a companion to bioethics...a companion to bioethics second edition edited by helga kuhse and peter...

A Companion toBioethicsSecond edition

Edited by

Helga Kuhse and Peter Singer

A John Wiley & Sons, Ltd., Publication

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A Companion to Bioethics

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Blackwell Companions to Philosophy

This outstanding student reference series offers a comprehensive and authoritative survey ofphilosophy as a whole. Written by today’s leading philosophers, each volume provides lucid andengaging coverage of the key figures, terms, topics, and problems of the field. Taken together,the volumes provide the ideal basis for course use, representing an unparalleled work ofreference for students and specialists alike.

Already published in the series:1 The Blackwell Companion to Philosophy,

Second EditionEdited by Nicholas Bunnin and Eric Tsui-James

2 A Companion to EthicsEdited by Peter Singer

3 A Companion to Aesthetics, Second EditionEdited by Stephen Davies, Kathleen MarieHiggins, Robert Hopkins, Robert Stecker, andDavid E. Cooper

4 A Companion to EpistemologyEdited by Jonathan Dancy and Ernest Sosa

5 A Companion to Contemporary PoliticalPhilosophy (two-volume set), Second EditionEdited by Robert E. Goodin and Philip Pettit

6 A Companion to Philosophy of MindEdited by Samuel Guttenplan

7 A Companion to Metaphysics, Second EditionEdited by Jaegwon Kim, Ernest Sosa, and GaryS. Rosenkrantz

8 A Companion to Philosophy of Law and LegalTheoryEdited by Dennis Patterson

9 A Companion to Philosophy of ReligionEdited by Philip L. Quinn and Charles Taliaferro

10 A Companion to the Philosophy of LanguageEdited by Bob Hale and Crispin Wright

11 A Companion to World PhilosophiesEdited by Eliot Deutsch and Ron Bontekoe

12 A Companion to Continental PhilosophyEdited by Simon Critchley and William Schroeder

13 A Companion to Feminist PhilosophyEdited by Alison M. Jaggar and Iris Marion Young

14 A Companion to Cognitive ScienceEdited by William Bechtel and George Graham

15 A Companion to Bioethics, Second EditionEdited by Helga Kuhse and Peter Singer

16 A Companion to the PhilosophersEdited by Robert L. Arrington

17 A Companion to Business EthicsEdited by Robert E. Frederick

18 A Companion to the Philosophy of ScienceEdited by W. H. Newton-Smith

19 A Companion to Environmental PhilosophyEdited by Dale Jamieson

20 A Companion to Analytic PhilosophyEdited by A. P. Martinich and David Sosa

21 A Companion to GenethicsEdited by Justine Burley and John Harris

22 A Companion to Philosophical LogicEdited by Dale Jacquette

23 A Companion to Early Modern PhilosophyEdited by Steven Nadler

24 A Companion to Philosophy in the MiddleAgesEdited by Jorge J. E. Gracia and Timothy B. Noone

25 A Companion to African-AmericanPhilosophyEdited by Tommy L. Lott and John P. Pittman

26 A Companion to Applied EthicsEdited by R. G. Frey and Christopher HeathWellman

27 A Companion to the Philosophy of EducationEdited by Randall Curren

28 A Companion to African PhilosophyEdited by Kwasi Wiredu

29 A Companion to HeideggerEdited by Hubert L. Dreyfus and Mark A.Wrathall

30 A Companion to RationalismEdited by Alan Nelson

31 A Companion to Ancient PhilosophyEdited by Mary Louise Gill and Pierre Pellegrin

32 A Companion to PragmatismEdited by John R. Shook and Joseph Margolis

33 A Companion to NietzscheEdited by Keith Ansell Pearson

34 A Companion to SocratesEdited by Sara Ahbel-Rappe and RachanaKamtekar

35 A Companion to Phenomenology andExistentialismEdited by Hubert L. Dreyfus and Mark A.Wrathall

36 A Companion to KantEdited by Graham Bird

37 A Companion to PlatoEdited by Hugh H. Benson

38 A Companion to DescartesEdited by Janet Broughton and John Carriero

39 A Companion to the Philosophy of BiologyEdited by Sahotra Sarkar and Anya Plutynski

40 A Companion to HumeEdited by Elizabeth S. Radcliffe

41 A Companion to the Philosophy of Historyand HistoriographyEdited by Aviezer Tucker

42 A Companion to AristotleEdited by Georgios Anagnostopoulos

43 A Companion to the Philosophy of TechnologyEdited by Jan-Kyrre Berg Olsen, Stig AndurPedersen, and Vincent F. Hendricks

Also under contract:A Companion to Philosophy of Literature, Edited by

Garry L. Hagberg and Walter JostA Companion to Schopenhauer, Edited by Bart

VandenabeeleA Companion to Relativism, Edited by Steven D.

