Bioethics

Methods, Theories, Domains

Marcus Düwell

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136190070
• Edition: 1
• Topic: Law
• Subtopic: Medical Law
• Index: Law

This book is a philosophically-oriented introduction to bioethics. It offers the reader an overview of key debates in bioethics relevant to various areas including; organ retrieval, stem cell research, justice in healthcare and issues in environmental ethics, including issues surrounding food and agriculture. The book also seeks to go beyond simply describing the issues in order to provide the reader with the methodological and theoretical tools for a more comprehensive understanding of current bioethical debates. The aim of the book is to present bioethics as an interdisciplinary field, to explore its close relation to other disciplines (such as law, life sciences, theology and philosophy), and to discuss the conditions under which bioethics can serve as an academically legitimate discipline that is at the same time relevant to society.

As a systematic and methodologically rigorous overview, Bioethics: Methods, Theories and Principles will be of particular interest to academics and students in the disciplines of Law, Medicine, Ethics and Philosophy.

'This is a book that embraces neither a single ethical theory nor a pragmatic melange of just-so-principles. It is a thoughtful and engaging analysis of diverse theoretical foundations in Bioethics. It is also an enormous step towards conceptual and philosophical clarity in this fascinating area.' - Professor Christian Illies, Chair for Practical Philosophy at the Otto-Friedrich University Bamberg, Germany

1	What is bioethics? An introduction

1.1	An introduction to bioethics?

Since the end of the 1950s, physicians have been able to use heart-lung machines to keep people alive for whom previously there was no prospect of recovery. Shortly thereafter, it also became possible to remove their organs for transplantation purposes. For many physicians, however, this raised the question whether it could be morally right simply to take away organs from living, breathing people. Interesting is the way in which an answer to this moral conundrum was sought: a number of medical practitioners asked the pope to pass judgment. This is an instance of a very early bioethical discussion. Another example would be the debate on the conduct of doctors in concentration camps in the Third Reich, as held in the Nuremberg Doctors’ Trial. Since then, developments in the life sciences have led to numerous discussions about cloning, embryo research, genetic diagnosis and selection, xenotransplantation and interference with the human brain – to highlight but a few themes. The contexts of these debates are no longer restricted to individual domains of medical practice, but have a far-ranging influence on the entirety of medicine and on everyday life. In addition, there is no universally accepted moral authority which could provide definitive answers. Bioethical discussions are partly held with considerable public participation and against a backdrop of extensive pluralism of moral convictions.

These are the circumstances and the very diverse contexts in which bioethics has established itself globally over the last 40 years. There are bioethics committees affiliated with parliaments, ministries, churches and scientific organisations. There are numerous research institutes engaged in bioethics, and enormous numbers of books, journals and other publications. In this respect, an introduction to bioethics is confronted with an unwieldy abundance of materials. It would seem positively implausible if a single author were to claim to possess an overview of all these different debates, positions and publications. Moreover, bioethical debate can change at such a speed that an introduction like that would see its expiry date pass in the blink of an eye.

For these reasons, the objective of the present introduction is not in the first place to provide an overview of the entirety of concrete discussions. Rather, the point is to provide an overview of the range of methodological problems and theoretical viewpoints that play a role in bioethics. It is important to keep in mind from the start that an introduction to bioethics is confronted with a variety of particular difficulties; in opposition, for instance, to an introduction to quantum physics, which presumably would not be an easy undertaking either. The difficulty of gaining an overview of bioethics is connected to the fact that bioethical debates take place on the boundary of academic and public-political discourse, that academic bioethics has an interdisciplinary character and that there is no agreement on what exactly bioethics is in the first place. In order to close in on the question of what ‘bioethics’ means, or should, or could mean, I shall first of all (in 1.1.1) take a look at some forms of institutionalisation and (in 1.1.2) elaborate on the interdisciplinarity of bioethics. Subsequently (in 1.2), I shall discuss the role of bioethics in the context of developments in the biosciences and, finally (in 1.3), I shall comment on a number of efforts to determine the meaning of the concept of ‘bioethics’.

1.1.1

Institutionalisation of bioethics

Bioethics, as I have indicated above, came into existence in the context of public debates about issues in (bio)medical science. The institutionalisation of bioethics is mostly a consequence of the increasing need of parliaments, governments and churches to obtain advice on ethical questions in the light of developments in medical science and biotechnology. Numerous ethics committees have been formed to fulfil this need. The functions of these institutions vary. Some committees were established merely to advise on concrete, well-defined questions; others are permanent advisory boards concerned with a whole range of societally relevant questions in the domain of the biosciences or other new technologies (i.e. the European Group on Ethics in the Sciences and New Technologies, the advisory board of the European Commission). While varied in assignment, they are also varied in size and composition. As a rule, these committees are interdisciplinary (with physicians, jurists, philosophers and theologians) and they usually consist not only of academics, but of representatives of relevant parties in society as well (churches, disability rights advocates, etc).

