Publishing in the field of medical ethics: From describing ethical issues to ethical analysis

I took on the role of Editor-in-Chief of Clinical Ethics in April 2022. During the months that followed, one thing that I and the members of the journal's Editorial Board noticed was that, despite the excellent articles being published, the overwhelming majority of submissions we received merely sought to identify and describe various ethical considerations, issues, problems, scenarios, or attitudes associated with a particular healthcare or public health practice or policy. As interesting as the findings were, in and of themselves, the purely descriptive approach taken in these submissions limited their potential (and, ultimately, their ability to be published in Clinical Ethics). Simply put, there was no reason to believe that these purely descriptive submissions warranted publication in an ‘ethics’ journal. For that reason, the Editorial Board and I decided to introduce new essential submission criteria, which have been made explicit in the submission guidelines on the journal's website:

Submissions must provide a substantial ethical, legal, and/or policy analysis that situates the author's arguments, claims, results, data, and conclusions in relation to debates in bioethics, medical ethics, medical law, or health policy.

Please note that purely descriptive empirical studies as well as papers that lack a substantive ethical, legal, or policy analysis will not be considered for publication.

Despite the introduction of these criteria, many the submissions Clinical Ethics receives still do not go beyond – in any substantive sense – descriptions of various ethical considerations, issues, problems, scenarios, or attitudes. Of course, this could mean that these authors haven’t carefully read the submission guidelines before making their submission. Alternatively, it could mean that the terms ‘descriptive studies’ and ‘ethical analysis’ are too vague, eliciting different inferences among different individuals or groups.

Perhaps the most important point to acknowledge is that ethics is a normative discipline, and this means that it has two primary functions: (a) to provide action guidance and (b) to provide action justification.^1–4 While there are different views about how we should taxonomize medical ethics and its associated disciplines, e.g. bioethics, public health ethics, and applied ethics, it's reasonable to assume that, in virtue of being forms of ethics, they should share these functions and aim to provide guidance and justification for actions in normative healthcare and public health matters. Providing action guidance, that is, delivering normative conclusions, can (and often does) involve appealing to descriptive information, including the ethical considerations, issues, attitudes, and perceptions that have been identified through, for example, scoping reviews or quantitative and qualitative studies that employ the methods of the social and behavioural sciences.^5,6 However, we cannot fulfil the normative functions of medical ethics by simply reading normative claims off of descriptive information. As John McMillan has argued in his superb introduction to doing ‘good bioethics’, ³ even if we should be ever vigilant of the risk of subscribing to the erroneous belief that ethical claims are not amenable to reason, the fact/value distinction still exists and provides us with a helpful reminder that that we must not make unwarranted inferences from descriptive premises to normative conclusions.

Ultimately, we cannot fulfil the functions of medical ethics as a normative discipline without the use of reasons.^7,8 By assessing ethical claims as legitimate or illegitimate, we can develop the reasons needed to justify our action guidance and thereby satisfy the functions of ethics as a normative discipline. And it is here that we go beyond merely identifying ethical considerations, issues, and attitudes to engaging in ethical analysis.

Broadly speaking, ethical analysis is about determining whether ethical claims, conclusions, and arguments are warranted or, at least, the degree or extent to which they are warranted. And the goal of ethical analysis is to deliver reasoned convictions and arguments about what should be done in response to an ethical issue or moral problem. ³

Of course, a copious amount of ink has been spilled on the topic of operationalizing ethical analysis, from theory-driven approaches embedded in, for instance, religious doctrine, moral particularism, neo-Kantianism, deontology, consequentialism, libertarianism, the interest theory of rights, etc., to more procedural approaches (e.g. principlism, casuistry), to those developing ethical arguments ostensibly without theory (for a discussion, see ⁹ ).

Practically speaking, some of these approaches to ethical analysis are more amenable to the demands and limitations of a journal article than others. For instance, I’ve lost count of the number of submissions we’ve received that seek to employ Tom Beauchamp and James Childress's ‘four principles’ (respect for autonomy, beneficence, non-maleficence, and justice) to identify or describe ethical issues associated with a normative healthcare phenomenon.

Bioethical principlism provides a useful starting point for identifying ethical issues to the extent that Beauchamp and Childress’ shared normative framework seeks to incorporate long-standing clinical duties to maximize benefits and minimize harms, while also addressing concerns about justice and respect for patient autonomy. ¹⁰ However, developing an ethical analysis within a principlist framework is a much more substantive and difficult task, something that is highlighted by the development of Beauchamp and Childress’ own framework over several editions in response to criticisms about the lack of justification for the choice of principles, the lack of a priority ranking among the four principles, the problems with filling the gap between abstract principles and concrete judgments, and the absence of any specified procedure for resolving the conflicts between the principles. ¹ In order to develop a suitable ethical analysis within a principlist framework, authors should be prepared to go beyond the principles themselves and consider the methods that Beauchamp and Childress developed in the wake of early criticisms for balancing and specifying principles. Otherwise, as Gert, Culver, and Clouser noted in relation to the widespread adoption of bioethical principlism in public health and clinical ethics policy documents in the 1990s, the risk is that ‘the principles of principlism primarily function as checklists, naming issues worth remembering when one is considering a biomedical moral issue. “Consider this … consider that … remember to look for …” is what they tell the agent; they do not embody an articulated, established, and unified moral system capable of providing useful guidance’. ¹¹

Not all medical ethics journals explicitly, or even implicitly, operate according to the criteria for ethical analysis that Clinical Ethics details in its submission guidelines. A good way to find out whether your manuscript is suitable for a particular journal is to spend some time looking at what that journal has recently published (i.e. the methods employed, the approaches adopted, the arguments they contain, and the forms those arguments take). Better yet, if you are in any doubt, then email the editor or the editorial office. In terms of Clinical Ethics, the key thing to bear in mind if you are considering the journal as a potential outlet for your research is that no matter how interesting, relevant, or timely the topic, how innovative or careful the design, and how robust the data or findings, your manuscript should fulfil the functions of ethics as a normative discipline, and that means delivering normative conclusions or recommendations justified by reasons.