bioethics

—bioethical, adj. —bioethicist /buy'oh eth"euh sist/, n.

/buy'oh eth"iks/, n. (used with a sing. v.)

a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures, technologies, and treatments, as organ transplants, genetic engineering, and care of the terminally ill.

[1970-75; BIO- + ETHICS]

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Introduction

      branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being, though it sometimes also treats ethical questions relating to the nonhuman biological environment. (Such questions are studied primarily in the independent fields of environmental ethics [see environmentalism] and animal rights.)

Definition and development

      The range of issues considered to fall within the purview of bioethics varies depending on how broadly the field is defined. In one common usage, bioethics is more or less equivalent to medical ethics, or biomedical ethics. The term medical ethics itself has been challenged, however, in light of the growing interest in issues dealing with health care professions other than medicine, in particular nursing. The professionalization of nursing and the perception of nurses as ethically accountable in their own right have led to the development of a distinct field known as nursing ethics. Accordingly, health care ethics has come into use as a more inclusive term. Bioethics, however, is broader than this, because some of the issues it encompasses concern not so much the practice of health care as the conduct and results of research in the life sciences, especially in areas such as cloning and gene therapy (see clone and genetic engineering), stem cell research, xenotransplantation (animal-to-human transplantation), and human longevity.

 Although bioethics—and indeed the whole field of applied ethics as currently understood—is a fairly recent phenomenon, there have been discussions of moral issues in medicine since ancient times. Examples include the corpus of the Greek physician Hippocrates (460–377 BC), after whom the Hippocratic oath is named (though Hippocrates himself was not its author); the Republic of Plato (428/27–348/47 BC), which advocates selective human breeding in anticipation of later programs of eugenics; the Summa contra gentiles of St. Thomas Aquinas (Aquinas, Thomas, Saint) (1224/25–1274), which briefly discusses the permissibility of abortion; and the Lectures on Ethics of the German Enlightenment philosopher Immanuel Kant (Kant, Immanuel) (1724-1804), which contains arguments against the sale of human body parts.

      Bioethics emerged as a distinct field of study in the early 1960s. It was influenced not only by advances in the life sciences, particularly medicine, but also by the significant cultural and societal changes taking place at the time, primarily in the West. The perfection of certain lifesaving procedures and technologies, such as organ transplantation and kidney dialysis, required medical officials to make difficult decisions about which patients would receive treatment and which would be allowed to die. At the same time, the increasing importance placed on individual well-being contributed to changes in conventional attitudes toward marriage and sexuality, reproduction and child rearing, and civil rights. The ultimate result was widespread dissatisfaction with traditional medical paternalism and the gradual recognition of a patient's right to be fully informed about his condition and to retain some measure of control over what happens to his body.

Issues in bioethics

The health care context

      The issues studied in bioethics can be grouped into several categories. One category concerns the relationship between doctor and patient, including issues that arise from conflicts between a doctor's duty to promote the health of his patient and the patient's right to self-determination or autonomy, a right that in the medical context is usually taken to encompass a right to be fully informed about one's condition and a right to be consulted about the course of one's treatment. Is a doctor obliged to tell a patient that he is terminally ill if there is good reason to believe that doing so would hasten the patient's death? If a patient with a life-threatening illness refuses treatment, should his wishes be respected? Should patients always be permitted to refuse the use of extraordinary life-support measures? These questions become more complicated when the patient is incapable of making rational decisions in his own interest, as in the case of infants and children, patients suffering from disabling psychiatric disorders such as schizophrenia or degenerative brain diseases such as Alzheimer disease, and patients who are in a vegetative state (see coma).

Traditional philosophical questions

      Another category of issues concerns a host of philosophical questions about the definition and significance of life and death, the nature of personhood and identity, and the extent of human freedom and individual responsibility. At what point should a fatally injured or terminally ill patient be considered dead? When his vital functions—e.g., heartbeat and breathing—have ceased? When the brain stem has ceased to function? Should the presence of deep coma be sufficient to establish death? These and similar questions were given new urgency in the 1960s, when the increased demand for human organs and tissues for use in transplant operations forced medical ethicists to establish guidelines for determining when it is permissible to remove organs from a potential donor.

