Bioethicists Today: Results of the Views in Bioethics Survey

Abstract

Bioethicists influence practices and policies in medicine, science, and public health. However, little is known about bioethicists’ views. We recently surveyed 824 U.S. bioethicists on a wide range of ethical issues, including topics related to abortion, medical aid in dying, and resource allocation, among others. We also asked bioethicists about their demographic, religious, academic, and professional backgrounds. We find that bioethicists’ normative commitments predict their views on bioethical issues. We also find that, in important ways, bioethicists’ views do not align with those of the U.S. public: for instance, bioethicists are more likely than members of the public to think abortion is ethically permissible but are less likely to believe compensating organ donors is. Our demographic results indicate the field of bioethics is far less diverse than the U.S. population—less diverse even than other academic disciplines—suggesting far more work needs to be done to build an inclusive field.

INTRODUCTION

Bioethics is a young and rapidly growing field focused on studying ethical issues related to medicine, the biological sciences, and public health (Emanuel, Upshur, and Smith 2022). Bioethicists work in academic institutions, medical centers, government agencies, think tanks, foundations, industry, and elsewhere. Many teach, conduct research, provide consultation and advice, serve on ethics committees, sit on institutional review boards (IRBs), and participate in standing and ad hoc committees (e.g., panels tasked with allocating scarce resources). In these various roles, bioethicists inform and help craft science and health policy, as well as influence the application of relevant laws, regulations, and practical guidelines. Driven in part by the COVID-19 pandemic, there is a growing recognition of the importance of ethics in decision-making (Emanuel, Upshur, and Smith 2022).

Yet, even as the influence of bioethics grows, there is little systematic knowledge of who bioethicists are and what views they hold. The goal of the present study, the Views in Bioethics Survey (VIBeS), was to characterize American bioethicists and their views on key bioethical issues, including those into which they may have special insight or around which they may influence policy or political discourse.

METHODS

Sample

In the fall of 2022, we compiled a list of names and contact information for 1,749 bioethicists who: (1) had, according to conference programs, presented in 2021 or 2022 at the American Society for Bioethics and Humanities (ASBH) annual conference, one of the largest bioethics conferences in the country, or (2) were affiliated with a U.S. masters, PhD, or fellowship program in bioethics (“bioethics training programs”). We identified bioethics training programs using the Association of Bioethics Program Directors (ABPD) Graduate Bioethics Programs database and filtered for programs in the United States; next, we reviewed each training program’s website to identify affiliated faculty.¹ In most cases, we were able to obtain email addresses from web searches (e.g., departmental or personal websites); occasionally, however, we used other means, such as reviewing corresponding author information included in recent publications.

The survey was sent to all of these individuals, but the sample was further refined, as explained next in the discussion of the survey instrument.

Survey Instrument

The survey instrument was developed by the authors based on a literature review and input from several individuals with bioethics expertise who were ineligible to take the survey. The survey assessed respondents’ views on foundational questions and contemporary issues in bioethics across the domains of: (1) clinical ethics; (2) public health ethics; (3) research ethics; (4) reproductive ethics; (5) disability ethics; and (6) animal ethics. Additional questions categorized respondents by their normative commitments (consequentialism, deontology, principlism, ethics of care, virtue ethics, other, or none) and gathered demographic information.

The final survey instrument (included as a supplement) included three questions to assess eligibility. Respondents were asked to confirm that they had presented at ASBH in 2021 or 2022 or were affiliated with a U.S. bioethics training program; were living or working in the United States; and were currently spending 20% or more of their time engaged in bioethics-related activities, such as “research, teaching, clinical ethics consultation or serving on an ethics committee.”

If a respondent did not meet all three eligibility criteria, the survey concluded. Eligible respondents were asked to complete 29 questions about their views on bioethical issues, including 19 Likert-type questions (with a 4-point scale that ranged from “never or almost never ethically permissible” to “always or almost always ethically permissible”), eight multiple-choice questions, and two questions with numerical sliding scales. Participants were also asked to complete 14 demographic questions. In total, for individuals who completed the entire survey, there were 46 questions (though respondents were not required to answer them all).

The survey was fielded using Qualtrics between August 31, 2022 and October 18, 2022. Prospective respondents received an emailed invitation and two reminders.

Data Analysis

Data were exported from Qualtrics, cleaned, and analyzed using R. We used descriptive statistics including proportions and measures of central tendency and variability to report sample characteristics and survey responses.

To calculate views on bioethical issues, we combined the categories of “generally ethically permissible” and “almost always or always ethically permissible” (hereafter, “permissible”) and “not generally ethically permissible” and “never or almost never ethically permissible” (hereafter, “impermissible”) and performed chi-squared tests. Similarly, we combined respondents who indicated religion is “not too important” or “not at all important” (hereafter, “less religious”) and those who say it is “very important” or “somewhat important” (hereafter, “more religious.”)

We performed additional subgroup analyses on the basis of hypotheses about predicted correlations between certain demographic traits and survey responses (e.g., gender and views on abortion).

Human Subjects Protections

The Harvard Longwood Campus IRB deemed this study exempt. Participants were assured confidentiality. Four hundred and fifty total respondents were randomly selected for a pilot study to assess the efficacy of different incentives: a $5 Amazon gift card, $5 charitable donation, or no compensation. Based on the results of this pilot study, we opted to offer the remaining 1,299 participants $10 Amazon gift cards; however, response rates did not differ significantly across any of the four groups.²

RESULTS

Characteristics of Respondents

After excluding individuals with undeliverable email addresses or out-of-office messages indicating that they were on long-term leave, there were 1,713 potential respondents. In total, 824 individuals responded, for an overall response rate of 48%. Of the 309 ineligible respondents, the most common reason for exclusion was spending less than 20% of their time on bioethics-related activities; most met the other two eligibility criteria. Going forward, our analyses reflect only the 515 respondents who met all eligibility criteria (“respondents”), although not every respondent answered every question.

Most respondents self-identify as white (339, 81%), and just over half identify as women (224, 53%) (Table 1). Their median age, as estimated by year of birth, is 45. Nearly two-thirds hold a PhD or DPhil (268, 63%), while approximately a quarter hold degrees in medicine or nursing (106, 25%), and an eighth hold degrees in law (51, 12%). More than half of respondents (262, 61%) report that the highest level of education attained by either of their parents was a degree beyond college (e.g., a professional degree, master’s degree, or PhD).

