Socratic empathy

November 14, 1997

Jonathan Glover, new director of the Centre for Medical Ethics at Kings College, London, explains to Harriet Swain how imagination is the key to making life and death decisions.

Philosopher Jonathan Glover just could not make up his mind when he was offered a job as the new director of the Centre for Medical and Legal Ethics at Kings College, London. He agonised. He wrote out a list of pros and cons and stared at them. Finally, he went on the "gut feeling that it would be sensible to go to Kings". No sooner had he done this than his resolve was shaken. He had to leave his students at New College, Oxford at short notice to help deal with a family crisis and when he returned he found a card signed by everyone in his department. How could he leave all those warm people?

Now he is sure he is doing the right thing in taking the job. Almost. "I have never run anything in my life," he says. "I have spent nearly 30 years as an Oxbridge tutor. I love teaching philosophy and I don't have any particular administrative capabilities so I was seriously worried about whether I was needed at Kings. I suspect it involves a lot more administrative work, which I will have to pretend to enjoy."

The holes in the carpet of his large, London home - a recent Turkish holiday offered the perfect chance to cover them up with rugs - his crumply tieless shirt and scattered papers suggest he does not like dwelling on the mundane. But although he will give all the time in the world to thinking, taking seven years to write a book, he wants his thought to be of some use. "I'm something of an old-fashioned utilitarian," he says. "I think philosophical questions about ethics ought to have some impact on the world. I would be worried about living a life of self-indulgent academia if it didn't have any impact at all."

He believes theory and practice fertilise each other and is worried about people such as doctors, lawyers or technical wizards becoming "too mechanical" in their work without any theoretical basis in medical ethics. In the other direction, he is an avid reader of newspaper stories involving real ethical dilemmas, using them to discover how theories are put into practice. He was pleased that his book Causing Death and Saving Lives may have played a part in decisions concerning Tony Bland, the Liverpool football fan who suffered injurues leading to an irreversible coma after Hillsborough. It was read both by the law lords deciding whether legally he should be allowed to die and by Bland's family.

In the book, Glover argued that people do not have a right to life. Killing is wrong because it is wrong to reduce the length of a worthwhile life and because, except in extreme cases, it is wrong to kill someone who wants to go on living. Furthermore, killing can have unacceptable side effects on the living, from causing sadness to family and friends, to robbing the community of a person's economic and social contribution, to encouraging people to take killing more lightly. For example, he says abortion differs morally from deliberate non-conception only in its side effects and that even these side effects do not outweigh the objections to bearing unwanted children. On euthanasia, he argues that "where we think someone's life is not worth living and he is beyond expressing a view, it is hard to see what case there can be (apart from possible side effects) for taking steps to postpone his death". In such cases, the side effects become all important. "Even in the case of unconscious patients, the distress a lingering death causes to the family will normally be a reason for thinking an accelerated death desirable."

He wrote the book 20 years ago but these remain hot issues. In the past month, a woman has won her right to receive pain-relieving treatment that would hasten her death; transplant surgeons have suggested giving lethal injections to patients in a permanent vegetative state so that they can use their organs, and the government has unveiled plans to allow people to draw up "living wills", allowing them to reject medical treatment.

But the idea of medical ethics as a distinct, and respectable, discipline, is only relatively recent. In 1976, Sheila McLean, now director of Glasgow University's institute of law and ethics in medicine, ran a course from the university's department of forensic medicine for six law students. The King's College Centre was set up around the time of the birth of the first test-tube baby, two years later. Other centres now exist in Cardiff, Nottingham, Birmingham and Manchester.

Glover says medical ethics used to be something medical students picked up from their seniors. Then, as students found their ethical beliefs did not necessarily coincide with those of their supervisors, the medical profession began to demand some kind of discussion. At the same time, the public became interested. With more publicity about reproductive technology, cloning, euthanasia and fertility, people began to feel they understood what had been only a matter for scientists.

"We live in a less deferential society than we did," says Glover. "It used to be that a doctor decided and you took it that he had made a medical decision. The huge publicity attending new developments has made people much more sophisticated." He is all for this, arguing that scientists should be democratically accountable. Glover will be the first philosopher to run the centre at Kings, which won a prize for teaching, research and public debate in this year's Queen's anniversary prizes for higher and further education. The centre's founder, Ian Kennedy, and professor Andrew Grubb who took over from Kennedy in 1992, were both lawyers. But Glover stresses that it is a place where doctors, medics, philosophers and theologians work together. "In medical law and ethics, all of us are aware we only bring part of the skills required," he says. While he has a keen interest in both medicine and law he does not pretend to approach either as anything but an amateur - "If someone wants fertility treatment they should go to a doctor, not a philosopher". And he acknowledges that in taking ethical decisions people rely partly on human sensititivity. But what philosophy brings is "the ability to clarify reasons". "Philosophy looks at the reasons we have for holding beliefs," he says. "It is a series of intellectual techniques for asking very fundamental questions that people don't generally ask." He believes nothing has yet beaten the Socratic method of developing thought by questioning why people think as they do and says this is one reason why he enjoys teaching. At Kings he will be teaching medical students who, in their everyday lives, face some of the ethical dilemmas they discuss with him. He says it is essential for them to have the chance to think about these dilemmas at a theoretical level, without having to act on them instantly.

Imagination, he says, is the key. He allows that everyone develops views in the light of their own experience and says he has faced several serious ethical dilemmas in his life which have influenced his ideas. But he tries to be as imaginative as possible. "I try to imagine what it is like to be every person affected by the things I'm thinking about," he says.

This approach will form the basis of the new project he aims to bring to Kings when he starts in January. Inspired by the fact that Kings has links with the Maudsley psychiatric hospital, he wants to look into ethical issues concerned with mental health. He sees it as a two-pronged project, looking first at philosophical questions involved in psychiatry, then at medical and legal aspects of dealing with people experiencing mental health problems. It will involve talking to patients and psychiatrists to find out where the system is working and where it is breaking down. Then, in true Glover style, he aims to make some practical suggestions for government to implement.

Kings has always played a role in policy-making. Politicians traditionally consult Kings academics on the implications of most medical ethics issues and Glover is keen to continue the practice. "In my view, a centre like that should make some difference to the world," he says. "It is meant to be an applied place." Its influence also extends beyond Britain. Members of the centre have just completed a research project for the European Union dealing with patients in persistent vegetative states and are now working on an EU study on palliative care. Glover himself has chaired an EU working party on new reproductive technology and surrogate motherhood.

When he wrote his book on genetics, The Philosophy and Psychology of Personal Identity, he was ahead of his time. Now, he says, genetics is set to be the ethical minefield of the next century. Scientists have discovered a gene that influences human intelligence, which Glover says, has huge social implications. In the long term, it could force people to decide whether to give limited resources to those with most IQ potential, or help people with less genetic advantages. But it may also involve rethinking values. "People are rather crude about thinking IQ is a highly desirable characteristic," he says. "There are other things, such as kindness, which are just as important."

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