      At about the same time, the development of safer techniques of surgical abortion and the growing acceptability of abortion as a method of birth control prompted increasing debate about the moral status of the human fetus. In philosophical discussion, this debate was framed in terms of the notion of a “person,” understood as any being whose interests are deserving of special moral concern. The central issue was whether—and, if so, at what stage—the fetus is a person in the moral sense. In slightly different terms, the issue was whether the class of persons is coextensive with the class of human beings—whether all and only human beings are persons, or whether instead there can be human beings who are not persons or persons who are not human beings (the latter category, according to some, includes some of the higher animals and hypothetical creatures such as intelligent Martians). These questions were raised anew in later decades in response to the development of drugs, such as RU-486 (mifepristone), that induce abortion up to several weeks after conception and to the use of stem cells (stem cell) taken from human embryos in research on the treatment of conditions such as parkinsonism (Parkinson disease) and injuries of the central nervous system.

      A closely related set of issues concerns the nature of personal identity. Recent advances in techniques of cloning (clone), which enabled the successful cloning of animals such as sheep and rabbits, have renewed discussion of the traditional philosophical question of what, if anything, makes a particular human being the unique person he is. Is a person just the sum of the information encoded in his genes? If so, is the patient who has undergone gene therapy a different person from the one he was before—i.e., has he become someone else? If a human being were to be cloned, in what sense would he be a copy of his “parent”? Would he and his parent be the same person? If multiple human beings were cloned from the same parent, would they and their parent all be the same person?

      The attempt to understand personal identity in terms of genetic information also raised anew the philosophical problems of free will and determinism. To what extent, if any, is human personality or character genetically rather than environmentally determined? Are there genetic bases for certain types of behaviour, as there seem to be for certain types of diseases (e.g., Tay-Sachs disease)? If so, what kinds of behaviour are so influenced, and to what extent are they also influenced by environmental factors? If behaviour is at least partly genetically determined, should individuals always be held fully responsible for what they do?

      Finally, the possibility of developing technologies that would extend the human life span far beyond its current natural length, if not indefinitely, has led to speculation about the value of life, the significance of death, and the desirability of immortality. Is life intrinsically valuable? In cases in which one is not suffering physically or emotionally, is it always better to be alive than dead? If so, is it rational to desire immortality? What would be the significance of death in a world in which dying was not biologically inevitable?

Social and legal issues

      Many of these philosophical questions, however they are answered, have significant social and legal dimensions. For example, advances in medical technology have the potential to create disproportionate disadvantages for some social groups, either by being applied in ways that harm members of the groups directly or by encouraging the adoption of social policies that discriminate unfairly against them. Accordingly, questions of discrimination in bioethics have arisen in a number of areas. In one such area, reproductive medicine, recently developed techniques have enabled parents to choose the sex of their child. Should this new power be considered liberating or oppressive? Would it be viewed positively if the vast majority of the parents who use it choose to have a boy rather than a girl? Similar concerns have been raised about the increasing use of abortion as a method of birth control in overpopulated countries such as India and China, where there is considerable social and legal pressure to limit family size and where male children are valued more highly than female children.

      In the field of genetics, the use of relatively simple tests for determining a patient's susceptibility to certain genetically transmitted diseases has led to concerns in the United States and other countries that the results of such tests, if not properly safeguarded, could be used in unfair ways by health-insurance companies, employers, and government agencies. In addition, the advent of so-called “genetic counseling”—in which prospective parents receive advice about the chances that their offspring will inherit a certain genetic disease (genetic disease, human) or disorder—has allowed couples to make more-informed decisions about reproduction but also has contributed, in the view of some bioethicists, to a social atmosphere considerably less tolerant of disability than it ought to be. The same criticism has been leveled against the practice of diagnosing, and in some cases treating, congenital defects (congenital disorder) in unborn children.