Table 1.

Respondent demographics.

	Eligible respondents (n = 515)
Age (median)**	45
Gender, n = 423
Women	224 (53%)
Men	183 (43%)
Non-binary	5 (1.2%)
Decline to answer	11 (2.6%)
Degree*, n = 423
PhD or DPhil	268 (63%)
MD or Do	92 (22%)
JD	51 (12%)
Nursing degree	14 (3.3%)
Master’s degree	161 (38%)
Race/Ethnicity*, n = 421
White	339 (81%)
Asian or Asian American	22 (5.1%)
Black or African American	13 (3.1%)
Hispanic or Latinx (a/e/o)	12 (2.9%)
Native American or Alaska Native	2 (0.48%)
Multiracial or biracial	8 (1.9%)
other	6 (1.4%)
Decline to answer	26 (6.2%)
Workplace, n = 423
Academic medical center	234 (55%)
Bioethics center	28 (6.6%)
College or school of arts and sciences	68 (16%)
Government	14 (3.3%)
Law school	15 (3.5%)
Nonacademic medical center	24 (5.7%)
Private company	2 (0.47%)
School of public health	11 (2.6%)
Think tank or NGo	5 (1.2%)
Health professions school	7 (1.7%)
other	17 (4.0%)
Role*, n = 426
Student	18 (4.2%)
Policymaker	29 (6.8%)
Post-doc or fellow	32 (7.5%)
Non-tenure track academic	134 (31%)
Tenure track academic	180 (42%)
IRB chair or member	53 (12%)
Clinical ethicist	144 (34%)
other	38 (8.9%)
Political leanings, n = 413
Very liberal	115 (28%)
Liberal	195 (47%)
Slightly liberal	49 (12%)
Moderate	37 (9.0%)
Slightly conservative	11 (2.7%)
Conservative	4 (1.0%)
Very conservative	2 (0.48%)
Religion*, n = 409
Protestant	63 (15%)
Catholic	53 (14%)
orthodox	6 (1.5%)
LDS	3 (0.73%)
Jewish	59 (14%)
Muslim	1 (0.24%)
Buddhist	14 (3.4%)
Hindu	3 (0.73%)
Something else	24 (5.9%)
Agnostic	55 (13%)
Atheist	74 (18%)
Nothing in particular	70 (17%)
Religiosity, n = 414
Very important	73 (18%)
Somewhat important	99 (24%)
Not too important	90 (22%)
Not important at all	152 (37%)
Parental education, n = 422
Some high school	11 (2.6%)
High school	34 (8.1%)
Some college	24 (5.7%)
College	92 (22%)
Master’s degree	101 (24%)
Professional degree	95 (23%)
PhD	65 (15%)

^*Percentages do not sum to 100 because participants were allowed to select multiple options.

^**Calculated based on year of birth.

Most bioethicists identify as “very liberal” (115, 28%), “liberal” (195, 47%), or “slightly liberal” (49, 12%), with only a handful identifying as “moderate” (37, 9%), “slightly conservative” (11, 3%), “conservative” (4, 1%), or “very conservative” (2, 0.5%). Asked about their religious affiliation, just under half say they are a member of an organized religion (199, 49%), while a similar number describe themselves as “atheist,” “agnostic,” or “nothing in particular” (197, 48%). Asked about the importance of religion in their life, more than half (242, 59%) say it is “not too important,” or “not at all important,” while others (172, 41%) say it is either “very important” or “somewhat important.”

When asked in what capacity they do their ethics related work, most respondents self-describe as tenure- or non-tenure track academics (312, 73%), and a third as clinical ethicists (138, 32%); individuals were able to select more than one role or write in their own (with responses including but not limited to chaplain, editor, and foundation director). The most common primary workplace setting is an academic medical center (234, 55%), followed by a college or school of arts and sciences (68, 16%).

We report descriptive statistics capturing respondents’ overall views before exploring associations between respondents’ views and the normative theory they endorsed.

Overall Views

Our questions sought to capture bioethicists’ views on both foundational questions and contemporary debates in the field and spanned clinical ethics, public health ethics, reproductive ethics, animal ethics, and more (Figure 1). Results on research ethics will be reported elsewhere.

Figure 1.

Bioethicists’ beliefs about the ethical permissibility of various practices; practices are arrayed from most permissible to least permissible overall.

Informed Consent

Nearly all surveyed bioethicists (473, 98%) consider it ethically impermissible for clinicians to provide life-saving care to “an adult patient who has refused that care and has decision-making capacity.” Reflecting the strength of this view, a majority of all respondents indicated that it is “never or almost never ethically permissible” to do so (287, 59%).

Slightly fewer respondents (410, 85%) consider it impermissible for a surrogate decision maker to make a decision that they believe is in a patient’s best interest, “even when that decision goes against the patient’s previously stated preferences.” This view tends to be less absolute; among those who consider it impermissible, more consider it “not generally ethically permissible” (332, 69%) rather than “never or almost never ethically permissible” (78, 16%).

Two-thirds of bioethicists (318, 66%) favor allowing a clinician to “treat a 14-year-old for opioid use disorder without their parents’ knowledge or consent.” Only a few (16, 3%) think this practice is “never or almost never ethically permissible.”

Medical Aid in Dying

More than half of respondents (278, 59%) consider it permissible for clinicians to “assist patients in ending their own lives if they request this.” At the extremes, however, more bioethicists say that this is “never or almost never ethically permissible” (68, 14%) than that this is “always or almost always ethically permissible” (31, 7%). Greater religiosity is associated with greater likelihood of finding it impermissible for clinicians to “assist patients in ending their own lives if they request this,” with fewer than half of more religious respondents regarding this practice as permissible, as compared to nearly three-quarters of less religious bioethicists (42 vs. 74%, p < 0.001).

Public Health

Nearly two-thirds of bioethicists (264, 62%) say it is ethically permissible to subject people to regulations they disagree with, solely for their own good. Few favor the extremes here, with only small proportions saying this is “always or almost always ethically permissible” (29, 7%) or “never or almost never ethically permissible” (18, 4%).

