Introduction
Bioethics has made remarkable progress as a scholarly and applied field. A mere fledgling in the 1960s, it is now firmly established in hospitals, medical schools, and government agencies and boasts a number of professional associations and a handsome collection of journals. The rapid rise and success of bioethics presents an unrivaled opportunity to observe a “profession in process.”Footnote 1 How did bioethics succeed in staking its claim in the fields of medicine and science? How has bioethics solved—or attempted to solve—the problem of separating the sheep (bona fide bioethicists) from the goats (pretenders to the title)? How is the next generation of bioethicists being recruited and educated?
This last question is our focus. In the 1970s and 1980s there was no defined pathway to becoming a bioethicist. People entered the field from a variety of disciplines and professions and brought what they knew to the work of bioethics. But the field is now more organized, complete with undergraduate minors and majors—and even high school courses—in bioethics, master’s degrees and doctoral programs, and professional associations. Like other new occupations, bioethics is moving from a collection of “pioneers”—those who created the field out of nothing—to a field populated by “professionals” who chose the field from among other possible opportunities for employment.
The shift from a field populated by bioethics pioneers to a field made up of bioethics professionals is more than just a demographic or sociological curiosity. This change has significant implications for the definition of bioethics and the nature of its work. As bioethics professionalizes, recruits to the occupation come with a new set of motivations and new understandings of what bioethics contributes to medicine and science. The work of bioethics—invented on the fly by the pioneers—becomes, in the words of Max Weber, “routinized.”
The path from pioneer to professional is inevitable; in order to survive in the larger division of labor, a new occupation must mark its boundaries and stake its claim to unique expertise.Footnote 2 As it moves down this path, bioethics—once steadfastly an interdisciplinary enterprise—is now tilting toward becoming a discipline of its own. Not all members of the pioneer generation are happy with this turn of events. At professional meetings and on LISTSERVs, the founding mothers and fathers of bioethics discuss the promise and peril of plans for certification, the changing content of bioethics work, and what a bioethicist must know and do to be identified as a bioethicist. Notable in this regard is the widely circulated (unpublished) response of Arthur Caplan to Ezekiel Emanuel’s plenary address at the 2009 meeting of the American Society for Bioethics and Humanities.Footnote 3 In his address, Emanuel questioned the value of master’s and Ph.D. programs in bioethics, arguing that young, would-be bioethicists should seek degrees in psychology, behavioral economics, and decision theory. In his opinion, the next generation of bioethicists must be armed with the theory and methods of the social sciences in order to provide what bioethics now lacks: a solid and empirically grounded foundation for bioethical decisionmaking. Caplan disagrees. He asserts that data and rigor are not, and never will be, enough to do the work of bioethics. A bioethicist must, Caplan says,
be able to present a cogent argument, know the areas of consensus that have been established about ethical issues over the history of medical ethics and bioethics, have a familiarity with health law, the infrastructure of policy and a grasp of political, cultural, literary, historical and social dimensions of what makes morality tick in various cultures. In the absence of these skills and knowledge data is completely and utterly blind, even useless. That is why it is precisely this skill set that the aspiring bioethicist should expect a master’s program or a PhD program in bioethics to provide in order to gain the analytical and argumentative skills to competently and responsibly carry out the crucial public role bioethics has.Footnote 4
Lost in this back-and-forth about the future of the field is the voice of the coming generation of (professional) bioethicists. Who are the members of the next generation of bioethicists? Where are they coming from? How did they choose a career in bioethics? How are they preparing themselves for this work? What do they hope to accomplish?Footnote 5 Given their importance to how the bioethical project will unfold, it is long overdue that we find out more about these heirs to the pioneers of bioethics.
The Coming Generation
In order to learn more about the members of the coming generation of bioethicists, we invited new and would-be bioethicists to submit a short essay describing their pathway to bioethics for consideration for publication in Cambridge Quarterly of Healthcare Ethics. We recruited via email announcements to bioethics LISTSERVs, organizations, educational programs (undergraduate, master’s, Ph.D., and postdoctoral), and directors of bioethics centers across the United States and Canada. We gave no criteria for membership in the coming generation. Our respondents included undergraduates, graduate students, students in professional schools, newly graduated Ph.D. students, postdoctoral students, fellows, and professionals of all ages who recently completed training in bioethics.
