Journal of Medical Ethics, I975, 1, 152-154 J Med Ethics: first published as 10.1136/jme.1.3.152 on 1 September 1975. Downloaded from

Correspondence

Composition and function of mathematical techniques and drive to present it to an ethical committee ethical committees towards the quantification of phe- in a fashion which corresponds to SIR, nomena and their properties which the procedural canons of orthodox had served the natural scientists so science. Two important conse- paper on the and In his composition well were adopted, often with their quences follow. First, ethical re- function of ethical committees, assumptions about causal determin- search may be turned down because William May (1975) sets out an ism. thescrutnizing committeeare unable argument that such committees to recognize its scientific quality, should be concerned with both Over the last few years, however, sociologists havebecomeincreasingly since they may be judging it by moral and scientific aspects of inappropriate standards. Secondly, medical research. Poorly designed disenchanted with such models of human conduct. In particular, it is and more seriously, unethical re- research is, a priori, unethical since search may slip through because it exposes subjects to an unnecessary argued that conduct is not causally determined behaviour but, rather, scrutineers lack the knowledge to risk for an unrealizable benefit. The pick up its defects. ethical committee's first response to intentional action which is to be to the a submitted project should, then, be, explained by reference At the end of the day, the only 'Is this good science?'. May elabora- purposes and motives of the actor. true safeguard is the integrity of the tes some criteria for identifying The language is one ofreasons rather researcher. This can be developed scientifically valid work. than causes. For example, sociolo- in undergraduate and graduate gists are coming to suggest that training but it is most important that

While we accept his view of the copyright. importance of ethical committees patients do not take up available integrity is sustained throughout the both in monitoring standards and services because they have what they institutions in which researchers promoting ethical awareness and find to be entirely adequate reasons actually work. All the training in the accept that the considerations he for not using them rather than world is likely to be rather ineffective sets out are both important and assuming that they have some ifit is not supported by the everyday relevant for clinical experiments, we defective form of rationality or attitudes and practices of colleagues. feel that it is necessary to go beyond viewing their actions as determined The role of an ethical committee these. If ethical committees are to by some occult force, while the needs to be a positive one of be really effective they must concern researcher is, of course, a 'free actively promoting ethical awarenesshttp://jme.bmj.com/ themselves with all research in their actor'. If we want to understand rather than merely inhibiting the institutions. While May's model for patients' actions, we need to be able slipshod. If it is to be successful in judging scientific acceptability is to tap the reasons which the this enterprise, the committee must fairly easily generalizable to most patients recognize themselves, since enjoy the whole-hearted confidence natural scientific investigation, it it is those reasons which are of every researcher coming under could present real problems for responsible for the observable con- its auspices. It must be seen to accord social scientists engaged in medical duct. This can only be done by fair representation to all disciplines, adopting methods of research whichx research. In this, a certain tension specialties and levels of experience on September 30, 2021 by guest. Protected access to between the programmes of the allow the investigator the and prestige and to be taken seriously social and natural scientist is cognitive framework through which by all members of the institution. exposed. the subject of the research interacts Otherwise one merely creates a. As Illsley (I975) observes, medical with his social enviroument. clmate in which the tacit cover-ups sociology is gradually beginning to In consequence, sociology has described by Barber et al (1973) shake itself free of its dominaton by adopted a less rigid view of what is flourish. Such confidence can hardly medical practitioners. In the past, acceptable scientific enquiry. Re- be said to exist among medical sociologists tended to study prob- search is relying a great deal more sociologists at the present time, and lems defined for them by doctors in on the observation of naturally this view is probably shared by other terms set by doctors. They looked at occurring social action and conversa- non-clinical researchers with inter- the social and economic correlates tion-like free interviewing. The true ests in medical practice. The situa- of disease incidence, at the failure objectivity of the scientist is seen tion is unlikely to change while of patients to make use of services to be his dispassionate, disinterested ethical committees have, and are and the inability of auxiliary and and sceptical state of mind rather seen to have, in their philosophy and paramedical workers to execute than some particular bundle of membership, the relatively narrow physicians' instructions. These in- techniques or quantitative proced- remit of reviewing only clinical vestigations were carried out within ures. Thus, while the sociologist research along the lines suggested a model ofinquiry which consciously may have a clear idea of what he in May's article. aped that ofthe natural sciences. The wants to do, it may not be possible The remedies are twofold. First, Correspondence 153 J Med Ethics: first published as 10.1136/jme.1.3.152 on 1 September 1975. Downloaded from

