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Bioethics

Bioethics Now

Jeffrey Spike explains the place of medical ethics within bioethics and in relation to philosophy.

What I want to do in this brief introduction is (1) help define what bioethics is, (2) identify its major aspects, and (3) clarify its relationship to philosophy. To this aim I will outline how bioethics has developed three distinct branches in its short history, and discuss the different groups of professionals who have been the primary contributors to the field.

By most accounts of its history, bioethics is about thirty years old now. That’s old enough to be treated as a respectable adult, even if it pales next to the 2,400+ years of Western philosophy as a whole.

There has been both ethics and philosophy of science for far longer than thirty years, so it is important to understand just what happened thirty years ago to justify the claim that bioethics is only thirty years old. I think the answer is twofold. First, many new topics for debate initially arose after World War II with the explosion of new medical technology. Indeed, almost every modern medical intervention was either developed or first used extensively in the period from the beginning of the war in Europe through the decade after its conclusion in the Pacific. From antibiotics to feeding tubes, from dialysis to ventilators, the ability for medicine to actually save lives is a surprisingly recent event in human history.

Note that I do not just mention the new technologies, but also the impact of the technologies on human life. For this too is why bioethics is considered a new subject. We did not just know more science, but this science had the potential to change our lives. Thus it affected not just the educated class’ thirst for understanding nature; it meant everybody who faced a treatable illness would be affected. It is this practical element that really marks the historical dividing line between philosophical ethics and bioethics.

But wait. Couldn’t the same issues have been raised by philosophical thought experiments before the technology was invented? Can’t we today discuss things which are as yet impractical? Well, of course we can discuss them as hypotheticals. But there are limits to the thought experiments tolerated in bioethics, and I believe this intolerance is a sign of the distinct nature of this young field.

Consider what are sometimes cited as seminal events in the early history of bioethics: the Doctors’ Trial at Nuremberg, the Shana Alexander article in Life magazine ‘Who Should Decide?’ or the publication of the first edition of Our Bodies, Ourselves [by the Boston Women’s Health Collective]. The first of these in particular is a historical contingency: we are lucky that the Allies won the war and the trial occurred, but it could have been otherwise. Bioethics has roots in the sort of historical contingencies that philosophy abhors. The other two are examples of the type of publications that even today keep the audience for bioethics considerably more egalitarian than just academics. Just as the public declared that ‘Ethics Committees’ should not play God and decide who lives and who dies, and women proclaimed that male gynecologists should not be allowed to make decisions for women concerning their own bodies, bioethics became a field of its own when it was removed from the academic realm of philosophers and joined the practical world of medicine, law, and public policy.

I propose this explanation because I sometimes get the impression that philosophers believe bioethics is ‘one of theirs,’ ie a specialist field of philosophy. Instead, I suggest philosophers would have a healthier attitude if they thought of it rather more like physics (formerly ‘natural philosophy’) and psychology. Philosophy can be the birthplace of new subjects, much as dark matter might be the birthplace of new galaxies.

One way to add some substance to this claim to separation is to identify the major branches of bioethics. As I said, there are at least three distinct branches now, each with its own journals and full-time professionals.

First there is clinical ethics. This subject is taught in medical schools around the English speaking world, and includes the following core subjects: informed consent, patient autonomy, decision-making capacity, risk-benefit analysis and the best interest standard, rationing and the just allocation of resources, professionalism, confidentiality and its limits, and the many issues concerning the end of life: the right to refuse treatment, withdrawing treatment, pain control, spiritual or existential suffering, physician-assisted suicide and euthanasia.

Second there is research ethics. This subject is primarily taught to graduate students and post-docs in PhD programs in the biomedical sciences. Preparation to teach research ethics at the graduate level often involves courses offered in law schools, or less often in a school of public policy or public health (especially at a university that lacks a law school). It includes the following core topics: the recording, preserving, and sharing of data, the role of mentoring, the rules of authorship, cooperation among competitors, rules governing public-private collaborations, conflicts of interest between private and professional responsibilities, copyrights and patents, and the wonderfully colorful world of scientific misconduct or ‘FFP’ (fabrication, falsification and plagiarism). Then there are the two most important topics of all in research ethics: the use of humans as subjects in research, and the use of non-human animals as subjects in research.

Third there is what is most often taught in undergraduate bioethics courses and in bioethics Masters Degree programs, which might be called theoretical bioethics. This can include meta-bioethics (considering bioethics as a species of pragmatism for example, or bioethics as mid-level principles derived from utilitarian and deontological sources), and speculative bioethics (such as discussion of whether we should allow the development of chimeras [where the genes from two species operate together in a single organism – Ed] or the genetic enhancement of species, once those are real possibilities). It also includes the impact of different religious and cultural systems on bioethics (Catholic bioethics, Jewish bioethics, developed versus developing world bioethics, and international research as a clash of bioethical cultures).

These three fields do not exhaust the possibilities – environmental ethics doesn’t fit into any of them, and isn’t usually taught to any of the three target audiences. But this gives an idea of the breadth of topics that has developed under the umbrella of bioethics over the past thirty years. I hope this helps explain why the subject is so large that its practitioners easily comprise a professional caste of their own, and so why bioethics cannot be simply subsumed under philosophy.

While it might seem tempting to suggest that philosophers have been the primary contributors to bioethical theory, lawyers to research ethics, and doctors to clinical ethics, I would protest that this not only oversimplifies the facts, but also would, if followed as advice on behaviour, lead to a flattening of the quality of thought in all three fields. Philosophers who do theory without the input of people grounded in clinical realities quickly revert to writing abstract philosophy of little interest to bioethics; physicians writing in clinical ethics quickly devolve into writing Codes of Professional Behavior that can hint more of defensiveness of the current practices than challenging them; and lawyers writing regulations become mere translators of laws waiting to be mistakenly overinterpreted by risk managers into defensive medical practice. In other words, each of the three fields of bioethics needs to have philosophers, doctors and lawyers in it.

What I propose as the one true hallmark showing that bioethics is indeed a new field and not just an amalgam of three old and well-grounded professions, is that in bioethics none of these three fields could exist alone. Thus my advice to readers: if you already have an adequate background in philosophy and find yourself interested in bioethics, it could well be that your next step into the field is to fill in gaps in your clinical or legal background. If you have already taken a course or two in bioethics, then consider volunteering as a community member of a hospital’s ethics committee or a university research ethics committee, for example. And go there prepared to learn from the other members rather than expecting to be considered the ethics expert. What you will quickly learn, after adopting the proper (humble) attitude of being a team player, is that philosophy and ethics can be an exciting contributor to the real world.

Jeffrey Spike currently teaches clinical and research ethics at the newest medical school in the United States, the Florida State University College of Medicine in Tallahassee, founded in 2000.