Respondents are nearly evenly split on whether it is ethically permissible (227, 52%) or impermissible (210, 48%) “for a government to allow an individual to access treatments that have not been approved by regulatory agencies, but only risk harming that individual and not others.” Again, this view tends to be less absolute, with few saying this is “always or almost always ethically permissible” (14, 3%) or “never or almost never ethically permissible” (31, 7%).

Compensating Organ and Tissue Donors

Bioethicists strongly differentiate compensation for organ donors and compensation for tissue donors. Two-thirds (290, 66%) say it is ethically permissible to offer payment in exchange for blood products. By contrast, just under a fifth (80, 18%) think it is ethically permissible to compensate organ donors, with only 1% reporting that this is “always or almost always ethically permissible.” Respondents are nearly evenly split between saying compensation for organ donors is “never or almost never ethically permissible” (39%, 174) versus “not generally ethically permissible” (43%, 189).

Clinicians are significantly less likely than non-clinicians to regard compensating blood and organ donors as permissible: just over half of clinicians think it is ethically permissible to compensate blood donors, while more than two-thirds of non-clinicians would permit compensating blood donors (53 vs. 70%, p < 0.01). Only 1 in 10 clinicians think it is ethically permissible to compensate organ donors, while non-clinicians are twice as likely to think doing so is ethically permissible (10 vs. 20%, p = 0.03). More religious bioethicists are significantly less likely than less religious bioethicists to think it is permissible to compensate blood donors (56 vs. 73%, p = 0.001) or organ donors (12 vs. 24%, p < 0.001).

Resource Allocation

When allocating scarce medical resources, most bioethicists (302, 69%) believe that “policymakers [should] consider non-health benefits and harms (like whether expanding access to a service will reduce beneficiaries’ financial risk).” A minority (37, 9%) oppose consideration of non-health benefits and harms, and the remainder (96, 22%) are unsure.

If there are not enough lifesaving resources for everyone at risk of death, more than half of bioethicists (228, 56%) think we should “prevent more deaths.” Other respondents are evenly divided between “prioritiz[ing] those who are more disadvantaged” (90, 22%) and “giv[ing] everyone an equal chance” (90, 22%).

Three-quarters of bioethicists (324, 74%) oppose considering “an individual’s past decisions” when determining their access to medical resources. Women are significantly less likely than men to think it is “ethically permissible to consider an individual’s past decisions when determining their access to medical resources” (21 vs. 31%, p = 0.02).

When deciding which patients are eligible for an expensive treatment, nearly three-quarters (294, 71%) of respondents think it is permissible to consider “the patient’s expected post-treatment quality and length of life.” Fewer think that it is acceptable to consider: only a patient’s expected post-treatment length of life (36, 9%); only a patient’s expected post-treatment quality of life (34, 8%); or neither length nor quality of life (50, 12%). We did not find a statistically significant correlation (r = −0.08, p = 0.17) between a respondent’s age and their willingness to consider post-treatment length of life.

Asked about the age at which it is most important to prevent someone from dying, most bioethicists responded that “preventing a death is equally important irrespective of age” (254, 63%). In order of frequency, other respondents indicated it was most important to prevent someone from dying at 10 years of age (65, 16%), 1 year of age (53, 13%), or 25 years of age (32, 8%). No respondents selected either 50 or 75 years of age. We did not find a statistically significant correlation (r = 0.08, p = 0.14) between a respondent’s age and their likelihood of reporting that “preventing a death is equally important irrespective of age.”

Disability

While nearly all respondents (402, 98%) agree that “being unable to see [is] disadvantaging,” they are divided on why this is so: over half (240, 59%) say that being unable to see would be disadvantaging “even if society were justly designed,” while less than half (169, 40%) think blindness is disadvantaging “only because society is unjustly designed.”

Reproduction

Whereas most bioethicists (350, 83%) think it is ethically permissible “to select some embryos over others for gestation on the basis of somewhat painful medical conditions,” most (335, 78%) think it is impermissible “to select some embryos over others … on the basis of non-medical traits (e.g., height or eye color).”

Women are likelier than men to view as permissible selecting “some embryos over others for gestation on the basis of somewhat painful medical conditions” (87 vs. 78%, p = 0.01); they are less likely than men to view as permissible selecting “some embryos over others for gestation on the basis of non-medical traits (e.g., eye color, height)” (17 vs. 29%, p < 0.01). While 92% of less religious bioethicists think it is ethically permissible to “select embryos on the basis of somewhat painful medical conditions,” only 70% of more religious bioethicists agree (p < 0.001).

Two-thirds of respondents (278, 66%) claim that “the fact that a person’s life is expected to be worth living once we bring them into existence” does not give us a moral reason to bring them into existence. Others think this fact does give us reason to bring them into existence (62, 15%) or describe themselves as unsure (83, 20%). Men are significantly more likely than women to believe that “the fact that a person’s life is expected to be worth living once we bring them into existence gives us a moral reason to bring them into existence” (21 vs. 10%, p < 0.01).

Abortion

Most respondents (370, 87%) believe abortion is ethically permissible. Women respondents are more likely than men to think abortion is ethically permissible (93 vs. 80%, p < 0.001). Additionally, religious beliefs are predictive of respondents’ views on abortion. Bioethicists who are less religious overwhelmingly think abortion is permissible, while a lower percentage of bioethicists who rate religion as “somewhat” or “very” important agree (99 vs. 72%, p < 0.001). Most of this difference is explained by the low permissibility of abortion among very religious bioethicists, less than half of whom think abortion is permissible.

We assessed respondents’ views on personhood, a concept associated with having moral rights and protections. Two-thirds of all respondents (289, 69%) indicated that personhood begins at or after viability. Only a few (6, 1%) of respondents believe personhood begins at “first heartbeat,” while slightly more (45, 11%) selected a point prior to this (e.g., fertilization).

Animals

More than two-thirds of bioethicists (286, 70%) deem “trade-offs between human welfare and non-human welfare” permissible. When respondents were asked how many chimpanzee deaths—out of a maximum of 1,000—it is “acceptable to cause in order to prevent one expected human death,” the median response was 14. Asked the same question about mouse deaths, the median response was 800 out of a maximum of 1,000, with a mode of 1,000, strongly suggesting a ceiling effect.

