"A small error in the beginning leads to a multitude of errors in the end." Thomas Aquinas, De Ente Et Essentia Aristotle, De Coelo
There is a strange phenomenon I have encountered over the last several years which I hope to at least identify with this essay. It is the apparent belief that bioethics is somehow the same as, or to be equated with, ethics per se, or at least with medical ethics per se. I have even heard it referred to as Roman Catholic medical ethics per se. Repeatedly, when I ask a group to define bioethics, I usually get the same sort of response. I hope with this essay to disenfranchise people of this belief.
Contrary to "popular opinion", bioethics, as predominantly practiced today -- especially as embedded in formal governmental regulations, state laws and a myriad of other documents, committees, guidelines, guidebooks, etc., around the world 1-- is not the same thing as "ethics per se". Academically it is actually a sub-field of ethics, and stands alongside many other theories of ethics, e.g., Kantian deontology, Millsean utilitarianism, casuistry, natural law, egoism, situation ethics, relativism, and various forms of theological ethics, etc. And like all ethical theories, bioethics is by no means "neutral" -- there is no such thing as a "neutral ethics".2 In fact, bioethics defines itself as a normative ethical theory -- i.e., it takes a stand on what is right or wrong.3
Nor is bioethics to be equated with "medical ethics", as that term is still generally understood.4 Nor is it the same as Roman Catholic medical ethics, or any other such subsystem of ethics that could be used to determine the rightness and wrongness of human actions within the medical context.
As we will see, bioethics understood as "principlism" is an academic theory of ethics which was formally articulated in 1979 by the Congressionally-mandated 11-member National Commission in their Belmont Report.5 That Report, as mandated, identified three bioethical principles: respect for persons, justice and beneficence. (As will be demonstrated below, the Commission defined these three bioethics principles in less than traditional terms). Nor is bioethics restricted to the medical context. Nor has bioethics ever even considered abortion a serious issue of debate6 (although the definitions of a "human being" and of a "human person" concretized in the Roe v. Wade decision has reverberated throughout the bioethics literature since then -- especially in the issues concerning human embryo and fetal research). At least this much must be clear before anyone enters these public "bioethics" dialogues.
As the formal body of bioethics literature is enormous -- extending over 30 years or more -- it will be impossible in this essay to properly evaluate in detail all of the ramifications of this "bioethics ediface".
My method will be primarily historical -- in terms of relating, only in the briefest of outline form, the short but extensively referenced and hectic history leading up to the actual articulation of the three bioethics principles of autonomy, justice and beneficence in the National Commission's Belmont Report. Because many of you are probably not familiar with those who have and still play major roles in bioethics, I will list as many of them as is reasonably feasible in the main text.
To put my endeavor into sharp focus, consider for a moment the strikingly different conclusions reached by secular bioethics and Roman Catholic medical ethics on an array of issues. Secular bioethics generally considers the following as ethical: contraception; the use of abortifacients; prenatal diagnosis with the intent to abort defective babies; human embryo and human fetal research; abortion; human cloning; the formation of human chimeras (cross-breeding with other species); human embryonic stem cell research; "brain birth"; "brain death"; purely experimental high risk research with the mentally ill; euthanasia; physician-assisted suicide; living wills documenting consent to just about anything; and, withholding and withdrawing food and hydration as extraordinary means.7 In contrast, Roman Catholic medical ethics, as expressed in the National Conference of Catholic Bishops' Ethical and Religious Directives for Catholic Health Care Services,8 as well as the Charter for Health Care Workers published by the Vatican, considers all of these unethical - with the exception of the use of "brain death" criteria (and some Catholic theologians are now becoming concerned about that as well). Probably the only issues on which they both agree is that the use of extraordinary means, e.g., a ventilator, is not morally required if a treatment is medically futile, and that even high doses of pain medication may be given if medically appropriate.
