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Introduction to Bioethics

What is bioethics?

What were the influential historical events andsocial processes that defined its emergence?

Pter Kakuk, kakukpeter@hotmail.com

Institute of Behavioural Sciences, 451-486, 55406, 55510

Bioethics seminars

2006/2007 2nd semester

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The emergence of bioethics

I doubt whether it will ever be a discipline. It

has become a meeting ground for a number

of disciplines, discourses and organisations

concerned with ethical, legal and socialquestions raised by advances in medicine,

science and biotechnology.(Onora ONeill)

The term, bioethics was coinedin 1971, with

the foundation of an institute in WashingtonDC. >> The Kennedy Institute for the Study of

Human Reproduction and Bioethics

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I will neither give a deadly drug to anybody who asked for it, nor will I

make a suggestion to this effect. Similarly I will not give to a woman

an abortive remedy. In purity and holiness I will guard my life and my

art.

I will not use the knife, not even on sufferers from stone, but will

withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick,

remaining free of all intentional injustice, of all mischief and in

particular of sexual relations with both female and male persons, be

they free or slaves.

What I may see or hear in the course of the treatment or even

outside of the treatment in regard to the life of men, which on no

account one must spread abroad, I will keep to myself, holding such

things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to

enjoy life and art, being honored with fame among all men for all

time to come; if I transgress it and swear falsely, may the opposite of

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Hippocratic OathModern VersionWritten in 1964 by Louis Lasagna, Academic Dean of the

School of Medicine at Tufts University

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians inwhose steps I walk, and gladly share such knowledge as is mine withthose who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required,avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and

that warmth, sympathy, and understanding may outweigh thesurgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in mycolleagues when the skills of another are needed for a patient'srecovery.

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Hippocratic OathModern VersionWritten in 1964 by Louis Lasagna, Academic Dean of the

School of Medicine at Tufts University

I will respect the privacy of my patients, for their problems are not disclosed tome that the world may know. Most especially must I tread with care in matters oflife and death. If it is given me to save a life, all thanks. But it may also be withinmy power to take a life; this awesome responsibility must be faced with greathumbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sickhuman being, whose illness may affect the person's family and economicstability. My responsibility includes these related problems, if I am to careadequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all

my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live andremembered with affection thereafter. May I always act so as to preserve thefinest traditions of my calling and may I long experience the joy of healing thosewho seek my help.

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Social processes that influenced the

modern ethical approach

Medicalization

Radical changes in the structure of health care

in the 20th century Development of powerful medical technologies

Human rights and anti-paternalist movements

Emerging demand on the wider social control ofscience and research.

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Science and responsibility

From the idea ofscience and humanityto the experience ofdestruction

The ethical self-controlof scientific practice: Isit sufficient?

The importance of awider publicity and

social control.

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Historical events and the application of

biological knowledge

Medicine under the Nazis

National Socialism as applied biology: racial hygiene and

the theory of the nordic superior race

Eutanasia program of the Nazis Research on humans and the final solution

Eugenics Movement (USA, England, North European

Countries)

Compulsary sterilization laws

Debated biomedical research on human subjects

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Eugenics as a social movement

Mostly positive propaganda for

achieving healthy nation

Pedigree construction

Fitter Family Contest

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Negative Eugenics:compulsory

sterilization laws

Buck vs. Bell case (2May 1927) JudgeHolmes famous

statement: Threegenerations ofimbeciles are enough.

This decision gave agreen light to

compulsory sterilizationin more than 30 statesof the US.

Estimates say about

60.000 sterilization.

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Eugenics supporting the political

program of immigration restriction

In the first two decades of

the last century

600 000 - 1250 000newcomers arrived an a

daily basis.

The 1924 Immigration

Restriction Act was based on

the ideology of eugenics. They reduced the number of

immigrants by 80 %.

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Eugenics propaganda; social reform

through biological knowledge

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Biological ideology

The obscurely and widely

defined concept of hereditary

diseases (low IQ, alcoholism,

criminality etc.)

The supposed close

relationship between

genetical impurity and the

numbers of offsprings

Endanger the nation and the

nordic race

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experiments

Mostly ordered by the

German army.

Victim of a medical experiment

immersed in freezing water at the

Dachau concentration camp. Dachau,

Germany, between August 1942 and

May 1943. YV

A prisoner in a compression chamber loses

consciousness (and later dies) during an

experiment to determine altitudes at which

aircraft crews could survive without oxygen.Dachau, Germany, 1942. NARA

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Nuremberg Medical Trial

and the Nuremberg Code

1947

Birth of the firstinternational codeconcerning the ethicalrequirements of humanexperiments

Stressing the importance ofinformed consent and theautonomy of researchparticipants

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NUREMBERG CODE, 1947

1. The voluntary consent of the human subject is absolutelyessential. This means that the person involved should have legal capacityto give consent; should be so situated as to be able to exercise free power ofchoice, without the intervention of any element of force, fraud, deceit,duress, over-reaching, or other ulterior form of constraint or coercion; andshould have sufficient knowledge and comprehension of the elements of

the subject matter involved as to enable him to make an understanding andenlightened decision. This latter element requires that before theacceptance of an affirmative decision by the experimental subject thereshould be made known to him the nature, duration, and purpose of theexperiment; the method and means by which it is to be conducted; allinconveniences and hazards reasonable to be expected; and the effects upon

his health or person which may possibly come from his participation in theexperiment.

The duty and responsibility for ascertaining the quality of the consent restsupon each individual who initiates, directs or engages in the experiment. Itis a personal duty and responsibility which may not be delegated to another

with impunity.

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2. The experiment should be such as to yield fruitful results for thegood of society, unprocurable by other methods or means of study, andnot random and unnecessary in nature.