Our initial email invited members of the coming generation to provide us a brief biographical description in exchange for further instruction on how to submit an essay. The response was enthusiastic. One hundred ninety-eight people answered our solicitation. In our instructions we asked respondents to consider some or all of the following in their 1,500-word essay: (1) what led them to seek a career in bioethics, (2) the path they have chosen to pursue that career, (3) how they decided on that path, (4) their aspirations as a soon-to-be or recently minted bioethicist, and (5) the successes and disappointments encountered on the way to becoming a bioethicist. We eventually received 69 essays. All 69 submissions were impressive, engaging, and thoughtfully written. Our final selection of the six essays published here was made after careful review by the six authors. Our goal was to balance the quality of writing with a selection that represented the variety found in all 69 essays. The essays offer a fair characterization of the many ways in which people found their way to bioethics and reveal the range of interests and goals of the members of the coming generation.
In collecting and reviewing the essays, we learned much about the coming generation. The essays provided rich descriptions of pathways and people of the coming generation, and the details of their journeys allowed us to develop a quantitative snapshot of the group. We asked the initial 198 respondents for permission to use (with no identifying details) information about their pathway to bioethics, and we also sent a survey to the 69 essay writers, asking for more demographic and educational detail. We are aware that this is a self-selected group and not necessarily representative of all members of the coming generation. Nevertheless, what we offer here is a first look at the next generation of bioethicists and perhaps, given their outspokenness, the next generation of leaders in bioethics.
A Quantitative Snapshot of the Coming Generation
What does the coming generation look like? Of the 198 people who responded to our initial announcement, more than half were female and, not surprisingly, they came to bioethics from a myriad of educational backgrounds, disciplines, and professions—including, among others, law, theology, social work, medicine, public health, science, and anthropology. A plurality (40.4%) were current students or (self-identified) “recent” undergraduates, and a significant proportion (24.2%) worked in clinical settings (Table 1). The 176 people who provided specific information about their education held 261 degrees, including M.A., Ph.D., M.D., J.D., M.B.A., and D.D.S., and degrees in allied health (Table 2). Approximately half in each degree category have more than one degree, with the majority of second degrees being master’s degrees; the exception is law, in which about one-third of those with a J.D. degree hold an M.A.
Table 1. Primary Occupation (General)
* Also current M.A. students in bioethics.
a Of which 2 nurses are current M.A. students in bioethics.
b Both hospital chaplains are also M.A. students in bioethics, one of whom is an on-line student.
c Law; 2 law students, 1 law clerk, 2 lawyers (1 M.A. student in philosophy, and 1 ethics fellow).
Table 2. Professional Degree Tallies
N = 176; 261 degrees among 176 respondents.
* Number also includes people who say they will be pursuing an M.A. in the near future.
The 69 people who submitted essays look quite similar to our larger group of respondents. We used a short Internet survey to ask this group more detailed questions about their education, place of employment, and connection to the larger field of bioethics. Sixty-five of the 69 submitters responded (94%). Thirty percent received their B.A. in the last 5 years, 25% between 6 to 10 years ago, 14% between 11 to 15 years ago, and 19% more than 15 years ago (12% did not indicate the year they obtained their B.A. degree). Bachelor’s degrees were fairly evenly spread among humanities (28%), the social sciences (20%), and the natural sciences (25%). The predominant majors within humanities and the natural sciences were philosophy and biology. The remaining 20% had various double majors, with a combination of a humanities and natural science major being the most frequent. Seventy-two percent had M.A. degrees, of which approximately 70 percent mentioned ethics or bioethics as their degree type, and 15% listed philosophy. Forty-eight percent received their M.A. within the last two years. In terms of advanced degrees, 20% held a Ph.D., 23% had an M.D., 16% held a J.D., and 13% had degrees in dentistry or allied health professions (e.g., public health).
