Chirality, clarification and caution.

I suspect that most readers will, like me, be unfamiliar with the concept of chirality. Indeed I had never heard of the term before reading Dahlen’s paper proposing the completely novel concept of ‘chiral equipoise’ in considering the outcomes of comparative therapeutic research in clinical trials. Chirality refers to ‘handedness,’ as in whether we are right or left-handed. Building on Freedman’s (1987) influential concept of ‘clinical equipoise’ which stipulates that research trials on humans can only be considered ethical when there is general disagreement among experts as to which treatment is the best, she asks if we need to go even further than this. She considers ‘any tendency to reductively consider the human participants of clinical research as a group of imagined ‘sex-neutral persons’ (most often male), rather than fully seeking to understand the variable of the unique needs of females, is an ethical error.’ Using chirality as a term to encompass her view that though ‘female and male are equally human,... knowledge of the biology of one sex cannot be completely superimposed onto the other,’ she argues that in addition to clinical equipoise, we need to consider chiral equipoise as something not just to receive practical attention but ethical attention as well in our approach to clinical research. Just as Freedman’s original concept of clinical equipoise was not only influential but highly contested even 30 years later (Hey et al 2017), I suspect that Dahlen’s chiral equipoise will raise considerable controversy also. Some terms not only generate controversy but also confusion. There are two papers in this issue examining this problem. The first of these examines the concept, popularized by, though not originating with Pellegrino, of ‘the internal morality of medicine.’ In a deft analysis of various competing accounts of what they call ‘essentialist’ and ‘evolutionist’ application of the term, Ng and Saad discuss the competing and contrasting elements of each position and outline what they see as the shortcomings of previous accounts. They recommend the term ‘internal morality’ should be jettisoned altogether, since ‘if its essence is its sole source of authority, the morality it derives from this essence alone is no more authoritative in such matters than the rules of chess are to cricket.’ They then suggest ways in which their examination of medical morality might be carried forward, concluding with admirable candour that ‘to fully develop it into a robust and clear argument is for another day.’ It sounds as if another paper to savour is already in the making there? the new bioethics, Vol. 27 No. 3, 2021, 195–196