How is it that these two different ethical systems lead to such opposite and contradictory ethical conclusions? The answer is rather predictable. Every academic ethical theory has its own idiosyncratic ethical principles. Deducing from different ethical principles necessarily leads to different ethical conclusions. For example, Roman Catholic medical ethics is grounded on the ethical principles embedded in the Moral Law (a combination of natural law philosophical ethics, the Divine Law, and the teachings of the Magisterium).9 Secular bioethics, as predominantly understood and applied, is grounded in the three bioethics principles of respect for persons (now referred to as autonomy), justice and beneficence as articulated in 1979 by the National Commission in their Belmont Report.10 Deducing from these two very different sets of ethical principles leads inexorably to the different ethical -- and therefore medical ethical -- conclusions noted above.
In short, there is really no such thing as just "ethics per se", or as just "medical ethics per se". There are different kinds of ethics, and therefore there are different kinds of medical ethics -- each with its own unique ethical principles, subject matter, method (epistemology), and squadrons of "experts". It is these inherently different characteristics of different ethical theories that are compared and contrasted in the ethics or medical ethics classrooms (or at least should be).
Likewise, different ethical or medical ethical theories have their unique historical records. The "history" of bioethics is no exception, although its "history" is rather recent. To understand how bioethics is not ethics per se, or even medical ethics per se, it is helpful to start by tracing some of its roots in the ancient medical tradition of Hippocrates.
Several of the Founders of the field of bioethics are now busily writing books containing their own various accounts and versions of the history of the new "field" of bioethics. One example is the recent book by philosopher-Founder Albert Jonsen, The Birth of Bioethics11 (well worth reading). Although Jonsen presents the history of bioethics from within his own idiosyncratic perspective and his own important role in that history, his book is a wealth of historical information and extensive, often unique and difficult to access, documentation. The book does help to explain a great deal of some of the historical roots of bioethics, precisely what bioethics is, and the "experts" who founded it and are currently plying this trade.
Jonsen (a trained philosopher and former Jesuit priest) starts his "history" of bioethics by outlining its roots in the ancient Hippocratic tradition, and then moves chronologically through the mediaeval and modern periods of medical ethics. He marks the contemporary "birth" of bioethics as beginning about 1947 and extends it to 1987. It is of note that he stops the "history" there -- and the burning question is "why"? "I chose 1987 as the terminus of this history, ... [T]he leading ideas that form the discipline have come under scrutiny; the theory, principles, and practices that evolved during the first decades do not seem to measure up to the new questions."12 Just what are these "new questions" which caused this abrupt end to such a glorious "history"?
Jonsen's presentation of the "pre-history" is already familiar enough to many of you, so I will only reiterate it quite briefly and in simplistic outline here. He traces the literature of "medical ethics" back to the Hippocratic School between 400-300 B.C. -- the tradition of "medical ethics" which has basically continued until modern times. It was concerned with the qualities of "the good physician", the decorum and deportment a doctor should exhibit towards patients. The "good physician" was gentle, pleasant, comforting, discreet, firm -- in other words, physicians should reflect true virtues. The duties of a good physician were incorporated in oaths, rules dictated by church, state or profession. They included benefiting the sick and doing them no harm, keeping confidences, refraining from monetary and sexual exploitation of patients and showing concern for those in need of medical help even at risk to one's own health and wealth. The paradigm of these duties is found in the Hippocratic Oath13 -- an oath, by the way, which is no longer usually required of our contemporary medical students upon graduation; or students often just create their own "modified version" of it. To personify this earliest stage of medical history, let us refer to the typical physician paradigm here as "Dr. A".
