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Taming Wickedness: Towards an Implementation Framework for Medical Ethics

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Abstract

“Wicked” problems are characterized by intractable complexity, uncertainty, and conflict between individuals or institutions, and they inhabit almost every corner of medical ethics. Despite wide acceptance of the same ethical principles, we nevertheless disagree about how to formulate such problems, how to solve them, what would count as solving them, or even what the possible solutions are. That is, we don’t always know how best to implement ethical ideals in messy real-world contexts. I sketch an implementation framework for medical ethics that can help clarify wicked problems and organize further ethics research toward their resolutions. This framework describes the procedural variables that work alongside substantive ethical ideals to deliver ethical decisions in complex real-world situations. Using controversial GM mosquito research as an example, I illustrate how the generalizable relationships between the variables clarify emerging ethical guidelines of research governance and provide a pathway to extend these guidelines in a way consistent with our ethical intuitions across a wide range of research and public health ethics.

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Notes

  1. The term ‘wicked problem’ was first widely used in the policy and organizational sciences. See Rittel and Webber [1]. The characteristics of ‘deep disagreement’ are explored in Fogelin [2] and Taylor [3].

  2. Evaluating efficacy will entail controlling for differences in provider training and patient compliance, for example. But these factors significantly affect effectiveness. Thus, clinical trials evaluating a therapy’s efficacy may be a poor guide to its effectiveness.

  3. This includes not only the principles in their most abstract form, but also in their more concrete, mid-level forms, such as that respect for persons requires the consent of research subjects without coercion or undue influence, or that justice requires the equitable recruitment of research subjects and a fair distribution of research risks and benefits across populations.

  4. Some procedural issues are addressed in a systematic way within the broader deliberative democracy movement. See, for example, National Coalition for Dialogue and Deliberation [35].

  5. In the organ allocation example, the tightness of a proxy is loosely analogous to the continuum described by decision theory under the rubric of ‘signaling.’ On one end of the continuum are ‘costly signals’ and on the other end, ‘cheap talk’ [37]. In the UNOS scheme, the fabrication of blood-level indicators would indeed be a costly signal, which explains why these levels are a tight proxy for medical need. However, the concept of a tight proxy articulated here is more expansive than the decision-theoretic concept, and can describe relationships that have nothing to do with signaling. For example, clearance by double-blind peer review may be a tighter proxy for the eventual truth of an academic article’s claims than pay-to-publish schemes are. But that fact, if true, is not explained by signaling in the decision-theoretic sense.

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  1. Washington and Lee University, 320 Washington Hall, 24450, Lexington, VA, USA

    Erin Taylor

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Taylor, E. Taming Wickedness: Towards an Implementation Framework for Medical Ethics. Health Care Anal 30, 197–214 (2022). https://doi.org/10.1007/s10728-022-00445-5

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