relevence.
123
N. Emmerich
prior to the committee being convened in 1968, and de-
votes a chapter to considering the relevance of the previous
work of Committee’s Chair, Henry K. Beecher, on medical
and ‘research’ ethics. As Beecher ‘‘rejected a sharp
separation between technical expertise and moral expertise
about that technical expertise’’ (Belkin 2014, p. 66) he can,
like Belkin, be understood as suggesting that ‘‘the knowl-
edge of the good [exists] within the knowledge of practice’’
(Belkin 2014, p. 231). Thus the evaluative nature of
medical knowledge, facts and practice is not a problem to
be eliminated, but a reality that any ‘external’ account or
analysis must not only recognize but respect. Whilst Belkin
does not use the term we might see this as a tacit ac-
knowledgment of the ‘factish’ nature of knowledge (Latour
2011). In this view, biological death (or brain death) cannot
be anything other than the fusion of fact and fetish, of
empirical and theoretical perspectives, an emergent reality
rooted in medical practice and knowledge in motion.
Seeing them as providing much needed theoretical con-
straints, various philosophical accounts of death prioritize
matters of metaphysics or ontology over the clinical epis-
temology of medical science. Furthermore, they often do so
in concord with particular moral or ethical imperatives or
commitments. This approach excludes clinical ways of
knowing embedded in medical practice, and prefers an
endless search for the perfect union between concept-and-
criteria (Belkin 2014, p. 230). From the perspective of
clinical practice, ontology and epistemology are insepara-
bly fused, both with each other and with ethics or ‘the
good.’ Indeed, given there are at least two different and
distinct ways one can be clinically dead, it would seem that
the best way of understanding death is through the lens of
ontological multiplicity (Mol 2002).
Views such as these prioritize the generative realities of
actual practice over the objectivity of empiricism and its
counterpart, universalist philosophical theory. Thus, in
Belkin’s view, applied (bio)ethics is good for very little. As
a result he suggests that the key to improving medical
practice may lie with ‘‘other, potentially more effective
critical perspectives [that have] … emerged within the
practice of medicine itself’’ (Belkin 2014, p. 231). He
points to projects such as Continuous Quality Improve-
ment, Participatory Research and Patient-Centered Care
(Belkin 2014, pp. 232–235) as endeavors that engage with
the complexity of clinical reality. However, given a
broader definition of the term, there may be no need to
consider these activities in opposition to bioethics. Belkin
suggests that certain ‘‘[n]iche approaches to bioethics such
as narrative or casuistical ethics’’ (2014, p. 235) can engage
with the complexity and diversity of practice. Furthermore,
Wilson positions recent developments in ‘clinical gover-
nance’ as representative of the ongoing process of ‘re-
making of bioethics’ in the UK and, we might add, beyond
What is Bioethics?
(2014, pp. 234–235, 262–264). Nevertheless, we might
reflect on Ferber’s suggestion that following the socio-
political, cultural and institutional success of scholarly
bioethics its ‘‘belief in the value of regulation appears to be
weaker, not stronger’’ (2013, p. 158). This is, I would
suggest, the flip side of Belkin’s claim that whilst applied
(bio)ethics has recognizes ‘‘the situated or constructedness
of meaning in practice, yet … desire[s] to nonetheless
create an objective, authoritative ethical or critical position
and expertise over those meanings’’ (Belkin 2014, p. 66).
Having variously contributed to the reformation of mean-
ing(s) in practice, applied (bio)ethics remains troubled by
the fact that such meanings inescapably remain situated
and constructed phenomena.
Whether implicit or explicit, the respective accounts
Belkin, Wilson and Ferber offer regarding what bioethics is
suggest there is an essential tension at its heart. Perhaps
because he is most explicit in defining bioethics as not only
historically mutable but continually subject to change and
development, Wilson goes furthest in embracing, rather
than highlighting, the conflicting nature of the bioethical
project. In contrast, by dichotomizing applied (bio)ethics
with nearly all other endeavors that might be labeled
‘bioethical,’ Belkin pushes it to the fore. Ferber mediates
between the two. Having suggested that bioethics has an
essentially political character, a claim that undermines
certain conceits of applied ethics, she also suggests that this
may yet prove to be its greatest strength (Ferber 2013,
p. 165). Such a view would suggest that applied (bio)ethics
might be well advised to reconsider its attitude to ‘insti-
tutional entrenchment’ and join the rest of bioethics in
embracing the complexity of practice, the multiplicity
generated by ontological and epistemological entangle-
ment, and the constructed nature of socio-bioethical reality.
Yet, if it were to do so the essential tension at the heart of
bioethics would be lost. The tension is generated because
applied (bio)ethics insists on the methodological value of
its ‘apolitical approach’ and the fact-value distinction.
There is, however, no question of eliminating applied
ethics from the bioethical canon, not least because doing so
would mean the end of bioethics as such. Nevertheless, I
would suggest that there is a need for some kind of de-
velopment. Applied ethics is less the bed of the bioethical
river than it is a particularly strong undertow.4 If we have
4
I am alluding, of course, to Wittgenstein’s notion that human
thinking is a river. In this view philosophical investigations cannot
aim at excavating its formal foundation so much as it plumbs the
depths, perhaps reaching the bed of the river. Whilst this bed may be
reasonably static it nevertheless remains mutable and responsive to
the currents of life that flow over and above it. Given the nature of
applied ethics, and the fact it lies somewhere between moral
philosophy and moral practice, I have adjusted the metaphor
accordingly.
moved past the social science critique of applied ethics
(Hedgecoe 2004)—and the emergence of ‘empirical ethics’
is one reason to think that it has—then, for the most part,
this is primarily because bioethical thought has adjusted
and accommodated itself to applied ethics. The question
we might now ask is whether applied (bio)ethics is able to
adjust itself to meet the challenges raised by the bioethical
enterprise as a whole, both in its disciplined and academic
guise and in the socio-political discourses of ‘governance.’
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