      Research on the genetic bases of behaviour, though still in its infancy, is controversial, and it has even been criticized as scientifically invalid. Whatever its scientific merits, however, it has the potential, according to some bioethicists, to encourage the adoption of crude models of genetic determinism in the development of social policies, especially in the areas of education and crime prevention. Such policies, it is claimed, could result in unfair discrimination against large numbers of people judged to be genetically disposed to “undesirable” forms of behaviour, such as aggression or violence.

      This last point suggests a related set of issues concerning the moral status of scientific inquiry itself. The notion that there is a clear line between, on the one hand, the discovery and presentation of scientific facts and, on the other, the discussion of moral issues—the idea that moral issues arise only after scientific research is concluded—is now widely regarded as mistaken. Science is not value-neutral. Indeed, there have been ethical debates about whether certain kinds of research should be undertaken at all, irrespective of their possible applications. It has been argued, for example, that research on the possible genetic basis of homosexuality is immoral, because even the assumption that such a basis exists implicitly characterizes homosexuality as a kind of genetic abnormality. In any case, it is plausible to suggest that scientific research should always be informed by philosophy—in particular by ethics but also, arguably, by the philosophy of mind (mind, philosophy of). Consideration of the moral issues related to one particular branch of medicine, namely psychiatry, makes it clear that such issues arise not only in areas of treatment but also in matters of diagnosis and classification, where the application of labels indicating illness or abnormality may create serious disadvantages for the individuals so designated.

      Many of the moral issues that have arisen in the health care context and in the wake of advances in medical technology have been addressed, in whole or in part, in legislation. It is important to realize, however, that the content of such legislation is seldom, if ever, dictated by the positions one takes on particular moral issues. For example, the view that voluntary euthanasia is morally permissible in certain circumstances does not by itself settle the question of whether euthanasia should be legalized. The possibility of legalization carries with it another set of issues, such as the potential for abuse. Some bioethicists have expressed the concern that the legalization of euthanasia would create a perception among some elderly patients that society expects them to request euthanasia, even if they do not desire it, in order not to be a burden to others. Similarly, even those who believe that abortion is morally permissible in certain circumstances may consistently object to proposals to relax or eliminate laws against it.

      A final class of social and legal questions concerns the allocation of health care resources. The issue of whether health care should be primarily an individual or a public responsibility remains deeply controversial. Although systems of health care allocation differ widely, they all face the problem that resources are scarce and consequently expensive. Debate has focused not only on the relative cost-effectiveness of different systems but also on the different conceptions of justice that underlie them. The global allocation of health care resources, including generic forms of drugs for life-threatening illnesses such as HIV/ AIDS, is an important topic in the field of developing world bioethics.

Approaches

Traditional and contemporary ethical theories

      As a branch of applied ethics, bioethics is distinct from both metaethics, the study of basic moral concepts such as ought and good, and normative ethics, the discipline that seeks to establish criteria for determining what kinds of action are morally right or wrong. To say that bioethics is “applied,” however, does not imply that it presupposes any particular ethical theory. Contemporary bioethicists make use of a variety of different views, including primarily Utilitarianism and Kantianism but also more recently developed perspectives such as virtue theory and perspectives drawn from philosophical feminism, particularly the school of thought known as the ethics of care.

      Utilitarianism is a normative-ethical theory that holds that the moral rightness or wrongness of an action should be ascertained in terms of the action's consequences. According to one common formulation, an action is right if it would promote a greater amount of happiness for a greater number of people than would any other action performable in the same circumstances. The Kantian tradition, in contrast, eschews the notion of consequences and urges instead that an action is right only if it is universalizable—i.e., only if the moral rule it embodies could become a universal law applicable to all moral agents. The Kantian approach emphasizes respect for the individual, autonomy, dignity, and human rights.