With regard to employment, 21.9% were students, 20.3% worked in an academic medical center, 15.6% worked in a hospital, and 12.5% were employed by a college, university, or seminary. Smaller percentages worked for government (9.4%), worked for a professional association (3.1%), were self-employed or worked for a private entity (3.1%), or were unemployed (1.6%).
People and Pathways
Our initial solicitation asked for “a brief description of your pathway into bioethics.” The 198 people who responded fell into two broad categories: those whose interest began in a school setting—going as far back as middle school (!) and extending through professional education—and those who began their encounter with bioethics after an event in their personal life or in their career. The 69 essays flesh out these pathways and allow us to learn more about the people who found their way to bioethics, the bumps in the road on the way to becoming a bioethicist, and how the coming generation sees the future of their chosen career.
Coming to Bioethics
What drew members of the coming generation to bioethics? Although there now exist a variety of ways to receive formal training in bioethics, many respondents report that they “stumbled upon” this career, or, as one essay writer put it, “bioethics discovered me.” As in the larger sample, the essay writers mentioned both personal experiences and coursework as the beginning of their interest in bioethics. Among the 69 who submitted essays were several individuals who added bioethics to an existing career; for this group the choice of bioethics was a response to events at work.
Personal Experiences. Often the experience that initiated an interest in bioethics was an illness or accident, either one’s own or that of a loved one:
The one event that most directly influenced my foray into bioethics [was] my cancer experience. . . . I had previously decided to pursue a bachelor’s degree in history en route to law school, but it was unclear to me which area of law I would enter. I continued along this path but with a new motivation. I began to realize that my interest in the law could be focused into helping others.
A subfield of ethics devoted to healthcare and medicine never occurred to me until my aging father was admitted to an area hospital . . . with an advanced case of double pneumonia.
My life as an individual growing up with [this disease] . . . sparked my desire to pursue the field of bioethics . . . though I didn’t realize it at the time. Growing up, I saw firsthand the challenges that faced patients and clinicians as they attempted to manage this disease. It was only after I took my first bioethics course in college that I began to articulate these challenges using the language of bioethics.
For some, the transformative experience was less personal and more about living in a world changed by technology:
[When I was] eleven, I looked into the face of a barnyard creature and was forever captivated. Peering out from magazine covers and television screens, Dolly introduced me to the subject of bioethics. . . . I was intrigued by the complex and morally thorny questions that the emerging frontiers of biology and technology pose to humanity.
Education. Others in the coming generation discovered bioethics in an academic setting, either through course work or an inspiring lecture or via the advice of an academic counselor.
My first real exposure to bioethics occurred in an academic setting. . . . In my first two religion classes [in college] we read the writings of Stephen Jay Gould, Ian Barbour, Gilbert Meilander, and Aaron Mackler. These courses prompted me to think deeply about complex interactions between religion and science, how we choose to engage with the world around us, and our perceptions of scientific and medical progress. By the end of my sophomore year, I had abandoned my childhood dream of being a doctor and decided instead to become a political science major with a concentration in medical humanities.
This young bioethicist traces her interest to a guest lecturer:
There was a guest lecturer, Arthur Caplan, who altered my perception of medicine. He was captivating, with his simple manner of communicating complex information. What I learned from him was that I did not have to become a doctor to study medicine. Instead, I would study what makes a good doctor from an analytical perspective. I looked forward to joining the physicians I’d always looked up to, my future colleagues, and to becoming an intricate part of the medical team. I would be a bioethicist.
Several of our respondents—like the previous two above—planned a career in medicine but found bioethics more compelling. Others came to bioethics when plans to become a doctor did not work out. One respondent wrote about being dissuaded from becoming a doctor by listening to physicians who were dissatisfied with the state of medicine:
Like prophets in the wilderness, they warned me not go into medicine, but to “change it from the outside.” Some even suggested ethics, but what, exactly, was it?
Turns out, it was my passion. I was converted after just one course, even though it was too late to abandon my biology, premed major. With zeal, I attended my classes, taught by professors with an equal fervor for the topic.
