Advancing methods in empirical bioethics:
bioxphi meets digital technologies
Emilian Mihailov,1 Ivar Hannikainen,2 and Brian D. Earp3,4
1 University of Bucharest, Romania
2 University of Granada, Spain
3 Yale University, USA
4 University of Oxford, UK
In this commentary, we explore some ways in which insights from experimental
philosophical bioethics (bioxphi), combined with the use of immersive digital
technologies, may yield an even clearer picture of the concepts, intuitions, reasoning,
and empirical assumptions commonly implicated in bioethics debates than is currently
possible with existing methods.
Historically, empirical research in bioethics has drawn on methods developed within the
social sciences, including qualitative interviews, focus groups, ethnographic studies, and opinion
surveys, to advance understanding of key issues in the field (Davies et al. 2015). In their target
article, Pavarini and colleagues (2021) emphasize some limitations to the ecological validity of
previous methods, and advocate a new approach they call design bioethics. Most saliently, this
This is the authors’ copy of an accepted manuscript, now published. It may be cited as:
Mihailov, E., Hannikainen, I., & Earp, B. D. (2021). Advancing methods in empirical
bioethics: bioxphi meets digital technologies. American Journal of Bioethics, 21(6), 53-
56. [version of record at https://doi.org/10.1080/15265161.2021.1915417]
approach harnesses the research potential of digital technologies, such as computer games and
virtual reality (VR). Pavarini et al. argue that immersive digital tools have the potential to simulate
lived contextual experience, embodied decision-making, and the narrative richness of a situation.
Accordingly, researchers can design interactive virtual scenarios in which participants’ choices
influence how the story unfolds (effectively, a high-tech “choose your own adventure”). The
prospect of incorporating these methods into the toolbox of empirical bioethics is exciting, and will
undoubtedly raise new questions, both empirical and normative.
In recent work with colleagues, we have similarly proposed a new framework for the use
of empirical methods in bioethics, what we call experimental philosophical bioethics or bioxphi
(Earp et al. 2020; Earp et al. 2021), modeled on the ‘parent’ discipline of experimental philosophy
or x-phi (Knobe et al. 2012). In this commentary, we explore some ways in which insights from
bioxphi, combined with the use of immersive digital technologies, may yield an even clearer
picture of the concepts, intuitions, reasoning, and empirical assumptions commonly implicated in
In a nutshell, bioxphi is a form of experimental moral philosophy as applied to topics in
bioethics. It uses controlled experiments rather than descriptive studies to understand morally
charged phenomena of interest to bioethicists, with the aim of contributing to associated
normative debates (Earp et al. 2020). When policymakers draw on public attitudes to decide about
the permissibility of using certain biomedical or neuroscientific technologies, for example, what
actually shapes the public’s moral attitudes toward these technologies (Mihailov et al. 2021)? How
do medical professionals distinguish between ‘ending’ a patient’s life and ‘allowing’ it to end, and
what factors influence attributions of the cause of death (Rodríguez-Arias et al. 2020)? By asking
questions such as these, bioxphi seeks not merely to document stakeholder judgments or
behavior in circumstances of bioethical relevance, but also to uncover the precise contextual
factors and proximate psychological mechanisms that explain why people judge and act as they
do (Earp et al. 2020). The immersive tools of design bioethics, with their emphasis on ecological
validity, could help identify additional factors and processes that shape moral intuitions, decisions,
and other outcomes of interest in bioethical contexts. For instance, controlled experiments using
virtual and augmented reality methods could systematically manipulate well-defined elements of
the experienced environment to study the influence of these factors on moral judgments and
behavior. This methodological design would be analogous to -- but going beyond what is possible
with -- the so-called contrastive vignette technique (Reimer 2019).
Bioethical judgment versus behavior: to each domain its own method
A principal concern in Pavarini and colleagues’ article (2021, p. 9) is that contrastive
vignette studies rely on static hypothetical scenarios, typically presented through short written
descriptions; and for this reason, they lack the emotional and contextual grounding of everyday
sensory experience. Without such grounding, participants’ responses may be unrepresentative of
their actual responses when engaging in the (virtually) real world. But are the situations or
judgments of interest to bioethicists invariably vivid and dependent on features of the physical
environment? Perhaps not. For instance, the experience of voting on a bioethical policy or forming
an abstract judgment about a range of policy-relevant issues might in fact be reasonably well-
captured by static, text-based stimuli. On the other hand, simulating a real-life emergency room
to understand the urgent judgment calls of physicians may demand richer and more realistic,
sensory-based research methods.
In other words, whether a particular research objective is best pursued through sensorially
rich, immersive methods, or through traditional, text-based methods, depends on the question at
hand. One way to answer this question is by considering the target behavior or judgment of
interest, and determining whether what is most (bioethically) relevant about it is people’s
embodied responses (i.e., how they actually react in vivid circumstances) or their declarative
judgments (i.e., what people decide when reasoning more abstractly). By taking advantage of
both immersive and conventional text-based stimuli, we might develop a more complete
understanding of people’s behavioral tendencies and declarative attitudes toward bioethical
questions. Thus, while we share Pavarini and colleagues’ enthusiasm about ongoing
developments in digital technology, we wish to call attention to the contingency or variability in
whether behavioral or vignette methods are better suited to a particular research objective. A
flexible use of these complementary research methods may furnish the most detailed
understanding of the bioethical mind.