By the middle ages, "Dr. B" moved on stage, at a time when a more social view of medical ethics was incorporated in which the physician also defined himself in society. Physicians must show themselves as worthy of social trust and deserving of social authority and reward. The marks of the profession of medicine included now the privilege to educate, examine, license and discipline their members, and the tacit pledge of public service.14
The next physician paradigm, "Dr. C" was articulated in the first book with the title of "Medical Ethics", written in 1803 by the English physician Thomas Percival. Percival combined the traditional virtues of medical decorum with new injunctions about the behavior of physicians among themselves. Still, social concerns in medical ethics were to be found the ethical codes of the American Medical Association since its establishment in 1847.15
In the United States, our "Dr. D" comes on the scene -- e.g., in the work of Dr. Richard Cabot. Cabot initiated what has been termed "an ethics of competence", especially in the practice of medicine in the hospital setting. For example, he stressed the need for extensive cooperation between physicians and all other professionals involved in the care of patients; he required accurate record keeping of the number of patients and the evaluation of their care; and he required a limit to the number of patients per physician so as not to compromise good patient care. Patients should be informed of their diagnoses, and their treatments should be explained to them by their physicians. Patients should not be exploited for teaching purposes, nor should senior physicians exploit junior physicians, etc. For Cabot, moral practice was competent; incompetent practice was unethical. And in the rapid advance of scientific medicine, the practitioner's highest moral duty was mastery of that science for the benefit of the patient.16
Dr. Chaunsey Leake (1896-1978) insisted that medical ethics should be concerned with the ultimate consequences of physicians' work on their individual patients and toward society as a whole. Professional ethics would be relocated in a foundation of moral philosophy!17 Of course, the question should arise as to which moral philosophy the profession of medicine should use as its foundations, given that by then there were multiple theories of ethics from which to choose? Dr. "E" is now on stage.
The contemporary history of medical ethics began after World War II, especially over controversies involving medical research. Medical ethics found itself increasingly confounded as medical science advanced and medical interventions became increasingly technical. As Jonsen notes, the important bonds of the physician/patient relationship began to suffer, and it was no longer clear what was "benefit" and what was "harm". Is it "harm" to experiment on a dying person to generate better ways of curing disease for the "benefit" of other patients, even if wouldn't "benefit" that individual patient? How should the growing intimacy of medical practice and medical research with government, commerce, and the new technologies be handled? If some patients cannot pay for medical care, who should? Who should live, and who should die? How should the limited resources of health care be justly distributed? How should the benefits and burdens of research be justly distributed? How far could individual physicians, medical investigators and the government go in advancing scientific knowledge and providing for our national security? And, of course, who should decide the answers to these difficult questions?18
These were, after all, issues that philosophy, theology and the law had previously pondered, rather than medicine. These disciplines were about to find their new home in the new field of secular bioethics,19 but with a difference. There would be a major shift from considerations of standard medical care and practice to those of cutting-edge medical scientific research, thus eventually blurring the distinction between the respective subject matters, methods and goals of these two very different fields of endeavor, and between the roles of physician and researcher. Further, the traditional roots of "medical ethics" in the Hippocratic Oath, religion and theology would be drastically cut as attempts to secularize "ethics" were rapidly articulated -- especially for use in our "pluralistic, multicultural, democratic" societies.
Starting in the '60's, important conferences took place which provided much of the materials, subject matter and debates later conceptualized in contemporary bioethics. The shift in theorists and in interests was dramatic. Of particular concern at these conferences were issues such as population control, eugenics, artificial reproduction, thought control, sterilization, cloning, artificial insemination, and sperm banks.20
For example, the conference, "Great Issues of Conscience in Modern Medicine", held at Dartmouth College in 1960, hosted distinguished medical scientists "to examine the issues of conscience in medical and scientific progress ... not simply the question of the survival or the extinction of man, but what kind of survival? a future of what nature?"21 [Emphasis in original]. The conference was chaired by Rene Dubos, a scientist at Rockefeller Institute who had just published a popular book entitled, Mirage of Health: Utopias, Progress and Biological Change.22 [Dubos was to become an original member of the yet-to-be-organized Hastings Center bioethics think-tank.]