      Unlike these traditional approaches, both virtue ethics and the ethics of care focus on dimensions of moral theorizing other than determining the rightness or wrongness of particular actions. Virtue ethics is concerned with the nature of moral character and with the traits, capacities, or dispositions that moral agents ought to cultivate in themselves and others. Thus, the virtue ethicist may consider what character traits, such as compassion and courage, are desirable in a doctor, nurse, or biomedical researcher and how they would (or should) be manifested in various settings. The basic aim of the ethics of care is to replace—or at least augment—the supposedly “masculine” moral values of rationality, abstraction, impartiality, and independence with ostensibly more “feminine” values, such as emotion (particularly compassion and benevolence), particularity, partiality, and interdependence. From this perspective, reflection on abortion would begin not with abstract principles such as the right to autonomy or the right to life but with considerations of the needs of women who face the choice of whether to have an abortion and the particular ways in which their decisions may affect their lives and the lives of their families. This approach also would address social and legal aspects of the abortion debate, such as the fact that, though abortion affects the lives of women much more directly than it does the lives of men, women as a group are significantly underrepresented in the institutions that create abortion-related laws and regulations.

The four-principles approach

      Whereas some approaches in bioethics proceed by applying principles derived from independent ethical theories to individual cases (a “top-down” approach), others proceed by examining individual cases in order to elucidate the principles that seem to guide most people's thinking about bioethical issues in actual practice (a “bottom-up” approach). One very influential approach along these lines, known as the “four principles” of bioethics, attempts to describe a set of minimum moral conditions on the behaviour of health care professionals. The first principle, autonomy, entails that health care professionals should respect the autonomous decisions of competent adults. The second principle, beneficence, holds that they should aim to do good—i.e., to promote the interests of their patients. The third principle, nonmaleficence, requires that they should do no harm. Finally, the fourth principle, justice, holds that they should act fairly when the interests of different individuals or groups are in competition—e.g., by promoting the fair allocation of health care resources.

      According to proponents of the four-principles approach, one of its advantages is that, because the principles are independent of any particular ethical theory, they can be used by theorists working in a variety of different traditions. Both the utilitarian and the Kantian, it is argued, can support the principle of autonomy, though they would do so for different reasons. Nevertheless, this adaptability may also be construed as a disadvantage. Critics have contended that the principles are so general that whatever agreement on them there may be is unlikely to be very meaningful. Thus, although the utilitarian and the Kantian may both accept the principle of autonomy, the principle as it is formulated allows them to understand the notion of autonomy in very different ways. Another criticism of the approach is that it does not offer any clear way of prioritizing between the principles in cases where they conflict—as they are often liable to do. The principle of autonomy, for example, might conflict with the principle of beneficence in cases where a competent adult patient refuses to accept life-saving treatment.

      Despite these problems, the principles remain useful as a framework in which to think about moral issues in medicine and the life sciences. This is not an inconsiderable contribution, for, on at least one conception of the field, the main task of bioethics is not so much to provide answers to moral problems as to identify where the problems lie.

The significance of public attitudes

      Since its inception the field of bioethics has been populated by specialists from a number of different disciplines, including primarily philosophers, lawyers, and theologians. In the last decade of the 20th century, however, the contributions of social scientists to bioethical research became particularly important. Work of this type involved surveys of public attitudes to advances in the life sciences, including xenotransplantation and genetic modification. Programs for facilitating public understanding of these advances were developed, leading to the establishment of “public understanding” and later “public engagement,” or “participation,” as distinct topics of study in bioethics and the social sciences.

      These topics have been important from both a practical and a theoretical point of view. In order to formulate sound public policies on issues such as human cloning, for example, it is important to be able to predict how such technology, were it to become widely available, would affect the public's decision making about reproduction. At the same time, research on public attitudes may reveal that some bioethical principles, such as the principle of autonomy, may not be suitable for some societies, particularly those with cultures that are not particularly individualistic. For these societies, something like a “principle of solidarity” may have greater relevance. Nevertheless, it would be a mistake to assume that one of these principles must apply to the exclusion of the other—it is possible for a society to value both autonomy and solidarity.

