Making the evidence (and arguments) count.

The academic field of medical ethics continues to evolve. One of the starkest features of this ongoing evolution is the increase in research studies that incorporate an empirical component. Although this trend is not new (Borry et al., 2006), empirical papers in the Journal of Medical Ethics now constitute a significant contribution to each and every issue. Disciplinary turf wars were a feature of the early days of this ‘empirical turn’ in medical ethics as philosophers and social scientists sought to articulate and defend why their different contributions were necessary to the advancement of the field. Crudely characterised, these battles were pitched over philosophers’ perceptions that social scientists lack rigour in articulating how the study of ethical attitudes and practices could inform normative reasoning, and by social scientists’ perceptions that philosophers’ analyses were blind to salient features of the realworld settings in which moral problems arise in health care practice and policy-making. As empirical contributions to medical ethics have expanded, these debates and disagreements have also evolved. One relatively new feature of the medical ethics and bioethics literature is the tendency to contrast ‘analytical’ medical ethics with ‘empirical’ medical ethics, as another of the journal’s Associate Editors does in a recent piece in this column (Wilkinson, 2014). This distinction has some advantages. It can help to avoid some of the cheap shots that were a feature of the earlier disciplinary disagreements. In particular, differentiating medical ethics research in terms of its methodological orientation can help to avoid common misrepresentations of the contributions of different scholars, and it explicitly recognises that both theoretical and empirical contributions have merit in advancing the field. There are, however, problems with dividing up academic medical ethics in this way. One concern is the risk that, as the field matures, it will bifurcate between those who are more inclined to undertake empirical research and those who are not. Placing scholars in one of two camps may increase the risk that the field fragments as those medical ethicists advocating for one of these two approaches fail to engage in substantive terms with those pursuing and advocating for the alternative. This ‘silo’ problem is not one to be taken lightly in a relatively young field that is only now becoming established in many parts of the world. Another, perhaps more important, concern is that differentiating between ‘analytical’ and ‘empirical’ contributions simply fails to recognise the interconnections in research between philosophical argumentation and the empirical study of ethical problems in real-world health care contexts, as well as the nuances that exist within each broad approach. Contributions to the medical ethics literature that involve empirical work, for example, are not a single category and they do not share the same kinds of aims or objectives. Many, indeed, are conceived with the sole purpose of interrogating practical normative questions, and do so by adopting novel methodological approaches that seek to avoid common fallacies of reasoning (e.g. Dunn et al., 2012; Ives, 2014). 4 Equally, those contributions that involve philosophical argumentation can be embedded in, or stimulated by, real-world experiences or new empirical insights. As such, the quality of the analysis can stand or fall not just on the soundness of the arguments, but on how the underlying ethical problem has been characterised, and how the normative claims that are being articulated and interrogated connect to the world in which they are designed to take effect. A number of the papers in this issue of the journal are illustrative of this nuanced and interconnected relationship between analytic and empirical contributions to the field of medical ethics. Raijmakers et al’s (see page 145) large cross-sectional survey of the Dutch population reveals that a minority of people in the Netherlands are supportive of physician-assisted dying in situations where patients do not have a serious medical condition, but are expressing the wish to be helped to die. The authors are clear that these results do not constitute an argument for extending the reach of physician-assisted dying in the country. However, they do suggest persuasively that such insights about the population’s attitudes justify a re-orientation in the field towards scrutinising the arguments for and against assistance in dying in this situation. In contrast to Raijmakers et al’s attempt to present data in order to shift the locus of the ethical debate in end of life care, Kitzinger and Kitzinger (see page 157, Editor’s choice) draw upon interviews with family members of individuals in a vegetative or minimally conscious state to countenance against implementing certain arguments for the withdrawal of artificial nutrition and hydration (ANH) in familial decision-making situations. Motivated by the recent case of W v M in the English Court of Protection in which the withdrawal of ANH was considered, the authors reveal that relatives’ primary concern is not whether their loved ones should live or die, but how they should die. In the face of familial refusals to consider ‘causing death by starvation and dehydration’, Kitzinger and Kitzinger are right to invite us to reconsider how lifeending interventions or withdrawals for patients in these conditions should be evaluated. This question is a different but, arguably, equally important question to the permissibility issue that medical ethicists have focused on following the case of W v M and others. Mellor et al (see page 151) go even further in the sense that they engage in ethical reasoning in order to directly scrutinise and interpret the implications of the empirical insights they offer. Examining treatment non-adherence amongst paediatric patients in renal failure and undergoing dialysis, the authors’ interviews with nurses show that these nurses struggled to align the responsibilities of the minor, parent and practitioner in relation to treatment decision-making, as well as how to respond to the challenge of nonadherence in ways that uphold the child’s best interests. Upon further analysis, the authors argue that, given the nature of the child’s needs, the responsibilities for safeguarding the child’s health should be shared between the health care providers and the parents. This is supported by the additional claim that their patients’ nonadherence should not necessarily be accorded the status of a treatment refusal rendering the nurses’ (and parents’) use of coercive practices less ethically problematic than they might first appear. Elsewhere in this issue, other authors undertake ethical analyses that are motivated by particular observations about the