In some cases interest in bioethics was prompted by a combination of experience and education:
My work in bioethics began in the laboratory. As a college sophomore, I assisted in preimplantation genetic diagnosis—embryo selection—to enable couples to avoid giving birth to a child with a serious heritable genetic disorder. . . . My college thesis, and one of my first articles, grew out of this work.
Adding Bioethics to an Existing Career. Several of our respondents came to bioethics from established careers. For these members of the coming generation, bioethics was seen as a solution to an ethical challenge in their work or frustration with the limitations of their professional expertise. A scientist describes the ethical issues that confronted her in the lab:
I was quite bothered by what I was doing in the neuroscience lab. . . . To create a depression model in rats was an easy job physically, but absolutely difficult emotionally for me. The rats must be tortured by hotness, icy water swimming, pinching tails, and so on. By actualizing these cruelties on the living creatures, I didn’t know who was more desperate, the rats or me.
Clinicians and clinicians in training mention being confronted with moral dilemmas in their practice:
Working in cardiac transplant opened my eyes to a whole different view of ethics. Issues became more philosophical. Should the patient receive a second heart transplant? Should we transplant multiple organs into one person or try to save many and transplant single organs into multiple patients? I became more intrigued.
My unconventional road to bioethics began not in undergraduate philosophy classes, but in medical school. I have been motivated by my need to address the disconnect between medical science and humanity—a disconnect vulnerable to the promise of bioethics.
Over the last 10 years, I have watched a paradigm shift in the fundamental emphasis of obstetrical care, from the maternal to the fetal. . . . The fetus seems to have gained rights and a morality that can trump maternal wishes such as court-ordered cesarean sections. . . . I need to understand these principles, and I felt that the most optimal way would be to embark on a path toward obtaining a master’s degree in bioethics.
A minister talks about the disparities in access to pain management:
As a minister and later a pastor, my duties required me to visit my parishioners pre- and post-surgery, in rehabilitation centers, and at their homes. . . . Rarely was I or family members able to spend those final moments of a parishioner in the serene environments of home with hospice care, or palliative care. . . . I was a bit curious about the information I found in my research regarding inadequate pain management for the poor and most often African American patients.
And then there are those who had bioethics thrust upon them:
I was ordered to be a bioethicist. I mean that literally. I was a young navy lieutenant who had just finished residency and reported to my first duty station. The director of clinical services called me into his office. Besides offering a brief handshake when I had checked in, it was the first time he had spoken to me. He said, “We need a bioethics committee. You’re the psychiatrist. That means you’re going to be the chairman.” “But . . . ,” I stammered, “I don’t know anything about bioethics. And I’ve never been the chairman of anything!”
Finding a Path
Although bioethics education is becoming more routinized, there remains a great deal of uncertainty about how to become a bioethicist. Not only are the members of the coming generation confused by the many certificate, master’s, and doctoral programs that promise entrée into the career, they also must deal with a general lack of knowledge about the field of bioethics. Many essay writers noted their difficulties in explaining their career choice to others.
Like many other young bioethicists, I’m sure, I’ve grown accustomed to the blank stares, looks of confusion, and (best of all) feigned understanding when I tell people that I study bioethics.
Another challenge I have faced can only be described as the “enquiring minds want to know” dilemma. The uniqueness of my path and the relative novelty of bioethics have led many to question my path, my pursuits, and my goals: from family and friends to new colleagues and a random hairdresser.
“Why aren’t you a pharmacist?”
“What do you do with your law degree? Why aren’t you a lawyer?”
“Why have you been in school for so long?”
. . . I would be lying if I said these external criticisms left me unscathed.
A common icebreaker question to ask someone at the bar is, “What do you do for a living?” When I respond, “I am a bioethicist,” I usually get two types of responses, which I will call the “intrigued by an alien” response, and the “hope you can get a job with that” response.