3. The experiment should be so designed and based on the results ofanimal experimentation and a knowledge of the natural history of thedisease or other problem under study that the anticipated results will

justify the performance of the experiment.

4. The experiment should be so conducted as to avoid all unnecessary

physical and mental suffering and injury.

5. No experiment should be conducted where there is an a priorireason to believe that death or disabling injury will occur; except,perhaps, in those experiments where the experimental physicians alsoserve as subjects.

6. The degree of risk to be taken should never exceed that determinedby the humanitarian importance of the problem to be solved by theexperiment.

7. Proper preparations should be made and adequate facilitiesprovided to protect the experimental subject against even remote

possibilities of injury, disability, or death.

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Nuremberg Code

9. During the course of the experiment the human subjectshould be at liberty to bring the experiment to an end if he hasreached the physical or mental state where continuation of theexperiment seems to him to be impossible.

10. During the course of the experiment the scientist in chargemust be prepared to terminate the experiment at any stage, if hehas probable cause to believe, in the exercise of the good faith,superior skill and careful judgment required of him that acontinuation of the experiment is likely to result in injury,disability, or death to the experimental subject.

Reprinted from Trials of War Criminals before the Nuremberg MilitaryTribunals under Control Council Law No. 10, Vol. 2, pp. 181-182..Washington, D.C.: U.S. Government Printing Office, 1949.

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Bioethics in the USA, problematic research on

humans, the Tuskegee Syphilis study and genetic

engineering

Henry Beechers classic paper in the

New England Journal of Medicine:

Ethics and Clinical Research 74

(1966) 1354-60.

The deliberate failure to treat a group

of male Negroes in Macon County

(near Tuskegee), Alabama who had

syphilis begun in 1932 and ended, by

unfavorable publicity, in 1972.

At the end of the 1960s: New

techniques for the direct manipulation

of genes: genetic engineering. Tuskegee Syphilis study

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Consequences

The importance of individual autonomy (instead

of collectivisim)

The growing importance of human rights

The social need for the transparency of scientificactivities

Insufficiency of the Hippocratic Oath

Need for new medical norms and regulations

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Medical ethics

traditional and modern

Hippocratic tradition

List of professional

moral duties From the perspective of

the doctor

Paternalism

Argumentative

Interdisciplinary

Moral pluralism Patient perspective

Stressing the autonomy

of the patient

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Bioethics as part of applied ethics

Modern

medical ethics

Applied ethics

Bioethics

A quite frequent definition of

bioethics as apllied ethics.

Bioethics applies moral

philosophical reasoning tothe ethical problems arising

in the diverse field of the

lifesciences.

criticism towards

this idea that stresses moral

philosophy in understanding

these problems

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The four principles approach (4PA)

(Childress and Beauchamp, 1979)

The four principles emerge from a rational reconstruction

of common morality (the immediate moral

intuitions/judgements) of ordinary people.

Respect for autonomy

Non-maleficence

Beneficence

Justice

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Attractions and Critiques of 4PA

its simple structure

its apparent ability to make adeeper understanding of,and engagement with moral

theory unnecesserary its apparent congruence with

common features of moralthinking

the derivation of the 4principles from moral theoryis problematic

the degree to which commonmorality can be said to

support the 4 principles isquestionable

the content of the 4principles is determinedwithin a specific culture

the four principles do not

cover the whole moraldomain

the guidelines forspecification and balancingare vogue.

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The pluralism in bioethical approaches

Legal context of the problem

Empirical evidences in approaching an ethical

problem

Social sciences approaches

Religious approaches

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DECLARATION OF GENEVAAdopted by the 2nd General Assembly of the

World Medical Association, Geneva, Switzerland, September 1948

AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICALPROFESSION:I SOLEMNLY PLEDGE myself to consecrate my life to the service ofhumanity;

I WILL GIVE to my teachers the respect and gratitude which is their due;

I WILL PRACTICE my profession with conscience and dignity;

THE HEALTH OF MY PATIENT will be my first consideration;I WILL RESPECT the secrets which are confided in me, even after thepatient has died;

I WILL MAINTAIN by all the means in my power, the honor and the nobletraditions of the medical profession;

MY COLLEAGUES will be my sisters and brothers;

I WILL NOT PERMIT considerations of age, disease or disability, creed,ethnic origin, gender, nationality, political affiliation, race, sexual orientation,or social standing to intervene between my duty and my patient;

I WILL MAINTAIN the utmost respect for human life from its beginning evenunder threat and I will not use my medical knowledge contrary to the laws ofhumanity;

I MAKE THESE PROMISES solemnly, freely and upon my honor.

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Further reading, useful sources:

World Medical Association (WMA), www.wma.net

American Journal of Bioethics, www.bioethics.net

Eugenics Archive (USA), www.eugenicsarchive.org

Tom L. Beauchamp, James F. Childress: Principles of

Biomedical Ethics. New York: Oxford University Press

(fifth ed.), 2001.

David J. Rothman: Strangers at the Bedside

Ahistory of how law and bioethics transformed medical

decision making. New York: Basic Books, 1991.

http://www.wma.net/http://www.bioethics.net/http://www.eugenicsarchive.org/http://www.eugenicsarchive.org/http://www.bioethics.net/http://www.wma.net/

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At the end of this section you should be able

to answer these questions!

What principles are formulated concretely in the original versionof the Hippocratic Oath?

What social processes and changes have lead to theemergence of bioethics?

What is the difference between traditional and modern medical

ethics? What does moral pluralism mean?

When was the Nuremberg Code established? What is the mainpoint the document is stressing?

What are the main points of the Declaration of Geneva?

What are the four principles of medical ethics? Define themeaning of each!

What are the attractions and critiques of the four principles?

What is eugenics? What is racial hygiene?