Bioethics

Bioethics, 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 ethicalquestions 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 encompassesconcern 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 (1224/25–1274), which briefly discusses the
permissibility of abortion; and the Lectures on Ethics of the
German Enlightenment philosopher Immanuel Kant (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 encompassa
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 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, 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 discriminationin 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 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 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. 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 dispositionsthat 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 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 encompassingthe 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.