Public uncertainty about bioethics is only part of the difficulty of finding one’s pathway to a bioethics career. Nearly all of our respondents expressed concern about the lack of clarity about a proper way to become a bioethicist. As one essay writer put it: “There is a line in a Grateful Dead song that states, ‘What a long strange trip it’s been.’ This line would best describe my journey into bioethics.” Others described their route to a career in bioethics as “colorful,” “circuitous,” “serendipitous,” “unique,” “a multistage process,” “an evolving journey,” and “uncharted.”
On the other hand, several respondents noted that the steps needed to become a bioethicist are much clearer today than they were earlier:
My career trajectory differs . . . from those who came in previous generations. First, I did not have to create my own job, department, or field. I entered the field just as it was maturing and standardizing. Second, I did not have to earn a degree in a discipline and then discover bioethics. Through formal coursework and established degree programs, I was trained in the field from the beginning. Third, I did not have to discover new sets of literature, as those were provided for me through course reading lists. Fourth, I did not have to find people who shared these interests on my own. I benefited from mentors who had already laid the foundations and introduced me to a vibrant network of scholars.
Unlike the pioneers, the coming generation has an array of options when it comes to getting an education in bioethics. For some this is a valuable development:
The bioethics-centered educational model has many benefits for aspiring students. First, the very existence of such programs creates a recognition that bioethics is a complex field that requires rigorous training and specific focus. Further, it provides concentrated training to those particularly interested in the issues faced within bioethics, without requiring educational dependence on another complimentary discipline that may be of secondary interest to the student. For those who have pursued a career in a field other than bioethics and who have come to appreciate the ethical nature of their work, bioethics-centered degrees may also offer relevant training to address these on-the-job needs. Finally, unique skills in bioethics, such as those gained through clinical, policy, or research ethics practice, may be more readily offered in a degree program focused in bioethics.
But not all are sanguine about the pathways to a career in bioethics. Several respondents shared the sentiment expressed by one young bioethicist: “Unlike more established fields, there is no singular way to prepare for a bioethics career or to make a contribution to the intellectual discourse.” Other respondents felt they were caught in a time of transition, when bioethicists are critical of the academic pathway to bioethics even though they themselves are uncertain of what one should do to prepare for a future in the field:
We seem to be caught in a turf war of differing expectations between generations of ethicists. One side is skeptical—and rightfully so—of academia’s ability to produce ethicists. . . . There are . . . good reasons to question academic content. Many current educational programs do not include the anthropological, sociological, or cultural dimensions that leaders in our field seem to tout. . . . Is it fair to hold graduates accountable for the less-than-optimal choices of academia? Defining a core curriculum for ethics academic programs is just as critical as defining competencies for ethics leaders and consultants. . . . Advanced degrees in healthcare ethics are relatively new—but so is contemporary healthcare ethics. Isn’t it hasty to assume that the coming generation, with academic degrees in ethics, is substandard to the previous one?
In spite of a move toward interdisciplinarity in the academy, many newly minted bioethicists worry about how they will survive a career in bioethics:
Unlike our predecessors, who created the field out of the cacophony of multidisciplinarity, many of us begin our careers with advanced degrees in bioethics, or, like myself, with other advanced degrees and a concentration in bioethics. Unlike many academics, we are faced with a variety of professional paths, and while thrilled at the prospect of choice, we are not yet completely secure in the frontier-like openness of our chosen discipline. Some of us are especially unsure how we might fit in with our “home” disciplines.
Some wonder about the future of a field that has no singular foundation:
My resistance to entering bioethics graduate programs was driven by skepticism about what it would mean to get a degree from these programs. While these programs certainly have value, I wonder what they may do for the future of the field. After a year or two of coursework in ethical theory, clinical ethics, research ethics, a collection of electives, and a thesis, are these individuals certified bioethicists . . . but is it possible to have certification in a field that is arguably still evolving and so interdisciplinary in nature?
The newness of the field and the uncertainty associated with how to become a bioethicist is evident in the many comments of essay writers about the importance of good mentors. In the absence of a defined pathway to the profession, the advice of mentors is critical.
Of the numerous experiences afforded by the fellowship [in bioethics], I have appreciated the mentorship most. Given the relative infancy of the field and the indeterminate path ahead of an aspiring bioethicist, these relationships have provided me with essential personal and professional insights.