Besides ethical advisory boards affiliated with political institutions, committees have also been formed to advise researchers and hospitals. These so-called ‘ethics committees’ at medical faculties are geared towards verifying that the protection of medical test subjects with regard to risks and informed consent is guaranteed. The title ‘ethics committee’ for these bodies is somewhat misleading, since their intention is not to carry out ethical reflection on the research project at issue, but merely to certify that the relevant codes of conduct are observed. These committees are standardly composed of physicians, complemented by a (theological or philosophical) ethicist and a jurist.

In recent years clinical ethics committees and institutionalised forms of ethics advisory boards in hospitals have also been created, to which doctors, nurses and patients can turn in case of conflicts and difficult decisions in treatment and nursing. The task of these advisory services is geared towards individual cases, and is typically not very well defined. Mainly, the point is to create a space within the clinical praxis in which conflict situations can be dealt with transparently with regard to both argumentation and procedure. It may be that, as a rule, these committees are forums that are partially about conflict moderation and the protection of decision-makers. But in any case they are places that should make it possible for difficult practical situations to be dealt with in morally responsible ways.

With these three types of committees, the contexts in which bioethics emerged have already been laid out. From the start, the objective of bioethics was to advise and reflect on complex decisions in politics, research and clinical practice. In the domain of medicine, more and more situations arose in which the traditional ethical guidelines of the discipline were not helpful, for which moral intuitions were not prepared, and in which there were no (or insufficient) legal arrangements to guide a decision-making process. In these contexts, the expression ‘bioethics’ signalled first and foremost a need for reflection on the moral and legal standards regulating medical practice, as well as a need for guidance on the part of decision-makers. It is still undefined, however, in what ways this specific form of advice and reflection differs from other kinds of conflict moderation. And it is even less clear how the advisory task of these boards relates to what has been established as ‘bioethics’ in academic spheres.

In addition, this advisory task turns out to differ greatly between the forms of institutionalisation discussed. A clinical ethics committee is confronted with particular cases. As a rule, these particular cases are settled against a backdrop of legal regulations, established practices and widely shared moral convictions. However, the great need for ethical advice indicates that ever more practices are becoming problematic, and ever fewer moral convictions can be taken for granted as shared. Nonetheless, no comprehensive ethical theories are called upon when such conflict situations are being dealt with in medical practice. Rather, those involved tend to fall back on medical knowledge, somewhat familiar standards of medical and nursing practice and moral principles that are (rightly or wrongly) considered to be unproblematic. Incidentally, the customs of medical practice are based only in part on the question whether those acts could meet with general approval in the public sphere. The medical profession has simply been successful in asserting certain standards of medical practice within its strongly hierarchically organised and legally regulated domain. In any case, factual observance of a given standard and its moral acceptance are two different things. Whenever the call for ethical advice arises in the clinic it is never enough merely to assess the particular case in light of established practical standards and moral convictions. These standards and convictions themselves must also be considered. The call for ethical advice is thus also an indicator for the necessity to think about established forms of practice.

Discussions of bioethical themes that are widely held in the public sphere, on the other hand, are characterised by the fact that in this sphere there are no collectively shared moral convictions; there is at best partial consensus. To an extent, that may be a consequence of the fact that many areas of research, for instance stem cell research, are rather inaccessible to day-to-day experience. Moreover, on many bioethical topics people’s moral intuitions are extremely varied. In these cases, a much more systematic kind of ethical guidance is called for. Discussions in media and politics, as well as institutionalised ethics committees, therefore, fall back on academics who inform participants about scientific, legal, sociological and ethical aspects of new forms of practice and new technologies. These informatory tasks then fall to biologists, jurists, sociologists and ethicists. This means that academic ethical discourse plays a role in public discussions as well. Yet the relation between the academic discipline and public bioethical debates is remarkable in several respects. First of all, the academic discipline did not exist until the need for reflection on its subject arose in practice. Now that is not all that surprising. Ever since Aristotle, ethics in general has been understood as a philosophical reflection on practices, and has conceived its task as guidance towards a good praxis. But there are some further particularities of bioethics compared with other debates on the boundary of academic and public discussion. For one, it is striking that many debates – for instance those on cloning – are largely defined by academics but disseminated by public media. It has thus been possible to read articles containing elaborate philosophical argumentation in national newspapers. Occasionally, philosophers and theologians will speak out and express their standpoints on cloning in the press before engaging with the subject in academic journals. Sometimes, philosophers and theologians will even present themselves publicly as bioethicists, despite the fact that their academic publications are in very different areas. Those practices, of course, evoke the question of exactly what competencies a bioethicist may be expected to have.

The relation between bioethics as a topic of public debate and as an academic discipline is thus unclear in many respects. In a public debate, every citizen can vocalise his own moral intuitions. Is the bioethicist then something like an official who receives a salary for expressing her moral beliefs? If bioethics is a practice of advising politics, is it merely a rhetorically pretentious way of making one’s own standpoint heard? Is the establishment of bioethics a product of some strategy to evade the plurality in the battle of opinions by grounding a pseudo-expertocracy? Is incapacitation of the public sphere impending?

