Abstract
This chapter is an outline of the basic issues in biomedical ethics and is intended to serve as a foundation for later chapters that draw on the concepts discussed. The chapter begins with an examination of the various categories of bioethical concerns as well as a look at the Hippocratic origins of medical ethics . Various instances of historical lapses in bioethics are then presented to the reader to serve as cautionary examples. The chapter then discusses various ethical theories, including Kantian ethics , principlism , virtue ethics and utilitarianism . Additional topics discussed include consent , medical futility , therapeutic privilege and a sampling of pertinent legal cases.
Science cannot stop while ethics catches up—and nobody should expect scientists to do all the thinking for the country.
(http://thinkexist.com/quotation/science_cannot_stop_while_ethics_catches_up-and/160138.html) Elvin Stackman
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Notes
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Although this particular categorization is my own, it has undoubtedly been influenced by both my prior classroom exposure to bioethics as well as by my reading of various canonical texts (e.g., Beauchamp and Childress 2013).
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The reader may note, for example, a shift from a set of specific governing rules (e.g., from the Hippocratic oath : “I will not cut persons laboring under the stone”) to a set of broad-based governing principles (e.g., from the Nuremberg Code : “The voluntary consent of the human subject is absolutely essential”) as one moves from the original Hippocratic Oath and its variants to more recent ethical guidelines such as the Nuremberg code , the Declaration of Helsinki, and the Belmont Report.
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I use the word “surprisingly” because the prohibition against euthanasia is a long-standing, central tenet of classical medical ethics .
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The most recent revision, issued in 2008, may be viewed online at http://www.wma.net/en/30publications/10policies/b3/index.html.
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The report may be viewed online at http://ohsr.od.nih.gov/guidelines/belmont.html.
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Relman was probably less concerned about the quality of the experimental data (although the project’s chief investigator, Sigmund Rascher, was admittedly a clinician and not a qualified scientist) than about the ethical propriety of publishing experimental data obtained in clear violation of the Nuremberg Code and the traditions of the journal, which had earlier published a sizeable number of seminal articles in the field of bioethics. For an interesting discussion on this matter, the reader is directed to a commentary by Berger (1990).
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Despite the absence of any code of ethics , the Nazi experiments were considered unethical on the principal grounds that the experiments were not conducted with the consent of the participants. Some experiments were judged to be unethical because there was an a priori reason to believe that either death or a significant injury would occur. Some experiments (such as those conducted by Dr. Joseph Mengele) were additionally unethical because they stood no chance of providing clinically useful information despite posing substantial risks and suffering to the experimental subjects.
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It is interesting to ask whether there would have been a need for a formal code of ethics to guide medical research if the Holocaust experiments had never taken place. My answer is that ethical codes such as the Nuremberg Code would still have arisen (albeit perhaps not as historically early) both because other identified ethical lapses in medical research would have made the need apparent, as well because of a perceived need by ethically sensitive medical researchers dealing with increasing complex experimental paradigms.
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Some authorities argue that the Nuremberg Code ’s requirement that animals be used in lieu of humans in the early phases of research and testing are based on scientifically outdated principles, and serves no useful function. One basis for this position concerns important genetic differences in how drugs are handled across various species. A specific example is the drug isoproterenol, once used to treat asthma, which turned out to be harmful to humans in the amounts originally recommended based on animal studies. Authors such as Greek et al. (2012) argue that the Nuremberg Code ’s requirement for animals testing only serves to “increase the cost of drug development, and prevent otherwise safe and efficacious drugs and therapies from being implemented.” In addition, some authorities argue that, in this particular respect, the Nuremberg Code fails to consider the moral rights of animals. For additional insight into this interesting and important problem see Shanks et al. (2009). For a comprehensive discussion on the moral rights of animals see Singer (1975).
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While justification for continuing the study following the availability of effective treatment is difficult to envision, the arguments offered were that continuing the study would provide information about the natural history of syphilis not readily available by other means, that the participants were receiving free medical care that they would likely not otherwise receive, and that the study might even show the pharmacologic treatment of syphilis to be unnecessary. Some physicians, believing that only autopsies would provide definitive information about the natural history of syphilis, lacked an interest in seeing their experimental subjects survive.
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In the present treatment the terms “moral” and “ethical” are used interchangeably, as per the practice of a number of authors. A number of other authors, however, clearly distinguish between the two terms, where ethics is taken to be that branch of philosophy which addresses questions about morality, while morality is taken to signify the moral principles of a particular tradition, group, or individual (http://plato.stanford.edu/entries/morality-definition/). In addition, some authors would restrict the use of the term “moral” to philosophical systems such as that developed by Kant, based on notions such as duty, obligation, and principles of conduct. Other authors state that ethics refer to the series of rules provided to an individual by an external source, such as their profession, while morals refer to an individual’s own principles regarding right and wrong. A distinguishing example sometimes offered is that a lawyer’s personal morals may tell him that murder is reprehensible and that murderers should be punished, but his professional ethics as a defense attorney may require that he defend his client with enthusiasm, even if he suspects that the client may actually be guilty.