With guidance from my mentors, I determined that legal and philosophical training would best prepare me for this pursuit.
There is no doubt that the world of bioethics as I know it is one of mentorship . . . the role of my mentors has been not only to teach me their diverse vision of bioethics, but also to provide me with the opportunity to embark on a journey rarely available to undergraduate students. . . . More than anything else, then, my story . . . is one of gratefulness for those supporting [aspiring bioethicists’] quest.
Shaping the Future
What are the aspirations of the coming generation? What do they hope to accomplish as bioethicists? Although a few indicated the desire to contribute to the building of bioethics knowledge (“More than anything, I’d like to add something new to the discourse”), many indicated that they wanted to bring bioethics to their profession or discipline. A surgeon wants to introduce his fellow surgeons to biomedical ethics; a medical anthropologist wants to cultivate greater dialogue between science and technology studies (STS) and bioethics; a dentist would like “to raise more provocative ethics issues in dentistry.” Rather than giving themselves over to bioethics and doing “bioethics research,” bioethics is seen as a needed addition to their home discipline:
I do not intend to abandon social work, but I fully intend to incorporate ethics into my career path.
I am excited about the fund of knowledge that this [bioethics] training has helped me to develop, and I look forward to integrating this new insight and perspective into patient care when I return to the clinical component of my residency.
But what is the worthwhile end in the case of a hospital ethicist? To put it simply, my role is to promote and enable the ethical delivery of healthcare in my organization. The pursuit of that end does sometimes require asking difficult questions, raising issues, challenging people on their opinions and assumptions, and engaging them in discussions they may not be particularly interested in having at that time (or at any time).
I just want to become a better researcher and have my work matter in public health (including bioethics). I would like to validate the inclusion of bioethics into the normative discussion of population-level health.
I hope to create a conversation among healthcare professionals in regards to disability thought, eugenics, and prenatal diagnosis. . . . I also want to capture those families with children with genetic or physical handicaps and their thoughts and experiences with prenatal testing. My hope is that this will lead to further discussion, work, awareness, and sensitivity in the field among all those providing care to families and prospective parents.
We asked our essay writers, “Do you consider yourself a bioethicist?” A clear majority, 72%, replied “No.” Fifty-nine percent did mention “ethics” or “bioethics” in their professional description (e.g., “I am a lawyer who works in bioethics”), and an additional 7% indicated they “will be” or “aspire to be” bioethicists. This attitude is perhaps the greatest challenge to the professionalizing project of bioethics: is it possible to have a strong and separate profession when bioethics is just an add-on to another occupation?
Conclusion: Whither Bioethics?
Listening to the next generation talk about where they came from, how they trained, and where they are going gives us a glimpse of the future of the field. It is clear from the content of these 69 essays that bioethics is a “profession in process.” The pioneer spirit is still present in bioethics, allowing several pathways to a career in the field and the opportunity for bioethicists to explore everything from the ethics of agriculture to the ethics of space travel.
But members of the next generation are aware that the profession is becoming routinized:
I realize that academic study in this discipline has shifted from the more informal and creatively assembled approaches of the past to the current state of specifically established courses of study. This shift toward a more structured and standardized study of bioethics has caused a similar trend in applicant expectations—a standardized conception of the ideal bioethics student, uncomfortably similar in form (although not content) to the standardized conception of the ideal medical student.
Some young bioethicists expressed their fondness for the more open view of the profession:
More direct ways to enter the field of bioethics now exist, but I am pleased that my own career has taken the path it has. As a relatively new and still evolving field, bioethics benefits from a plurality of voices.
Others worry that the pioneer history of bioethics weighs too heavily on the coming generation:
I suspect others in the coming generation of bioethics feel judged by the previous one. It appears that much energy is spent on perceived shortcomings and differences. Being well-rounded and grounded are significant, but finding a way to allow the strengths of the coming generation to grow and flourish seems ideal.
The task of the coming generation is to structure the pathway to the profession without losing its freshness and vigor. Listen now, as six members in that generation describe their encounters with bioethics.
