Summary of the impact

Baroness Professor Onora O'Neill has applied ideas derived from her extensive research in the field of moral philosophy to substantive practical questions in bioethics: for example, what is it for patients to give their consent? Should assisted dying be legalised? And more generally, what kinds of safeguards should be employed to protect patients? O'Neill developed this work together with Dr Neil Manson while working at the University of Cambridge. This research has had impact on decisions and the reports made by the Commission on Assisted Dying (2011-12). O'Neill was an expert witness for the Commission and her ideas were incorporated into the 2012 report of that commission.

Underpinning research

Onora O'Neill was Principal of Newnham College Cambridge from 1992 to 2006, and she was a Professor in the Faculty of Philosophy at Cambridge during that period. Since her retirement she has remained very active in the Faculty, which still serves as her research base. Neil Manson, with whom she collaborated on some major research, was a postdoctoral research fellow at King's College Cambridge from 1998-2005.

O'Neill's work in bioethics is motivated by her more theoretical work on moral philosophy. The idea that moral agents are autonomous — that they act, in some sense, out of their own motivation and nature — has been a dominant idea in ethics, and in bioethics too. Yet O'Neill argues that the conceptions of individual autonomy so widely relied on in bioethics are philosophically and ethically inadequate. In a number of works [3.1-3.3] she proposes a more Kantian, non-individualistic conception of autonomy, which provides a stronger basis for a better approach in bioethics. For O'Neill, autonomy is not a matter of mere `existentialist' freedom of choice, nor of simply acting as some idealised version of reason demands, but rather should be understood as a property of principles of action: `Principles of action are Kantianly autonomous only if they are law-like in form and could be universal in scope; they are heteronomous if, although law-like in form, they cannot have universal scope' [3.3: p.1]. So it is a mistake to think of Kantian autonomy in terms of agents going about their business universalizing; it is rather that their actions are universalisable if they are governed by autonomous principles in the Kantian sense.

In Rethinking Informed Consent (2007) [3.2] Neil Manson and O'Neill apply some of these ideas to the question of consent in medical ethics. They argue that informed consent can never be wholly specific or explicit, and indeed, it would not be a good thing if it were. In addition, Manson and O'Neill argue that consent needs a particular kind of communicative transaction, by which other obligations, prohibitions, and rights can be waived or set aside in controlled and specific ways.

The upshot of this research is that we should not expect that bioethics can provide a set of rules or procedures which remove the need for trust, trustworthiness and interpretation.

References to the research

Details of the impact

O'Neill research has had an impact via a variety of routes. Drawing on her expertise in moral philosophy and bioethics, O'Neill served on House of Lords select committees on genomic medicine (2008-2009) [5.1], nanotechnology and food (2009) [5.2] and Behavioural Change (2011) [5.3]. She was elected as Chair of the Nuffield Foundation (1998-2010) and on 19 May 2011 she gave the Foundation's annual public lecture, on the topic `Broadening bioethics: clinical ethics, public health and global health' [5.4]. Since 2012, she has been Chair of the Equality and Human Rights Commission [5.5] and also an expert lay member on the Medical Research Council [5.6], and she chairs the MRC's Ethics, Regulation and Public Involvement Committee, whose role is `to advise Council on policy concerning the conduct of research involving human participants (including personal information and human biological material) and animals, with respect to ethics, legislation and regulation' [5.7]. In 2008, she was awarded an honorary degree from the University of Newcastle. On the occasion of this award, it was said that `she has a knack for making rigorous analysis highly accessible to non-specialists. Few can match the flair with which she successfully marries lucidity to conciseness,' and that her `work has been key to the creation of an enabling environment' in stem cell research in the UK [5.8].

However, the focus of this case study is the impact on policy debate achieved via her contribution to the Commission on Assisted Dying in 2011. The Commission's brief was to consider the current state of the law on assisted dying, assisted suicide and voluntary euthanasia. O'Neill gave evidence to the Commission on 19 January 2011 [5.9]. In her submission, she discussed three different conceptions of autonomy: an idealized Kantian conception (choosing according to universalisable principles, something which she argued has little relevance to medical ethics), a simple conception of autonomy as `mere sheer choice', and a non-individualistic conception of the autonomous agent (also inspired by Kant) who balances their own needs with the needs and desires of others. Individual freedom of choice can be limited by the circumstances of choice, and the fully autonomous agent will recognize this. She then argued that such abstract conceptions of autonomy should not be applied slavishly in these discussions and that a more practical approach was needed.