Results by Normative Theory

Respondents were asked which, if any, normative theory best captures their views. The choice set included five pre-specified theories—consequentialism, deontology, ethics of care, virtue ethics, and principlism—as well as options to indicate “other” (with an opportunity to specify) or “no normative ethical theory.” Respondents were not provided definitions of the normative theories. Of the 413 respondents who answered this question, 293 picked one of the five pre-specified theories, 55 picked “other,” and 65 selected “no normative ethical theory.”

Here, we highlight salient demographic characteristics for those who endorsed the various normative theories; additional information is presented in Table 2. We then compare the views of respondents who endorsed a theory—e.g., consequentialism—to those who selected a different normative theory—e.g., anything other than consequentialism. We report only significant differences (Table 3).

Table 2.

Demographics by normative theory.

	Consequentialism	Deontology	Ethics of care	Virtue ethics	Principlism
Gender	n = 51	n = 44	n = 77	n = 71	n = 47
Men (n, %)	29 (57%)	20 (45%)	19 (25%)	37 (52%)	23 (49%)
Women	20 (39%)	22 (50%)	54 (70%)	30 (42%)	23 (49%)
Non-binary	0	0	2 (2.6%)	1 (1.4%)	0
Decline to answer	2 (3.9%)	2 (4.5%)	2 (2.6%)	3 (4.2%)	1 (2.1%)
Degree	n = 51	n = 44	n = 78	n = 71	n = 47
PhD or DPhil	37 (73%)	29 (66%)	46 (59%)	49 (69%)	24 (51%)
MD or Do	10 (20%)	10 (23%)	14 (18%)	13 (18%)	14 (30%)
JD	8 (16%)	5 (11%)	6 (7.7%)	6 (8.5%)	8 (17%)
other	17 (33%)	15 (34%)	44 (56%)	32 (45%)	19 (40%)
Religion	n = 50	n = 42	n = 75	n = 69	n = 44
Christian	10 (20%)	10 (23%)	19 (25%)	36 (52%)	17 (39%)
Jewish	7 (14%)	6 (14%)	11 (15%)	3 (4.3%)	8 (18%)
Atheist or nothing in particular	23 (46%)	13 (31%)	27 (36%)	20 (29%)	13 (30%)
Religiosity	n = 51	n = 43	n = 78	n = 69	n = 44
Low	40 (78%)	20 (47%)	51 (65%)	29 (42%)	22 (50%)
High	11 (22%)	23 (53%)	27 (35%)	40 (58%)	22 (50%)

Table 3.

Results by normative theory.

	Consequentialism	Deontology	Ethics of care	Virtue ethics	Principlism	Overall (includes respondents who did not endorse one of these ethical theories)
Q1: Clinicians assist patients in ending their own lives % permissible* (n respondents)	82% (50)	57% (44)	63% (75)	38% (73)	64% (47)	59% (475)
Q2: Provide life-saving care to capacitated adult who has refused	2.0% (51)	0% (44)	6.5% (77)	0% (73)	0% (47)	2% (483)
Q3: Surrogate decision-making against previously stated preferences	22% (51)	4.6% (44)	21% (77)	9.6% (73)	23% (47)	15% (482)
Q4: Treat 14-year-old for oUD without parental consent	75% (51)	70% (44)	71% (76)	58% (73)	57% (45)	66% (480)
Q12: Subject people to regulation they disagree with for their own good	67% (51)	51% (41)	54% (74)	75% (72)	58% (45)	62% (431)
Q13: Consider individual’s past medical decisions when allocating resources	33% (51)	16% (44)	24% (75)	29% (73)	24% (45)	26% (438)
Q14: Offer payment in exchange for organs	39% (51)	23% (44)	12% (76)	8.2% (73)	21% (47)	18% (443)
Q15: Offer payment in exchange for blood	71% (51)	70% (44)	57% (75)	63% (73)	79% (47)	66% (439)
Q17: Allow individuals to access treatments not approved by regulators	51% (51)	48% (44)	55% (76)	51% (73)	50% (46)	52% (437)
Q18: Select some embryos over others on the basis of non-medical traits	31% (51)	31% (42)	19% (75)	14% (73)	32% (47)	22% (428)
Q19: Select some embryos over others on the basis of medical traits	96% (49)	93% (42)	83% (75)	63% (72)	89% (45)	83% (423)
Q20: Abortion ethically permissible	96% (51)	88% (42)	95% (76)	66% (73)	94% (47)	87% (427)
Q23: Make tradeoffs between human and non-human animal welfare	80% (49)	74% (43)	58% (73)	74% (73)	76% (45)	70% (407)
Q16: Should policymakers consider non health benefits? (% yes)	78% (51)	63% (44)	73% (74)	56% (73)	73% (46)	69% (435)
Q21: A being becomes a person at or after viability	67% (48)	64% (42)	84% (75)	51% (72)	84% (44)	69% (419)
Q22: Moral reason to make happy people (% yes)	10% (50)	19% (42)	6.7% (74)	16% (73)	11% (45)	15% (423)
Q24: Triage (n)	51	43	72	73	44	406
Prevent more deaths (%)	75%	44%	38%	59%	61%	56%
Prioritize disadvantaged (%)	10%	33%	40%	18%	20%	22%
Give equal chances (%)	16%	23%	22%	23%	18%	22%
Q25: Blindness disadvantaging? % yes (n)	100% (50)	98% (43)	95% (75)	100% (72)	98% (44)	98% (409)
Yes, because society is unjust (%)	28%	35%	52%	35%	45%	40%
Yes, even if society is just (%)	72%	63%	43%	65%	52%	59%
Q26: It is most important to prevent death at which of the following ages (n)	50	43	73	73	46	404
1 (%)	26%	21%	5.5%	8.2%	17%	13%
10 (%)	28%	26%	9.6%	15%	13%	16%
25 (%)	13%	2.4%	5.5%	6.9%	13%	8%
Regardless of age (%)	34%	50%	79%	70%	57%	63%
Q27: Expensive treatment: Consider both length and quality (n)	92% (50)	74% (43)	67% (75)	61% (72)	70% (46)	71% (414)
Q28: Chimpanzee deaths (median)	25	11.5	10	51	25	14
Q29: Mouse deaths (median)	850	1000	923	800	756	800

^*“Permissible” is calculated by summing the responses for “generally ethically permissible” and “almost always or always ethically permissible.”