This relation between academic bioethical debates and the public and political spheres makes it difficult to provide a systematic introduction to bioethics in the first place. Yet insofar as bioethics constitutes a reflection on the praxis of medicine and the development of the life sciences, ethical consultation of politicians, physicians, etc. is only possible if there is a background of academic debates as well. Bioethics as an academic activity is therefore also presupposed in the established practices of various kinds of ethics committees, if their claim to provide guidance is in fact taken seriously.

For this reason, considering the academic profile and the expectations for bioethics is necessary in light of the public debate as well. But given the interdisciplinarity of bioethics it is not easy to identify a clear-cut profile of the field (Green 1990; Holmes 1990; Pellegrino 2002). As a branch of ethics, bioethics seems to have a special connection to philosophy (and theology), yet as an institutionalised subject it is often part of medicine or interdisciplinary centres. Opinions regarding the methodological and professional roles of the different disciplines in bioethics vary greatly. Below, I shall work out one single proposal for understanding the interdisciplinarity of bioethics by way of the example of ‘enhancement’.

1.1.2

Interdisciplinarity: judgments in bioethics are mixed judgments

For a few years now there has been a discussion of the question to what extent it is morally defensible to use the possibilities of medical science not only to cure people from disease, but also to improve their physical or mental capabilities (Parens 1998; President’s Council on Bioethics 2003). These ‘improvements’, which are known as ‘enhancements’, range from plastic surgery to memory-improving pharmaceuticals. The range of applications is broad and the boundaries with therapy are fuzzy. The same medication can be used to slow down the loss of memory in people suffering from dementia or to boost the mental capabilities of students shortly before an exam. Enhancement is morally controversial, since traditionally, the task of medicine has been formulated in terms of therapy, diagnosis and prevention of disease. Yet the question what exactly health and disease are in the first place is itself disputed in medical science (Murphy 2009). If one understands the medical task of healing to be the rectification of dysfunction in order to enable a functioning that is typical for the human species (Daniels 1985: 26ff), the applications mentioned above do not necessarily qualify. But why should this definition of disease be our guiding thread? And what right would we have to deny people medical possibilities that would improve their lives? So-called ‘transhumanists’ even claim that one should free oneself as much as possible from the arbitrary limits to which humankind is evolutionarily subject (see e.g. Bostrom 2005). I shall return to the subject of enhancement (see Chapter 4) shortly. At this point, I merely want to differentiate between some questions and topics in order to make the division of the roles of the various disciplines within bioethics a little more transparent.

1.1.2.1

Scientific and technical possibilities

First of all, no bioethical reflection will be able to say anything about enhancement without being informed about the possibilities that are currently technically possible and implemented. In terms of plastic surgery this is not difficult to establish; in terms of pharmaceuticals it is significantly more problematic. In this respect, it is of course important to survey the relevant effects – both direct and lateral – and the limits of our knowledge of those effects. Not only are the facts relevant; it is also important to reflect critically on the question how these facts were generated and which theoretical conceptions led to their establishment.

1.1.2.2

Prognosis of future possibilities and uncertainties

What technical possibilities can we expect? What issues are being researched? What research aims are there? Why is there a desire to fulfil these aims? How realistic are they? Are there alternative ways in which these aims could be reached? If bioethics is to avoid losing itself in passing judgment on completely irrelevant future scenarios, these are essential questions. They might sound trivial, but they are in fact very hard to answer. Scientists themselves usually have difficulties making claims about the development of their research. As a non scientist, one is inclined to overestimate the predictive capabilities of those in the field.

1.1.2.3

Social and psychological reality

What do we know about dealing with these technical possibilities in ‘real life’? How often does cosmetic surgery fail? What do patients say: are they actually happier afterwards? What hopes do these possibilities arouse in people? What impact does the presence of these technical possibilities have in the media? How do different cultures handle these possibilities? (Plastic surgery, for instance, seems to be employed predominantly in the USA and Brazil.)

1.1.2.4

Possibilities for legal regulations

To what extent does interaction with enhancement technologies allow for regulation? What regulative possibilities are there? What could be said about the expected effectiveness of these regulative possibilities? Do these regulations have further implications for, say, the protection of private information and the over abundance of regulations in the domain of medicine? What effects do these regulations have on legal policy? What is the symbolic meaning of the prosecution or authorisation of these technologies?

1.1.2.5

The meaning of the notion of disease in medicine

Traditionally, medical practice is legitimated on the ground that the physician’s task is to cure disease. This duty to cure determines the professional self-understanding of physicians. The financial facilitation of medical research and the solidary funding of health benefits are justified on the same grounds. In a sense, even the moral meaning of medicine is connected to this duty to cure: we understand the development of medical science not just as a technical challenge but also as a moral duty. ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• 1 What is bioethics? An introduction
• 2 Bioethics and moral philosophy
• 3 A cross section of bioethical questions
• 4 Domains and debates in bioethics
• 5 Conclusion
• Bibliography
• Index