The "savants" who participated included several Nobel Prize winners, and such distinguished scientists as: Sir George Pickering, (Oxford University), Brock Chisholm, (WHO), Wilder Penfield, father of neurosurgery, Walsh McDermott, M.D., Hermann J. Muller, (Nobelist in physiology and medicine for his work in genetic effects of radiation), and George Kistiakowsky, (Assistant to President Eisenhower for Science and Technology). C.P. Snow and Aldous Huxley represented the humanities.23
Issues at this conference included: the effects of ionizing radiation; the pollution of water and air; chemical adulteration of food; and, the "conquest of infectious disease" and its converse problem of over-population. As Jonsen notes, "The claim that medical advances had contributed to the population explosion and to the pollution of the gene pool became a common theme of the conferences during the 1960s."24 Genetics and eugenics loomed very large. Soon-to-be common themes of later secular bioethics debates emerged. It is worth quoting Jonsen directly:
Rene Dubos called "prolongation of the life of aged and ailing persons" and the saving of lives of children with genetic defects "the most difficult problem of medical ethics we are likely to encounter within the next decade ... To what extent can we afford to prolong biological life in individuals who cannot derive either profit or pleasure from existence, and whose survival creates painful burdens for the community? ... It will be for society to redefine these ethics, if the problem becomes one that society is no longer willing or able to carry." Geneticists worried that the gene pool was becoming polluted because the early death of persons with certain genetic conditions was now preventable; in addition to antibiotics, insulin for diabetes and diet for phenelkytonuria were frequently mentioned. A unique solution was offered by Nobelist Hermann J. Muller, who promoted his concept of a bank of healthy sperm, together with the "new techniques of reproduction" to prevent the otherwise inevitable degeneration of the race."25 [Emphasis mine.]
Of note too was the attitude of elitism exuded on all sides in the face of such complex dilemmas. Dubos explained: "We are not assembled here to solve problems. Our purpose is to air problems ... to state our problems as clearly and thoughtfully as we can, so that they can be better analyzed by the scientific community and so that the community at large -- lay people -- can struggle under our guidance to form its own opinions ... ." As Sir Charles Snow concluded, the way to deal with such problems is by foresight and intelligence and, above all, by scientists telling the truth. But "it is not enough for scientists to make statements of the greatest possible truth; [scientists] must have the courage to carry those statements through because they alone know enough to be able to impress their authority upon a world which is anxious to hear." And as Jonsen notes, "The public was only rarely invited to partake in resolving these great problems. ...for the most part, the public is seen as an audience, waiting for scientists to bring solutions to the problems they have created."26
Similar themes and speakers were repeated at the conference, "Man and His Future", sponsored by the Ciba Foundation in London in 1962. Among the speakers and illuminaries were: Dr. Brock Chisholm, Dr. Hermann Muller, Aldous Huxley and his scientific brother Julian Huxley, Joshua Lederberg, J.B.S. Haldane, Albert Szent-Gyorgyi, Francis Crick, Jacob Bronowski, and Peter Medawar. Themes also included agricultural productivity, world resources, environmental degradation, genetics and brain science. Of special note were the similar concerns with evolution, eugenics and population control:
Sir Julian Huxley opened the conference with a wide-ranging lecture entitled, "The Future of Man -- Evolutionary Aspects." He painted a picture of evolution that for the first time had become conscious of itself in human kind and thus was responsible for its population, economics, education, and above all, for the exploration of "inner space -- the realm of our own minds and the psychometabolic processes at work in it." The problems of overpopulation and the dysgenic effects of progress had to be overcome to assure the realization of human fulfillment: "Eventually, the prospect of radical eugenic improvement could become one of the mainsprings of man's evolutionary advance." Man was, he triumphantly proclaimed, "the trustee ... of advance in the cosmic process of evolution.27 [Emphasis mine.]
Scientists took sides for and against programs of eugenics and thought control. J.B.S. Haldane described a vision of his own "utopia", imagining the biological possibilities in the next ten thousand years. His "utopia" included broad control of physiological and psychological processes, achieved largely by pharmacological and genetic techniques, including cloning and deliberate provocation of mutations, to suit the human product for special purposes in the world of the future.28
Several other conferences delved into the implications of science in the modern world, e.g., the series of Gustavus Adolphus Nobel Conferences in Minnesota, in which many Nobel winners again participated. The first Nobel Conference in 1965 was devoted to "Genetics and the Future of Man." Dr. William Shockley, who had won the Nobel prize for physics, presented his views on eugenics, suggesting that, since intelligence was largely genetically determined, serious efforts to improve human intelligence should be pursued by various means, including sterilization, cloning, and artificial insemination. He praised Hermann Muller's advocacy of sperm banks.29