Alex John London, For the Common Good: Philosophical Foundations of Research Ethics. Oxford University Press, 2022, pages 480, £64.00 (Hardback), ISBN: 9780197534830

Introduction

Alex London’s book, For the Common Good: Philosophical Foundations of Research Ethics, philosophically analyses some of the foundational tenets of medical research ethics. Before discussing the core arguments of this book, it is important to clarify the relevance of introducing a work like this when the current dominant view — shared within the bioethics community as was reported recently by a few scholars [1] — is that philosophy is no more relevant for the field. Though these scholars meticulously argue about how this disposition can be detrimental to the field, we need to pause and ask why this kind of view arises in the first place. This view, interestingly, is different from similar ones raised in other contexts. For instance, in contrast to the dominant view in science — where scientists think that philosophy is “antagonistic” to science [2] — this view advocates an early retirement for philosophy in bioethics. Why is a discipline once considered central now considered obsolete?

This might be due to the presumption that among the sub-disciplines of philosophy, it is only moral philosophy that is relevant to bioethics and once a blueprint for ethical rules is available, the job of philosophy is over. Bioethics, in its early days, was indeed proximate to moral philosophy. However, continuing to believe that only this sub-discipline is relevant, fails to acknowledge that bioethics has matured into an independent field with its own foundational questions, answering which requires the entire gamut of philosophy. A fine illustration of how philosophy would be relevant in this way can be found in London’s book.

Problems of orthodox research ethics

The larger argument of the book is a response to the current dominant form of medical research ethics which London labels as “orthodox research ethics” (ORE). Because of the historical aspects that shaped the field, ORE has come to have a particular conceptual configuration. Research in ORE is a private, non-public affair between researchers and participants. Due to this, research needs to be governed by review boards, where the ethical duties of the involved stakeholders are derived from their functional roles. For instance, the responsibilities of medical practitioners (whose primary function is to give care) differ from those of researchers (whose duty is to work on uncertainties and advance medical knowledge).

London argues that these fundamental aspects render ORE defective. Since research is a private endeavour, there is no social imperative to carry out research. The functional interpretation of responsibilities limits the scope of ethics to protecting patients from research abuse, and justice gets translated merely as beneficence and respect towards participants. This interpretation makes ORE presume that medical practice and research are intrinsically opposed activities, and that this dilemma is the inescapable foundational truth on which the ethical edifice must be built. This framework is unable to recognise the people involved — researchers and participants — as free and equal individuals.

Reconfiguration of research

ORE professes that there is no social imperative for carrying out research because of the specific way it understands the common good — what is good for all individuals. London substantiates this using Hans Jonas’ influential argument that it is not an individual’s illness, but large-scale disasters like epidemics that concern society as a whole [3]. Therefore, Jonas asserts, there is no imperative for society to undertake medical research as it is not for the common good.

By showing how the initial ORE proponents’ interpretation of the common good was different from and opposed to the individual’s good, London motivates his central claim: that with a better conception of the common good at the foundation, medical ethics can be reconfigured to overcome the above problems. This alternative proposal is formulated at the level of individuals, unlike the orthodox variant that was defined at the level of the community. Drawing mainly from Rawls’ work, London distinguishes the individual’s interests into two kinds. There are personal interests, which are part of every individual’s life plan. Apart from these, there are basic interests that are generic to all individuals of a community.

London thinks that basic interests are better candidates for defining the common good. With this reconstitution, medical research gains a social imperative: it is necessary for society to carry out research since the outcome of this directly aids social institutions (such as healthcare systems, etc) in protecting the basic interests of individuals. Here, individuals too have an imperative to participate in research, as it contributes to their basic interests. And this can be enabled by conceiving of research as a cooperative scheme where individuals volunteer to join, with the assurance that their basic interests will not be compromised. Thus, by reinterpreting the common good, London claims to resolve the orthodox problems pertaining to research participation, and articulation of justice for the participants.

Observations

The starting point for London’s analysis is the “problematic commitments that shape the conceptual ecosystem of orthodox research ethics” (p 4). However, he does not substantiate what he means by “orthodox research ethics”. Indeed, “orthodox” is a standard qualification for referring to the dominant, consensual viewpoint about a specific topic. But, when it is used at the level of a field, some concerns emerge. First, for an interdisciplinary field that comprises numerous kinds of practitioners, it is important to clarify which perspective’s orthodoxy is being considered. For instance, do medical researchers also think that their profession is a non-public and optional affair or is it confined to the bioethics moral philosophers?

The other concern is the role of ORE in the book’s larger argument. What does the overall argument gain when the criticisms are recognised as pertaining to “orthodox” research ethics? At the beginning of the book — within a stretch of a paragraph — London describes how the conceptual ecosystem and the commitments make “certain views seem natural and intuitive” and “determine the scope and limits” of the field (p 4). Given that ORE is portrayed as a unified framework whose characteristics can be reduced to a few tenets, the discussion could have been supplemented with clarification on what falls within and outside ORE. Even though the tacitness does not dampen any of the specific arguments in the book, this makes ORE appear like a vague placeholder that facilitates pinning these arguments to a singular opponent and thereby bringing them together into a coherent criticism.

One of the central preoccupations of the book is to arrive at a balanced understanding of research that captures its essential nature and yet makes it amenable to ethical analyses. London effectively does this by interpreting research as an activity that contributes to the basic interests of individuals. This formulation of research, however, is specific and limited to the problems it has come to solve in medical research ethics. London does mention that his interpretation is useful to understand “a wide range of research…of any social institution that impacts the basic interests of that community’s members” (p 148). However, the applicability of this to understand research in other avenues where the research outcomes might not directly connect with the basic interests — such as physics and mathematics — is not clear. With this, the limitation of research ethics based on this concept of research comes to the fore: it can tackle those questions that pertain to research implications. Other kinds of ethical difficulties — for instance, the role of values in studies about IQ distribution in society or production of genetically modified objects — seem to require a different notion of research.

Philosophy for bioethics

Regarding the book’s larger theme, how does such a philosophical enquiry contribute to a field like medical research ethics? Primarily, the book does the hard work of answering the basic questions that are crucial for practitioners, like: what is research in medicine; how it is a social endeavour; and how research can be made egalitarian. Going beyond this, the book’s arguments demonstrate how the field’s practices are invariably dictated by the way we think about the relevant concepts. For instance, ORE fails to figure out how to ascertain the individual’s participation in a research trial because it misinterprets the concepts of “research” and “practice” in medicine. As London illustrates, clarity of the involved concepts can resolve the hurdle. With these conceptual refinements enabling us to perceive things differently, we may be able to see what philosophy can do for medical research ethics.