Bioxphi and normative inference
What are some ways in which the bioxphi approach may offer distinct advantages? As we
see it, bioxphi is especially well-suited to identifying the factors that influence moral judgment,
allowing us to probe the epistemic or normative value of these factors. Consider the following
schema of a bioethical argument:
1. The moral condemnation M of biomedical technology X is mainly influenced by
factor/process F/P. [empirical premise]
2. F/P is a normatively unreliable factor/process. [normative premise]
3. So, moral condemnation M of biomedical technology X is unjustified.
The normative premise may require a sophisticated argument to show that a factor F is
morally unreliable or irrelevant. But either way, the empirical premise will be crucial to determining
whether the moral condemnation M of biomedical technology X is unjustified. Without the
knowledge that factor F underpins moral condemnation M, we would not be in a position to
question the epistemic or normative merit of M.
Let us illustrate. In a recent experimental study, we investigated potential factors that
undergird moral attitudes toward cognitive enhancement (Mihailov et al. 2021). We described a
series of agents who took ‘smart pills’ during a competition, and asked participants whether the
agents’ subsequent achievements were the result of their abilities or of the pills’ effects.
Participants who were especially concerned with fairness tended to diminish the role of the
agents’ skill and dedication, concluding instead that the ‘smart pills’ were ultimately responsible
for bringing about success. Importantly, this pattern arose only when cognitive enhancement was
described as abnormal. Describing smart pill use as commonplace eliminated such fairness-
This raises a complex ethical question: Normatively speaking, does mere normalization
constitute reliable or unreliable grounds for one’s moral approval of cognitive enhancement?
Depending on one’s normative or epistemic commitments about what makes a moral judgment
reliable or unreliable, these empirical findings might help us decide whether, and to what extent,
such judgments should play a role in guiding associated policy debates.
In another study, Earp and colleagues used a mix of digital and text-based materials to
test whether the perceived gender of a child influences the amount of pain the child is judged to
be feeling. Earp et al. showed participants a video of a young child dressed in gender-neutral
clothing getting a finger-stick to draw blood and asked how much pain the child experienced (Earp
et al. 2019). Earp et al. found that when the child was called “Samuel” participants rated the child
as experiencing more pain than when the child was called “Samantha,” holding everything else
equal. Thus, perceived gender alone appeared to bias observer interpretations of felt pain in this
relatively context-rich study (i.e., due to the use of a video of an actual clinical encounter). These
results might then cast doubt upon the reliability of a moral judgment that, say, children of different
genders should receive different levels of pain control for a comparable injury.
These studies show how normative inferences in bioethics might draw on empirical
findings from bioxphi studies, an important enterprise given that empirical research in bioethics is
still predominantly descriptively oriented (Wangmo and Provoost 2017).
The role of situated behaviors in moral inference
Suppose that certain situational factors or psychological processes have been identified,
in bioxphi research, as likely to play a role in people’s moral judgments or behaviors. Design
bioethics offers a valuable opportunity to show how these factors or processes actually play out
in the (virtually) real world. In other words, the results of bioxphi studies may inspire thinking within
design bioethics as to what kinds of phenomena to simulate; and then potential differences
between abstract judgments and context-specific behaviors may be explored. There is some
precedent for this sort of comparison. Within moral psychology, researchers have simulated
sacrificial dilemma scenarios developed by armchair philosophers (Francis et al. 2016; Patil et al.
2014). The emotionally arousing nature of virtual reality generated different behavioral responses
from choices made using text-based methods.
Given the discrepancy between moral thought
and moral action, simulation technologies are well suited to serve the implementation purpose of
bioethics. Design bioethics, with its capacity to impose time constraints, mimic real-world
uncertainty, and include visual and tactile interaction, can help us evaluate the feasibility of certain
At the same time, the implementation aspect of design bioethics can provide a feedback
loop to bioxphi. Realistic simulations of moral scenarios elicit high-fidelity cognitive and emotional
responses. The contextual richness of virtual reality might reveal details not seen by conventional
(e.g., text-based) analysis. Sometimes, it will only be possible to determine which stimuli are
Surprisingly, as emotional arousal had been expected to reduce utilitarian choices, the virtual
simulation of the so-called footbridge moral dilemma actually increased such choices (Francis et
al. 2016; Patil et al. 2014).
relevant for understanding moral judgments or behavior after these have actually occurred in a
Ultimately, we see bioxphi and design bioethics as complementary, rather than competing,
approaches. Indeed, insofar as design bioethics employs an experimental design to examine how
particular variables influence moral judgments or behavior (for example, by manipulating key
features of the environment across virtual reality sessions), it could be seen as an instance or
extension of the bioxphi approach we have advocated in recent work: a kind of "high-tech bioxphi.”
We look forward to exploring the interface between these emerging methodological frameworks
for empirical studies within bioethics, and reflecting on potential normative implications for
bioethical theory, practice, and policy.
This work was supported by a grant of the Romanian Ministery of Education and Research,
CNCS – UEFISCDI, project number PN-III-P4-ID-PCE-2020-0521, within PNCDI III.
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