Based on the views developed in the research cited above, she expressed some skepticism about the need for the law to be changed to allow assisted dying in any straightforward way. Safeguards are needed, and even as it currently is, the law will not provide a simple decision procedure for when various real cases of assisted dying should be the basis of prosecution.

Ranging more broadly, O'Neill argued that a full discussion of this question requires us to think more openly about how we approach dying in general, in a society like ours. She argued forcefully for a more thought-out approach to, and more support for, palliative care and hospice care.

Although the Commission concluded that the current state of the law on assisted dying was unsustainable, O'Neill's views were noted by the Commission:

`Baroness Onora O'Neill's evidence also highlighted the philosophical and practical limits to the concept of autonomy. She began by identifying three very different conceptions of autonomy employed in public and political debate: "Kantian autonomy", "existentialist autonomy" and "rationalist autonomy", and went on to explore their social and legal implications...She said that the more precise Kantian conception of autonomy "plays almost no part in contemporary debate on medical ethics". Instead, the more contemporary "existentialist" and "rationalist" conceptions of individual autonomy predominate public conceptions of autonomy... Baroness O'Neill then contrasted these "endlessly complicated" theoretical conceptions of autonomy with a more practical approach to the concept of autonomy, which she said was inspired by the many letters she received from members of the public when Lord Joffe's Assisted Dying for the Terminally Ill Bill was being debated... She commented finally in her evidence to us: "I do not believe that it is possible to draft adequate safeguards without invoking misleading and unrealisable fantasies about individual autonomy... Whatever one thinks about the legitimacy of assisted suicide it's not legislatable; not safely legislatable".' [5.10]

In addition, her argument that more adequate care needs to be provided in general at the end of life was endorsed in one of the Report's main conclusions:

`The issue of assisted dying cannot be viewed in isolation from the need for adequate health and social care or from the need to protect terminally ill people from the risk of abuse or indirect social pressure to end their lives, if such an option were to become available. Therefore if an assisted dying framework is to be implemented in the future, it must have these concerns at its heart and its purpose must be viewed as providing all people with access to high quality end of life care.' [5.11]

Sources to corroborate the impact

[5.1] O'Neill a member of House of Lords Science and Technology Committee, for report on genomic medicine:
http://www.publications.parliament.uk/pa/ld200809/ldselect/ldsctech/107/10702.htm

[5.2] O'Neill a member of House of Lords Science and Technology Committee, for report on nanotechnology and food:
http://www.publications.parliament.uk/pa/ld200910/ldselect/ldsctech/22/2202.htm

[5.3] O'Neill a member of House of Lords Science and Technology Committee, for report on behaviour change:
http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf

[5.4] O'Neill gives the Nuffield Council on Bioethics 20th anniversary lecture, 19 May 2011:
http://www.nuffieldbioethics.org/events/events-20th-anniversary-lecture

[5.5] O'Neill appointed chair of the EHRC:
http://www.equalityhumanrights.com/news/2012/october/commission-welcomes-appointment-of-new-chair/

[5.6] O'Neill appointed as expert lay member on Medical Research Council from 1st Oct 2012 - 30 Sept 2016 (http://www.mrc.ac.uk/Newspublications/News/MRC008756).

[5.7] O'Neill chairs the MRC Ethics, Regulation and Public Involvement Committee:
http://www.mrc.ac.uk/Ourresearch/Ethicsresearchguidance/ERPIC/index.htm

[5.8] O'Neill given an honorary degree at the University of Newcastle for her work on bioethics 2008: http://www.ncl.ac.uk/congregations/assets/documents/OnoraONeill.pdf

[5.9] Onora O'Neill's evidence to the Commission:
http://www.commissiononassisteddying.co.uk/read-evidence

[5.10] Evidence from O'Neill in the Commission's Report:
http://www.demos.co.uk/files/476_CoAD_FinalReport_158x240_I_web_single-NEW_.pdf?1328113363 p.72

[5.11] The Report's endorsement of O'Neill's recommendations about end of life care: http://www.demos.co.uk/files/476_CoAD_FinalReport_158x240_I_web_single-NEW_.pdf?1328113363 p.19