Policy making

      The importance of the social and legal issues addressed in bioethics is reflected in the large number of national and international bodies established to advise governments on appropriate public policy. At the national level, several countries have set up bioethics councils or commissions, including the President's Council on Bioethics in the United States, the Det Etiske Råd (Danish Council of Ethics) in Denmark, and the Comité Consultatif National d'Ethique (National Consultative Bioethics Committee) in France. Elsewhere, as in the United Kingdom, there are a variety of different bodies that consider bioethical issues. The Nuffield Council on Bioethics has taken on the role of a national bioethics committee to a certain extent, but there also are national bodies that deal with specific fields, such as the Human Genetics Commission.

      Several international organizations also are involved in policy making on bioethical issues. The United Nations Educational, Scientific and Cultural Organization ( UNESCO), for example, has an International Bioethics Committee; the Human Genome Organisation has an Ethics Committee; and the Council of Europe (Europe, Council of) has issued the Convention on Human Rights and Biomedicine. The proliferation of such committees is evidence of the increasing political influence of the work performed by bioethicists. Indeed, acquaintance with developments in bioethics arguably is becoming an important aspect of national and global citizenship. At the same time, however, the role of bioethical experts on advisory or decision-making bodies has itself become a topic of study in bioethics.

Global bioethics

      The field of bioethics has grown most rapidly in North America, Australia and New Zealand, and Europe. Cross-cultural discussion also has expanded and in 1992 led to the establishment of the International Association of Bioethics. A significant discussion under way at the start of the 21st century concerned the possibility of a “global” bioethics that would be capable of encompassing the values and cultural traditions of non-Western societies. Some bioethicists maintained that a global bioethics could be founded on the four-principles approach, in view of its apparent compatibility with widely differing ethical theories and worldviews. Others argued to the contrary that the four principles are not an appropriate basis for a global bioethics because at least some of them—in particular the principle of autonomy—reflect peculiarly Western values. Although the issue remains unresolved, the field as a whole continues to grow in sophistication. At the same time, the increasing pace of technological advances in medicine and the life sciences demands that bioethicists continually rethink the basic assumptions of their field and reflect carefully on their own methodologies.

Ruth Felicity Chadwick

Additional Reading

General

Helga Kuhse and Peter Singer (eds.), A Companion to Bioethics (1998), features reviews of key topics in the field.

Issues

Allen Buchanan et al., From Chance to Choice (2000), discusses the new genetics and its implications for ethics, especially as they concern issues of justice. Also noteworthy is Justine Burley and John Harris (eds.), A Companion to Genethics (2002) . Ruth Chadwick, Mairi Levitt, and Darren Shickle (eds.), The Right to Know and the Right Not to Know (1997), a multidisciplinary research project in bioethics, examines issues relating to genetic information. Other issues are discussed in Norman Daniels, Just Health Care (1985); Len Doyal and Jeffrey S. Tobias (eds.), Informed Consent in Medical Research (2001); Jennifer Jackson, Truth, Trust, and Medicine (2001); and the journal Developing World Bioethics.

Approaches

Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 5th ed. (2001), expounds and defends the “four principles” approach. Raanan Gillon (ed.), Principles of Health Care Ethics (1994), contains a large number of essays on the four principles and their application to different issues. Helga Kuhse, Caring: Nurses, Women, and Ethics (1997), is a critical account of the attempt to base nursing ethics on a feminine ethics of care. Edmund D. Pellegrino and David C. Thomasma, The Virtues in Medical Practice (1993), offers a virtue-based ethics for medicine and health care. Susan Sherwin, No Longer Patient: Feminist Ethics and Health Care (1992), is an exposition and defense of feminist bioethics.

Policy making

Examples of publications of policy-making bodies in bioethics include Human Genome Organisation, Ethical, Legal, and Social Issues Committee, Statement on the Principled Conduct of Genetic Research (1996), and Statement on Stem Cells (2004); United States National Bioethics Advisory Commission, Ethical Issues in Human Stem Cell Research, 3 vol. (1999–2000); and Nuffield Council on Bioethics, Genetic Screening: Ethical Issues (1993), and The Ethics of Research Involving Animals (2005).

Global bioethics

Global bioethics is covered in Bioethics: Special Issue: IV World Congress of the International Association of Bioethics (July 1999).Ruth Felicity Chadwick

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