Introduction to Bioethics

Bioethics seminars 2006/2007 2nd semester

What is bioethics?

What were the influential historical events and social processes that defined its emergence?
Pter Kakuk, [email protected] Institute of Behavioural Sciences, 451-486, 55406, 55510

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 social questions raised by advances in medicine, science and biotechnology. (Onora ONeill) The term, bioethics was coined in 1971, with the foundation of an institute in Washington DC. >> The Kennedy Institute for the Study of Human Reproduction and Bioethics
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Hippocratic Oath

(Classical Version)

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
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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 4 time to come; if I transgress it and swear falsely, may the opposite of

Hippocratic OathModern Version

Written 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 in whose steps I walk, and gladly share such knowledge as is mine with those 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 the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
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Hippocratic OathModern Version

Written 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 to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness 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 sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately 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 and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who 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 of science and research.

Science and responsibility

From the idea of

science and humanity to the experience of destruction The ethical self-control of scientific practice: Is it sufficient? The importance of a wider publicity and social control.

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

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 (2

May 1927) Judge Holmes famous statement: Three generations of imbeciles are enough. This decision gave a green light to compulsory sterilization in more than 30 states of 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 000 newcomers 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 first

international code concerning the ethical requirements of human experiments

Stressing the importance of

informed consent and the autonomy of research participants

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NUREMBERG CODE, 1947

1. The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonable to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment. The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another 17 with impunity.

2. The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methods or means of study, and not random and unnecessary in nature. 3. The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease 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 priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects. 6. The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment.

7. Proper preparations should be made and adequate facilities provided 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 subject should be at liberty to bring the experiment to an end if he has reached the physical or mental state where continuation of the experiment seems to him to be impossible. 10. During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgment required of him that a continuation 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 Military Tribunals 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 scientific activities 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

Argumentative
Interdisciplinary Moral pluralism

moral duties From the perspective of the doctor Paternalism

Patient perspective
Stressing the autonomy

of the patient

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Bioethics as part of applied ethics

A quite frequent definition of bioethics as apllied ethics.
Bioethics applies moral philosophical reasoning to the ethical problems arising in the diverse field of the lifesciences.

Applied ethics

Bioethics

Modern medical ethics

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 a the derivation of the 4

deeper understanding of, and engagement with moral theory unnecesserary its apparent congruence with common features of moral thinking

principles from moral theory is problematic the degree to which common morality can be said to support the 4 principles is questionable the content of the 4 principles is determined within a specific culture the four principles do not cover the whole moral domain the guidelines for specification and balancing are 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 GENEVA
Adopted 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 MEDICAL

PROFESSION: I SOLEMNLY PLEDGE myself to consecrate my life to the service of humanity; 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 the patient has died; I WILL MAINTAIN by all the means in my power, the honor and the noble traditions 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 even under threat and I will not use my medical knowledge contrary to the laws of humanity; 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 A history of how law and bioethics transformed medical decision making. New York: Basic Books, 1991.
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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 version

of the Hippocratic Oath? What social processes and changes have lead to the emergence 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 main point the document is stressing? What are the main points of the Declaration of Geneva? What are the four principles of medical ethics? Define the meaning of each! What are the attractions and critiques of the four principles? What is eugenics? What is racial hygiene?
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