Consequentialism

Generally speaking, consequentialism is the view that whether an action may or should be performed depends solely on its consequences. Fifty-one surveyed bioethicists self-describe as consequentialists, though how they define consequentialism may vary. Of those 51, slightly more than half (29, 57%) identify as men; nearly three-quarters hold PhDs or DPhils (37, 73%), and 20% (10) hold medical degrees.

Consequentialists’ views differ from the views of non-consequentialist bioethicists (i.e., those who answered the normative theory question with any response other than “consequentialist”) in several ways.

First, more consequentialists than others view medical aid in dying as permissible (82 vs. 57%, p = 0.001)). Although a majority of consequentialists are, like bioethicists generally, opposed to compensating organ donors, consequentialists are significantly more likely than others to favor paying donors (39 vs. 16%, p < 0.001). Consequentialists are also more likely to say that, if there are not enough lifesaving resources for everyone at risk of death, we should “prevent more deaths” (75 vs. 53%, p = 0.01). Meanwhile, they are significantly less likely to report that “preventing a death is equally important irrespective of age” (34 vs. 67%, p < 0.001). Instead, they consider it most important to prevent someone from dying at 1 (26%), 10 (28%), or 25 (13%) years of age. Finally, although respondents overall consider it permissible to select some embryos over others for gestation on the basis of painful medical conditions, significantly more consequentialists view this as permissible (96 vs. 82%, p = 0.02).

Deontology

Unlike consequentialists, deontologists believe that features of actions other than their consequences (e.g., whether they respect people’s rights) can affect their permissibility. Forty-four respondents identify as deontologists. Individuals who identify as deontologists are roughly equally divided between men and women (22, or 50%, are women); two-thirds (29) hold a PhD or DPhil, and 23% (10) have medical degrees.

Deontologists’ views closely resemble the views of the broader bioethics community. They are, however, less likely than other bioethicists to think saving lives is equally important regardless of age (50 vs. 65%, p = 0.03).

Ethics of Care

Ethics of care, a feminist approach to ethics, holds roughly that morality arises from and aims to support interpersonal relationships of caring and dependency. Seventy-eight respondents selected ethics of care as the normative theory that best captures their views, making ethics of care the most popular normative theory among respondents. Of those who endorse ethics of care, more than two-thirds (54) are women; 59% (46) hold a PhD or DPhil, and 18% (14) have medical degrees.

These respondents are significantly less likely than respondents who selected other normative theories to approve of tradeoffs between human and non-human animal welfare (58 vs. 74%, p = 0.01). Respondents endorsing ethics of care are far less likely than others to favor preventing more deaths if there are not enough lifesaving resources to treat everyone (38 vs. 60%, p < 0.001); instead, they are more likely to favor prioritizing more disadvantaged patients (40 vs. 18%, p < 0.001). These respondents are also more likely to report that being unable to see is disadvantaging only because society is unjustly designed (52 vs. 37%, p < 0.001) and are more likely to think saving lives is equally important regardless of age (79 vs. 59%, p = 0.01).

Virtue Ethics

Virtue ethicists think, generally, that the morally right action is the one a person of virtuous character would perform. Seventy-three bioethicists self-describe as virtue ethicists. About half (37) of virtue ethicists are men, and just over two-thirds (49) hold a PhD or DPhil, while 18% (13) have a medical degree. Half of virtue ethicists (36) describe their present religion as some form of Christianity (e.g., Protestantism), a significantly higher share than those who selected any other normative theory (52 vs. 26%, p < 0.001).

Virtue ethicists are less likely than respondents who selected other normative theories to think it is ethically permissible for clinicians to assist patients in ending their own lives if patients request this (38 vs. 64%, p < 0.001). They are likelier to view subjecting individuals to regulations they disagree with “solely for the sake of their own good” as permissible (75 vs. 59%, p = 0.01). Although bioethicists are widely opposed to compensating organ donors, virtue ethicists are especially opposed, with less than 10% approving of such compensation (8.2 vs. 21%, p = 0.02). Virtue ethicists are also less likely than others to favor selection of embryos on the basis of somewhat painful medical conditions (63 vs. 88%, p < 0.001) or to think policymakers should take the non-health benefits and harms of treatment into account when distributing medical resources (56 vs. 73%, p = 0.01).

Principlism

Principlism is an ethical approach that centers on weighing and balancing four key principles: autonomy, beneficence, nonmaleficence, and justice. Forty-seven respondents endorse principlism. The gender of these respondents is equally split between men (23) and women (23); half (24) hold a PhD or DPhil, while roughly a quarter (14) hold a medical degree. Respondents who identify as principlists do not differ significantly from all other respondents in their views on any questions.

Other

Fifty-five respondents chose “Other.” Of those, seven self-identified as pragmatists in the free response box; two authors (LP and SG) independently analyzed the remainder of the 48 written responses and classified 24 of these as pluralists. While these respondents did not provide definitions, pluralists generally think there are multiple fundamental values, none of which is reducible to the others or to any overarching value; pragmatists focus not on discovering fundamental ethical principles that hold independently of us, but on determining what actions, ways of thinking, and forms of social organization best foster our flourishing. The remaining 24 respondents who provided free text responses endorsed theories such as constructivism, personalism, or Buddhism. Due to their relative popularity, we included pluralism and pragmatism in our sub-analyses. There are no notable differences between these groups and bioethicists as a whole.

DISCUSSION

VIBeS, a first-of-its-kind survey of American bioethicists, sought to describe them and to characterize their views on a variety of foundational issues and contemporary questions. Other surveys have characterized related disciplines. Notably, there have been two PhilPapers surveys (conducted in 2009 and 2020) examining the views of the English-speaking philosophical community on a range of topics. The PhilPapers authors note various roles for such surveys, including describing the state of the field for future scholars and providing evidence for claims about the distribution of views amongst philosophers (Bourget and Chalmers 2023). Our survey might serve these same roles for bioethics. Further, understanding bioethicists’ views is important because bioethics is a form of applied ethics, and bioethicists influence not only academic discourse but public discourse and public policy.