ethical committees should draw on Active and passive euthanasia with both. But it is only through the both clinical and non-clinical disci- SIR, benefit of time for thought that I plines for their membership. The Dr Richard Nicholson in his article, have identified, for myself at least, committees cannot hope to evaluate 'Should the patient be allowed to the area in which they are unable to the scientific merits of research die?' writes: 'Euthanasia, literally a meet. It is the area of priesthood. without the benefit of informed "well, or good death", may be Illich articulated the concept of opinion. Without an adequate voluntary or involuntary; it may the area of man's autonomous self evaluation, the ethical may be also be either active or passive, these control. As he was talking of excluded and the unethical slip terms in practice being used synony- medicine he was constantly in fear through. But the committees would mously with positive or negative of appearing to glorify the miseries be hopelessly unwieldy if all poss- euthanasia. Active, or positive, of human suffering. He carefully ible disciplines and grades were euthanasia involves the use of picked his way through the dangers represented. This might suggest treatments designed to promote of holding a brief for the ultimate some kind of division into death sooner than would otherwise value of human responsibility, constituencies which could nomi- \ be expected. Passive, or negative, whether for your bank balance or nate representatives. However, euthanasia is a fiire to use thera- your death. secondly, where a discipline is not pies that would prolong life in a Marinker seemed to me the almost represented directly it is important patient with a terminal illness.' perfect apostle of enlightened con- that the investigator be allowed to We are writing to you jointly, one temporary society. He was concerned present his case in person and that ! of us a supporter and the other an to justify historically what he called a representative of that discipline opponent of legalized voluntary 'the clinical transaction'. Tbe ghast- who is fully conversant with the euthanasia, in the hope of checking liness of the term did not deter me investigator's approach should join the spread of the expression 'passive from the intellectual substance ofhis with the ethical committee and euthanasia'. In this and other position. He saw the doctor as participate fully in the discussions English-speaking countries the something more than a mere tech- which precede their decision. established usage of 'voluntary nician: he saw him as the senior The effective operation of ethical euthanasia' refers only and precisely partner in an almost metaphysical committees depends upon the con- to what Nicholson calls active relationship. sent of those they are set up to voluntary euthanasia. Furthermore, Now it is that point that identified monitor. That consent cannot be 'good terminal care', which Nichol- for me, at least, the reason why imposed or demanded. It can only be son regards as synonymous with Illich caused a greater spiritual copyright. acquired ifthe committee's decisions passive euthanasia, is anything but empathy. Man does need to be and justifications are seen to be fair, passive or negative. cared for and to believe, but it is not just and reasonable, based on a full The effect of introducing his the doctor but the priest who has and informed consideration of all distinction must be harmfully divi- traditionally fulfilled this role. the issues involved. Such confidence sive. If the avoidance of 'furor Marinker was wrong when he said: will be most readily accorded to a therapeutica' comes to be thought 'History suggests that the fact of the broadly representative committee ofas a form ofeuthanasia, then those wbo are against dialogue will not be changed'. Even with open procedures and a readi- euthanasia will be his delightful reference to the http://jme.bmj.com/ ness to accept the diversity of inclined to support 'furor thera- bistorical Ivan Ilyich betrays the scientific investigation. peutica'. This is a result which both point. This man's question whether MICHAEL BLOOR the present writers, and Nicholson his condition is 'dangerous or not?' R W J DINGWALL too, would deplore. does not indicate a man seeking a GORDON HOROBIN A. G. N. FLEW personal spiritual relationship. On J MCINTOSH University of Reading the contrary, he is a man seeking M L SAMPHIER R. G. TWYCROSS information about the physical para- MRC Medical Sociology Unit, St Christopher's Hospice, London meters of his existence. Certainly on September 30, 2021 by guest. Protected Centre for Social Studies, there is no indication from the reply Westburn Road, Dialogue between Marshall of the doctor - 'mind your own Aberdeen Marinker and Ivan Illich business' - that he is aware of this SIR, need for a relationship. On the References he a Barber, John J, As a lawyer surreptitiously present at contrary is aware of purely Bernard, Lally, the London Medical Group con- technical superiority, independent Makarushka, Julia Loughlin and of any transcendental spiritual com- Daniel Research on ference on iatrogenic disease, I was Sullivan, (1973): aware of partaking in a function munication. The Ivan Ilyich of Human Subjects, Russell Sage, New history on hearing that his condition York. not only of medical significance, but of a deeper philosophical, even was fatal would be far more likely Illsley, Raymond (I975). 'Promotion The real to satisfy bis economic commitment to observer status' Social Science theological, importance. dialogue of the day seemed to me to to the doctor and then seek the priest and Medicine, 9, 63-7. be between Marshall Marinker and for the arrangement of his deeper May, William W. (I975). 'The spiritual relationships. composition and function of ethic- Ivan Illich. al committees' J7ournal of medical Illich I was prepared to be dis- As I understand Illich - and I I, appointed in or impressed with. don't pretend he is easy to under- ethics, 23-9. Marinker I did not know of. Both stand - he is trying to assert the their contributions were articulate value of man breaking free from the and compelling, and I was impressed institutionalized provision of his