Translational bioethics

Abstract

Bioethics as a field has sometimes struggled to have, and demonstrate, “real-world” impact. Notwithstanding the fact that bioethics lies at the practical/applied end of the ethics spectrum, and for some can only really be understood as a field concerned with ‘practical ought questions’,1 it is hopefully not too controversial to say that bioethics has tended to adopt a relatively passive ‘if we build it, they will come’ attitude to impact. That is, impact being achieved ad hoc through, for example, committee work, rather than systematically as a planned output of research.2 The problem with this kind of approach is that clinicians and policymakers at all levels will be largely unaware of much of the bioethics literature, and bioethicists may not always have a full understanding of evolving clinical realities. As such, bioethicists may not be producing work that resonates sufficiently with decision makers, even if they happened to come across it at an apposite time. An obvious recent example was the response of the bioethics community to the COVID-19 pandemic. Countless publications explored various challenges, but there is an open question as to how much impact resulted.

Efforts to overcome accusations of ivory tower ethics have included the so-called ‘empirical turn’ in bioethics.3 That is, combining normative and empirical inquiry with the aim of grounding ethical theorising in context.4 Whilst not universally adopted, there has certainly been a strong uptake of empirical bioethics methods and methodologies, as scholars look to orient their works towards practice and impact. Complementing this empirical turn, and possibly even prior to it, a literature has been developing that consider impact in different ways—focussing on the idea of translational bioethics. The first use of this term is often attributed to Cribb, who argued in 2010 that just as scientific research paradigms have ‘bench to bedside’ process, so might bioethics, explicitly introducing the idea that translational work might be undertaken to develop impact from bioethics research.5 Bærøe later explicitly developed this idea of translational bioethics.6 More recently, Sisk and colleagues have argued for the incorporation of implementation science into bioethics, to ensure that impact is achieved.7

Whether positioned as parallel to, or part of, empirical bioethics, this developing literature is distinct, as it is concerned with the role of bioethics research in policy and practice, and how this relationship can be characterised—in terms of process, scope, and direction. Important questions in translational bioethics discourse include: How should translational bioethics be defined? What is the purpose of translational bioethics? Is there a need for translational bioethics? What does good translational bioethics look like? How can/should translational bioethics be evaluated?

These questions formed the basis of a workshop hosted at the University of Bristol in September 2021, thanks to the support of the Institute of Medical Ethics. With talks from Ian Thomas (North Bristol NHS Trust), Albert Weale (University College London), Michael Dunn (National University of Singapore), and Katharine Wright (previously Nuffield Council on Bioethics), the workshop brought together participants from varied backgrounds, including academics, doctors, nurses, paramedics, and policy workers. A live illustrator attended the workshop to capture the discussions in a series of images (see Figures 1.-4.).

The workshop, perhaps unsurprisingly, gave rise to more questions than answers, with some areas of agreement and many areas of disagreement. Importantly, however, the disagreement was stimulating and productive; even where participants disagreed, there was nonetheless a sense when someone was felt to be wrong, they were wrong in an interesting way.

Being wrong in an interesting way is really the jumping off point for this special edition, in which we have attempted to cultivate a collection of papers that will stimulate thought, generate discussion, and send the debate in different—and hopefully productive—directions. Papers included present, for example: arguments that we should think of ethics education as a form a translational activity; sceptical accounts about the value of translational bioethics; stepwise processes for translational activity; and examples of translation in action.

To help the reader navigate, we provide below brief summary of each paper, which may be useful for anyone who wants to dip in and out.

Kremling and colleagues draw on the translational pipeline in medicine, exploring possible analogies and disanalogies between it and translational bioethics. Dissecting this pipeline to propose an analytic definition, they argue that unresolved conceptual problems prevent the translational analogy being meaningfully used in the bioethics context. Nonetheless, they highlight lessons that might be learned from exploring the analogy to better understand the nature and purpose of bioethics research more broadly.

Bærøe then reflects on what translational bioethics can be, analysing the philosophical foundations of bioethics itself as an academic field as they relate to questions of practical relevance and impact. She suggests that the socio-political influences on academic ethics are not appreciated nor are the limits to the real-world impact that it can or should aspire to. To begin addressing these problems, she offers a new approach to translational bioethics that speaks to real-world ethical practice.

Next, Dunn and Sheehan critique the need for translational bioethics as a branch of bioethics. They suggest that proponents of translational bioethics often misunderstand the theory-practice gap and that bioethics is inherently practical, thus any proposed subdivision is both unnecessary and potentially harmful to the field as a whole. Perceiving a suggested shift in focus from practical relevance to an “application requirement” on bioethicists, Dunn and Sheehan argue that we should be sceptical of such a reshaping of the underlying goal of scholarly activity in the field.

In contrast, Frith makes a case for the development of translational bioethics as a specific subdisciple, presenting an account of translational bioethics that is intended to complement existing bioethics scholarship. Similarly looking to the translational medicine pipeline, Frith's proposal for manoeuvring from theory to practice progresses from research that is philosophical, to theoretical, to practical, to translational, before resulting in implementation in practice. The translational bioethics stage, she argues, would be different to existing bioethics research in taking practical influence as its main motivation.

In the next paper, Wilson and colleagues consider the COVID-19 pandemic context and overwhelming volume of bioethical issues arising. Taking translational bioethics to be the transfer of insights from theory to practice, they explore the challenges—both practical and political—of influencing policy, using the Ethics Advisory Board established for the NHS COVID-19 App as a case study. Reflecting on the approach of the UK Government to ethics advice following the board's demise, a framework is proposed for analysing ethics advice, comprising four possible characterisations of the nature of translational bioethics taking place.

Knochel and colleagues also look to the pandemic context, exploring the translation of theories of justice into a triage model for the allocation of scarce intensive care resources. In the setting of a German university hospital, they describe bridging the ought-is gap from aspirational norms to specific norms and the resulting institutional policy for implementation. Finally, they reflect on the use of participatory research methods and what can be learned from their experience.

Metselaar then raises further clinical practice considerations, also looking to participatory methods. Drawing on hermeneutic ethics and pragmatism, she details the development of clinical ethics support instruments tailored to specific care contexts to highlight translational bioethics as a “two-way street”. That is, recognising how bioethics scholarship may similarly be enriched by the insights gained from a coproductive approach to translational bioethics.

Next, Kuehlmeyer and colleagues present their framework for translational bioethics, termed “transformative medical ethics”. Seeking to overcome the ought-is gap, the proposed framework details six clear phases with 12 distinct steps to translation, moving from the concretisation of normative requirements to the endorsement of practice change. They then highlight the value of such an approach using the translation of respect for autonomy into medical decision making as an example.

Considering translational bioethics in approaches to research, Parsons and colleagues suggest a need for bioethicists to consider our contextual awareness, proposing the approach of “ethno-immersion” to complement bioethics research. In response to what they frame as the context detachment problem, ethno-immersion requires the bioethics researcher to gain first-hand exposure to the context under investigation, regardless of whether they are engaged in empirical bioethics research.

Finally, Young and colleagues discuss the interface between translational bioethics and medical education, looking to concepts of embodiment and reflection as translational tools. Taking knowledge translation as non-linear, they suggest that medics embody knowledge about ethics drawn from various sources—not only that contained within their formal medical education. Through reflective practice, they argue, this embodied knowledge can then be refined within a moral community.

We hope that the conversations that are both continued and started within this special issue will be of interest to a wide range of readers. The breadth of considerations offered seeks to move translational bioethics discourse forward in a constructive manner. Finally, we invite others to join and continue these discussions and develop further our understanding of translational bioethics in the years to come.