The PhilPapers authors additionally note that if philosophy converges on truth over time, philosophers’ views might provide some guidance on truth. They are, however, skeptical of this claim, noting that it is not clear philosophy does converge on truth. We are similarly skeptical. Thus, we do not seek here to assess whether any views are correct or mistaken, true or not true, and we urge readers to keep the is-ought fallacy in mind. Just because there is relative consensus on a topic does not necessarily mean it is rightly settled. The history of bioethics is notable for sweeping changes in views—for example, the shifting emphasis from paternalism to patient autonomy that contributed to the evolution and centrality of informed consent.

Today’s Bioethicists

Bioethicists have training in disciplines as diverse as philosophy, theology, medicine, nursing, social science, and law. Correspondingly, bioethicists employ a broad range of methodological approaches. While there are an increasing number of university-based graduate programs in bioethics (particularly but not exclusively bioethics master’s programs), members of the field have generally resisted certification (Lee and McCarty 2016). This can yield concerns that there is no unified basis for judging who “qualifies” as a bioethicist but also recognition that disciplinary diversity is a strength of the field.

As reflected here, U.S. bioethicists are whiter and more educated than the overall U.S. population; they are also more liberal and less religious. Nearly 80% of bioethicists in our sample identify as white alone, while only 64% of American adults do (Jones et al. 2021). Bioethicists are also whiter than academics generally, a group that more closely resembles the U.S. population: 61% of tenure-track academics are white, while 74% of tenured faculty are (Matias, Lewis, and Hope 2021). A majority of respondents hold a PhD or other professional degree, likely reflecting bioethics job requirements. Notably, respondents also hail from educated families. In the United States, only 14% of people have completed an advanced degree, including a master’s, professional, or doctoral degree; however, 62% of respondents in our sample have at least one parent with an advanced degree (United States Census Bureau 2011).

The bioethicists in our sample are overwhelmingly liberal (87%), while only a small fraction identify as moderate or conservative; by contrast, only 25% of Americans self-describe as liberal, while 37% self-describe as moderate, and 36% identify as conservative (Saad 2022). Academics overall also skew quite liberal. While political party affiliation is not the same as political ideology, it can serve as a rough proxy. For every professor who is registered as a Republican, there are more than 11 registered as Democrats (Swanson 2016). Notably, the social sciences and humanities—fields from which bioethics tends to draw—tended as early as the mid-2000s to be even more liberal than other academic disciplines, with social scientists and humanists identifying as liberal by more than 11:1 ratios and specific fields like history and English having nearly or over 20 Democratic faculty members for every one Republican (Gross and Simmons 2014).

Lastly, bioethicists are less religious than members of the U.S. public, and their religious backgrounds differ. In our sample, just under half of the bioethicists report belonging to an organized religion; by contrast, more than three-quarters of Americans consider themselves a member of an organized religion (Pew Research Study 2014). Moreover, in our sample, 14% of bioethicists identify as Jewish, 15% identify as Protestant, and 14% identify as Catholic; of Americans, only 2.5% identify as Jewish, while 47% identify as Protestant, and 21% identify as Catholic. In our sample, 13 and 18% of respondents identify as agnostic or atheist, respectively; of Americans, 4% identify as agnostic and 3% identify as atheist.

There have been calls to recognize the “moral and professional responsibility of those working in bioethics to make the field more equitable, more diverse, and more inclusive” (Fletcher et al. 2022). Our findings are suggestive of the distance the field still needs to traverse to reach this goal. Diversity has intrinsic value but also instrumental value. Lived experience influences the perspectives bioethicists bring to bear on their work as well as the questions they ask (Best 2022; Hofstra et al. 2020). If bioethics is primarily comprised of privileged individuals, it is of little surprise that the field has, for instance, focused excessively on “problems of affluence” while also failing to adequately address anti-Black racism (Rennie and Mupenda 2008). Because bioethicists sometimes serve as ethical authorities who shape policies and practices in hospitals, academia, and government, the unrepresentativeness of the field risks retrenching institutional structures that are unfavorable to populations under-represented in bioethics.

Building a more equitable, diverse, and inclusive bioethics will require recognizing and addressing the barriers that exist to becoming a bioethicist. There are, for instance, social and economic barriers to pursuing higher education; as a result, a disproportionate share of master’s, professional, and doctoral degrees in both the humanities and health sciences—fields from which bioethics draws—are earned by white students (American Academy of Arts & Sciences 2019). However, some challenges are unique to bioethics: for instance, due to the lack of well-defined disciplinary boundaries, credentials—like a master’s of bioethics degree or a health care ethics consultant license—can constitute expensive barriers to entry (Pierson 2021). Making matters worse, some programs offer limited or no financial aid or fee assistance to students and applicants. These factors make it difficult for underserved students to enter the field (Pierson 2021). Further, because the field is relatively young, students from groups underrepresented in bioethics may not know the field exists or be aware of opportunities for mentorship or entrance.

What Do Bioethicists Agree and Disagree on?

One striking finding is that there is relative consensus among bioethicists on many ethical issues. For the Likert-type questions discussed here, we dichotomized the answers as impermissible (encompassing “never or almost never ethically permissible” and “not generally ethically permissible”) and permissible (encompassing “generally ethically permissible” and “always or almost always ethically permissible”).

The position for which we found the most consensus is that it is ethically impermissible “for a clinician to provide life-saving care to an adult patient who has refused that care and has decision-making capacity.” In response to all but two questions, 60% or more of respondents gravitated to just one of the two possible positions (i.e., impermissible or permissible). The questions about which bioethicists were most divided were: “Is it ethically permissible for a government to allow an individual to access treatments that have not been approved by regulatory agencies, but only risk harming that individual and not others?” (for which 52% were in favor) and “Is it ethically permissible for clinicians to assist patients in ending their own lives if they request this?” (for which 59% were in favor).

Bioethicists’ endorsements of different normative theories may partly explain their disagreement on certain issues. There is no consensus on what counts as a normative theory (Flynn 2022). It is, however, agreed that normative theories tend to play a systematizing role, identifying connections and priority relations among different normative concepts (e.g., goodness, rightness, virtue) and organizing them into a simple, coherent, and generalizable scheme for answering normative questions. And our data suggest they serve this function in bioethics.