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A categorical imperative is an absolute, unconditional moral requirement that applies to all circumstances. It is distinguished from a hypothetical imperative, where certain ends apply (e.g., if I wish to tame my hunger, I must eat a meal). Note that while it is common to identify the categorical imperative as a principle, it is easy to get the wrong idea about what Kant takes it to be. Kant’s categorical imperative is a command, an unconditional command, and as such is neither true nor false. And although its form can be taken to be a self-generated, self-directed command, it is not an object of knowledge. It is essentially practical—something we do.
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As discussed herein, deontological approaches to ethics judge the ethical propriety of an action based on the action’s adherence to one or more rules.
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Hamlet, Act 1, scene 3, 75–77.
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Kant, Immanuel; translated by Mary Gregor [1788] (1997). Critique of Practical Reason. Cambridge University Press. pp. 25/5:27. ISBN 0-521-59051-5.
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It is not clear why uniformity of approach to tackling bioethical problems should be a bad thing. At a minimum a uniform approach would be expected to produce more consistent outcomes compared to an approach that draws on different philosophical bases on different days. The criticism that Principlism is “sterile” is arguably meaningless (at least in the sense used by the logical positivists), but in any event fails to appreciate the real value that it so often offers in dealing with the complex, real-world bioethical problems encountered in real life . While it is undoubtedly true that the central tenants in Principlism sometimes come into conflict (most notably, respect for autonomy versus beneficence) it is not clear that other approaches to dealing with ethical issues are free of similar difficulties. For example, both the deontological and consequentialist approaches to ethics have important limitations that are discussed later in this chapter.
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Examples of different approaches would include, for example, Impartial Rule Theory, Casuistry (Jonsen 1995), and (3) Virtue Ethics (Pellegrino 1995).
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As discussed in detail in Sect. 3.3, not all persons are human and not all humans are persons. Personhood requires that one (ordinarily) be in possession of continuous consciousness over time and that one be capable of mental representations concerning the world, as well as able to consider options, develop tactics and act on plans.
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It could be argued, of course, that our humanity is precisely situated in our ability and willingness to protect those who cannot fend for themselves.
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Thomas Jefferson appears to have felt that slavery was wrong but evidently never spoke against it publically, perhaps to avoid charges of hypocrisy. The January 1862 issue of The Atlantic makes passing reference to this issue. It can be read at http://www.theatlantic.com/past/politics/presiden/jeffslave.htm.
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Additionally, maximizing the happiness of all is not the same as maximizing ‘the satisfaction of all desires’, with the result that these two approaches could conceivably contradict each other. Also, a solution offered by one form of utilitarianism (e.g. one choosing the greatest good as the desired utility) would be expected to be different from a different approach, such as an approach based on preferences.
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A categorical imperative is an absolute, unconditional moral requirement that applies to all circumstances. It is distinguished from a hypothetical imperative, where certain ends apply (e.g., if I wish to tame my hunger, I must eat a meal).
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For example, many religious traditions have rules of behavior that are revealed via sacred scripture rather than being the result of rational discourse. Wrote Martin Luther: “Reason is the greatest enemy that faith has; it never comes to the aid of spiritual things, but more frequently than not struggles against the divine Word, treating with contempt all that emanates from God.” (www.godlessgeeks.com/LINKS/Quotes.htm).
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Cogito ergo sum is a Latin proposition offered by René Descartes in his Discourse on Method. Usually translated into English as “I think, therefore I am” it became a founding pillar of Western philosophy, purporting to form a secure foundation for knowledge in the face of radical doubt (wherein one refuses to accept anything as true unless it appears to be “clearly and distinctly” true). Descartes argued that while other kinds of knowledge could actually be a figment of one’s imagination, a deception, or a mistake, the very act of questioning one’s own existence necessarily confirms the reality of one’s own mind.
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Schloendorff vs. Society of New York Hospital and Malette vs. Shulman are two notable examples. Both these important legal cases are discussed in Sect. 2.29.
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Matter of Baby K. 16 F.3d 590 (4th Cir. 1994), n. 9 at 598.
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Schloendorff vs. Society of New York Hospital, 105 N.E. 92,1914.
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Great Britain. England. Queen’s Bench Division. Hills vs. Potter. All Engl Law Rep. 1983; 3:716–29.
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Doyle, D.J. (2018). Biomedical Ethics. In: What Does it Mean to be Human? Life, Death, Personhood and the Transhumanist Movement. Anticipation Science, vol 3. Springer, Cham. https://doi.org/10.1007/978-3-319-94950-5_2
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