Looking within each normative theory, respondents exhibit considerable consistency between the theory they endorse in the abstract and their responses to questions about specific issues in bioethics. That is, respondents who identify with a given normative theory generally express views that are, as represented in the wider bioethics literature, congruent with that theory. While some convergence is to be expected, we would not expect—and did not find—complete convergence within adherents of any given theory, as individuals may reasonably differ in their specific understanding of the theory’s precepts or in the precepts they emphasize. For example, virtue ethicists may differ regarding what constitutes virtuous character. As a result, they may differ in how they understand the theory to resolve any particular ethical question. In addition, moral uncertainty may play a role in shaping bioethicists’ practical views: for instance, a bioethicist might consider themselves a consequentialist (in that they have the most credence in consequentialism), but have some credence in other moral theories, and think it makes sense to act in accordance with another theory under certain circumstances (MacAskill, Bykvist, and Ord 2020).

Looking across normative theories, proponents of different theories exhibit substantial overlap in their views on specific questions. This is to be expected, as proponents of different theories may reasonably come to the same answer, albeit by different values or forms of reasoning. We would, however, expect some disagreement, as proponents of different normative theories hold distinct views about what is good or right that—in some instances—yield substantively different conclusions. And, indeed, that is what we found. Here, we discuss one example: paying organ donors. Consequentialists in our sample are more amenable than others to compensating these donors. One of the most prominent arguments in favor of compensating donors is that doing so would mitigate the shortage of transplant organs, thereby saving lives (Becket and Elías 2007), and saving lives is a goal that consequentialists in our sample frequently endorse. Several prominent arguments against paying donors appeal to considerations that many (though not all) consequentialists think are not directly relevant to the permissibility of an action, such as the intrinsic value of altruistic acts, the intrinsic badness of commodifying the human body, and the status of exploitation as a rights violation. Arguments appealing to the value of altruistic acts may help explain why, for instance, virtue ethicists in our sample are particularly opposed to paying organ donors.

Considered together, these findings provide some limited empirical support for the claim that normative theories do meaningful work in bioethics, informing adherents’ positions on important topics. (Alternatively, it is possible that bioethicists’ views on applied issues affect their more fundamental normative beliefs.) Views often, but do not always, converge, which explains both the overall high degree of consensus amongst respondents and the reasonable disagreements. Although the connections between the normative views bioethicists hold and their actual decisions (e.g., during a clinical consultation) are unknown, it seems the labels are useful for self-identification and can also be used by others to understand roughly where a person stands on key issues.

Do Bioethicists’ Views Align with Others’?

Many issues in our survey are important topics of both professional discourse and public debate. Therefore, where data were available, and where question wording and research methods largely aligned with ours, we sought to determine how respondents’ views do or do not align with clinicians’ views and with broader public opinion.

Engaging with the views of the public may serve various purposes in bioethics. For example, because bioethicists do not have unique access to the truth, surveys of the public may inform normative guidance (though the question of how to incorporate opinion into policy is large and complex). Alternatively, a survey may help predict the acceptability of a proposed policy amongst stakeholders or inform efforts to shape or influence public opinion (Kim et al. 2009). Whatever the reason, bioethicists should be mindful of gaps between the positions they endorse and those endorsed by others lest they be accused of being “out of touch (Dickenson 2000; Fins 2013).”

Medical Aid in Dying

In our survey, 59% of bioethicists report that it is “ethically permissible for clinicians to assist patients in ending their own lives if they request this.” A 2018 Gallup poll asked Americans a similar question: “[P] lease tell me whether you personally believe that in general [doctor-assisted suicide] is morally acceptable or morally wrong” (Brenan 2018). Over half (54%) of the Gallup respondents said it is morally permissible; nearly two-thirds (65%) said it should be allowed by law. In responding to a 2018 Medscape survey, 58% of physicians indicated that physician-assisted suicide should be made legal for terminally ill patients (Martin 2018). Despite the varying emphasis on morality and legality, comparing these findings to ours suggests that bioethicists’ views on the ethical permissibility of medical aid in dying mostly align with those of physicians and the public.

Compensating Organ Donors

Most bioethicists indicated that it is ethically impermissible to offer payment in exchange for organs. Our ability to make direct comparisons between our findings and others’ is limited by methodological differences; nevertheless, the contrasts suggest that bioethicists’ strong opposition is inconsistent with the views of the U.S. public. A 2019 study of U.S. residents found what the authors described as “strong polarization” of views on payment for kidney donation (Elías, Lacetera, and Macis 2019). Nearly half (46%) favored paying donors regardless of whether this would affect kidney supply, whereas less than a quarter (21%) of respondents opposed paying kidney donors even if payment would result in transplant gains (Elías, Lacetera, and Macis 2019). Taking a more outcome-dependent position, 18% of respondents opposed compensation if there were no transplant gains but switched to favoring compensation if it increased supply.

Among our respondents, views on payment for kidney donors correlate with broader moral values: stronger non-consequentialist views were attributed to those who always opposed payment and stronger consequentialist views to those who always favored it. Though we did not see significant differences between self-identified deontologists and other bioethicists, we did find that self-identified consequentialists are significantly more likely than other bioethicists to say that paying donors is ethically acceptable; yet, even among consequentialist bioethicists, support for paying organ donors is seemingly not as high as among U.S. residents.

Resource Allocation

In our survey, most bioethicists responded that it is “equally important to prevent deaths” regardless of someone’s age, while only about a third said it was more important to prevent the death of a 1-, 10-, or 25-year-old. Bioethicists’ responses may differ from those of the American public: two samples drawn from the American public favored prioritizing younger patients when asked to allocate ventilators or flu vaccines in hypothetical vignettes (Huang et al. 2021; Li et al. 2010). In surveys of the public, there is evidence that older respondents are less likely to prioritize younger patients; however, this effect is mitigated by asking members of the public to reason from behind a “veil of ignorance.” Moreover, in one study that assessed the relationship between age and willingness to prioritize younger patients, the mean participant was 46—very similar to our mean of 48—suggesting that the differing views of bioethicists and the public cannot be explained by age alone (Huang et al. 2021).

Notably, bioethicists’ majority opinion that it is equally important to prevent deaths regardless of someone’s age contrasted somewhat with their responses to the following question, to which more than two-thirds responded that we should consider both a patient’s post-treatment quality and length of life when allocating expensive treatments (emphasis added), and 8% responding that we should only consider post-treatment quality of life. On this latter question, bioethicists’ views seem to hew more closely to those of the American public.

Treatment without Parents’ Knowledge or Consent

Two-thirds of bioethicists think it is ethically permissible to treat a 14-year-old for opioid use disorder without their parents’ knowledge or consent. This position is consistent with professional society guidelines, most of which recommend that doctors maintain confidentiality with their adolescent patients (Song et al. 2019). Strikingly, though, it appears that bioethicists would permit confidential health care for adolescents at a greater rate than either adolescents or their parents. According to a survey of American adolescent-parent dyads published in 2019, slight majorities of adolescents (ages 13–18) and of their parents said that “care from an adolescent’s regular health care provider should be provided confidentially” (59 and 53%, respectively) (Song et al. 2019). Yet, less than half of respondents thought counseling for drug or alcohol use in particular should be provided confidentially (adolescents: 48%; parents: 43%), and only a third thought adolescents should be able to “receive treatment at an inpatient facility (e.g. rehab) for drug and alcohol use” confidentially (adolescents: 39%; parents: 28%) (Song et al. 2019).

Abortion

American bioethicists overwhelmingly think abortion is ethically permissible, though we found differences by religiosity. In a 2022 survey conducted by the Pew Research Center, 7% of U.S. adults say that having an abortion is “morally acceptable in all cases” and 24% say it is morally acceptable in most cases; meanwhile, 33% say it is morally wrong in most cases, and 13% say it is morally wrong in all cases. About a fifth (21%) say abortion is not a moral issue. Of course, there are wide religious and partisan differences in views on the morality of abortion, with Republicans more likely than Democrats and Christians more likely than religiously unaffiliated individuals to say abortion is morally wrong. Bioethicists’ views align more closely with clinicians’ views, although our data suggest more bioethicists think abortion is permissible than do obstetrician-gynecologists, who are, in turn, more accepting of abortion than are other physicians (Frederiksen et al. 2023; Sermo Team 2021).

Just over two-thirds of bioethicists believe person-hood begins at or after viability. This is in sharp contrast to the U.S. public. According to the Pew Research Center, more than half of U.S. adults say that the statement “human life begins at conception, so a fetus is a person with rights” describes their views extremely or very well (38%) or somewhat well (18%). Support was even higher amongst those who identified as Protestant (very well: 52%; somewhat well: 19%) or Catholic (very well: 44%; somewhat well: 20%) (Pew Research Center 2022).

Animals

Most bioethicists believe it is ethically permissible to make tradeoffs between human welfare and non-human animal welfare; moreover, the median bioethicist thinks it is acceptable to cause 14 chimpanzee deaths or 800 mouse deaths to prevent one human death. We could not find studies analyzing tradeoffs involving mice or chimpanzees; however, 75% of American adults were willing to accept 100 pig deaths to prevent one human death, suggesting that, like bioethicists, American adults are also willing to make tradeoffs and to prioritize one human life over many animal lives (Wilks et al. 2021). Conversely, however, 52% of Americans oppose using animals in scientific research (Strauss 2018). This data suggests that, in the context of scientific research, bioethicists are more willing to make tradeoffs between human and non-human welfare than the average American, but appear similar to the average American asked to make tradeoffs in more abstract contexts.

Limitations

As discussed above, there is no agreement on who “counts” as a bioethicist. For this survey, our eligibility criteria were designed to include individuals meaningfully involved in the field through both the activities they engage in (i.e., teaching/training, research, or engagement in professional meetings) and also their allocation of time (i.e., 20% or more). We acknowledge that these criteria may have resulted in excluding some individuals who would fairly be deemed bioethicists, and academic bioethicists may be represented disproportionately in our sample. This may be, for example, because nonacademic bioethicists have fewer reasons or resources to attend academic conferences or are less likely to be affiliated with bioethics training programs. Because we do not know about the backgrounds, views, or normative commitments of bioethicists overall, we could not weight our sample. Further, we cannot say how respondents compare to non-respondents, and we cannot rule out the possibility that non-respondents differ meaningfully from respondents. These considerations limit the generalizability of our findings, as does our decision to focus on American bioethicists.

To minimize survey length and participant burden, we elected to focus on topics that were likely to be familiar to a wide range of respondents and did not ask about all relevant bioethical issues. Future surveys might explore additional issues of importance to the field; however, we would encourage some repetition of questions in order to capture change over time.

Question wording and difficulties in conducting online surveys can introduce error and bias. Respondents were given Likert-type questions to assess the ethical permissibility or impermissibility of various practices; this did not allow for nuance, though we did use qualifying language such as “generally,” “always or almost always,” or “never or almost never” to reflect that views are rarely absolute. We acknowledge this is a simplification of complex topics, and we would encourage others to engage in further survey and qualitative research that casts more light on the nuances of bioethicists’ views on specific issues. Further, we did not define terms, making it possible for individuals to have different understandings of their meanings. Social desirability bias may have affected respondents’ answers, although this concern is reduced in an anonymous survey; moreover, given that reasonable disagreement is a hallmark of bioethical discourse, bioethicists may be less susceptible to such bias.

CONCLUSION

The purpose of VIBeS was to give information about who bioethicists are and what views they hold over a broad range of topics. Far more than a novelty, this survey records where the field of bioethics currently stands and creates a baseline for future work aimed at understanding longitudinal change in bioethicists’ views. Moreover, it calls on bioethicists collectively to address issues related to representation within the field and reflect on how our views may resemble or depart from the views of others.

Other academic disciplines increasingly aspire to aggregate and share experts’ views on certain issues, and the bioethics community can gain from doing the same (Apollo Academic Surveys 2022; University of Chicago IGM Surveys 2023). Regardless of whether bioethicists’ views are the “right” ones, it is useful for others who work with, read the work of, or cite bioethicists to understand the normative landscape. Identifying areas of especially strong disagreement may help bioethicists prioritize research projects; conversely, in some arenas, bioethicists might leverage existing consensus to advocate for more ethical practices and policies in medicine, science, and public health.