Hales

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A Companion toBioethicsSecond edition

Edited by


A John Wiley & Sons, Ltd., Publication

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This second edition first published 2009© 2009 Blackwell Publishing LtdExcept chapter 18 © Gregory E. PenceEdition history: Blackwell Publishing Ltd (1e, 1998)

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell.

Registered OfficeJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom

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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording orotherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

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Library of Congress Cataloging-in-Publication DataA companion to bioethics / edited by Helga Kuhse and Peter Singer. — 2nd ed.

p. cm. — (Blackwell companions to philosophy ; 15)Includes bibliographical references and index.ISBN 978-1-4051-6331-6 (hardcover : alk. paper)

1. Bioethics. 2. Medical ethics. I. Kuhse, Helga. II. Singer, Peter, 1946–

R724.C616 2009174.2—dc22

2009007422

A catalogue record for this book is available from the British Library.

Set in 10/12.5pt Photina by Graphicraft Limited, Hong KongPrinted in Singapore

01 2009

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For Brent

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Contents

List of Contributors xi

Acknowledgments xiii

Part I Introduction 1

1 What Is Bioethics? A Historical Introduction 3Helga Kuhse and Peter Singer

Part II Questions About Bioethics 13

2 Ethical Theory and Bioethics 15James Rachels

3 Culture and Bioethics 24Segun Gbadegesin

4 Gender and Bioethics 36Jan Crosthwaite

5 Religion and Bioethics 46Eric Gregory

6 Law and Bioethics 56Wibren van der Burg

Part III Ethical Approaches 65

7 A Principle-based Approach 67James F. Childress

8 Exceptionless Rule Approaches 77Joseph Boyle

9 A Utilitarian Approach 85R. M. Hare

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contents

10 A Virtue Ethics Approach 91Justin Oakley

11 A Care Approach 105Rita C. Manning

12 A Case Approach 117John D. Arras

Part IV Before Birth: Issues Involving Embryos and Fetuses 127

13 Personhood 129Michael Tooley

14 Abortion 140Mary Anne Warren

15 Mother–Fetus Conflict 149Bonnie Steinbock

Part V Issues In Reproduction 161

16 Population 163Margaret Pabst Battin

17 Assisted Reproduction, Prenatal Testing, and Sex Selection 178Laura M. Purdy

18 Cloning 193Gregory Pence

Part VI The New Genetics 205

19 Gene Therapy 207Ruth Chadwick

20 Genetic Enhancement 216Julian Savulescu

21 Creating and Patenting New Life Forms 235Nils Holtug

22 Genetic Counseling, Testing, and Screening 245Angus Clarke

Part VII Life and Death Issues 261

23 Medical Decisions at the End of Life 263Dan W. Brock

24 Severely Disabled Newborns 274Eike-Henner W. Kluge

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contents

25 Death, Brain Death, and Persistent Vegetative State 286Jeff McMahan

26 Advance Directives 299Alexander Morgan Capron

27 Voluntary Euthanasia, Suicide, and Physician-assisted Suicide 312Brian Stoffell

28 The Slippery Slope Argument 321Govert den Hartogh

Part VIII Resource Allocation 333

29 Deciding Between Patients 335John Harris

30 Society’s Allocation of Resources for Health 351Daniel Wikler and Sarah Marchand

31 Is There a Right to Health Care and, If So, What Does It Encompass? 362Norman Daniels

Part IX Organ Donations 373

32 A World of Transferable Parts 375Janet Radcliffe Richards

Part X Global Health-care Issues 391

33 Global Health Responsibilities 393Christopher Lowry and Udo Schüklenk

34 Developing World Challenges 404Udo Schüklenk, Michael Kottow, and Peter A. Sy

35 Global Pharmaceutical Markets 417Kevin Outterson and Donald W. Light

36 Infectious Disease 430Michael J. Selgelid

37 AIDS as a Global Health Emergency 441Udo Schüklenk

Part XI Experimentation With Humans and Animals 455

38 Research Involving Human Beings 457Florencia Luna and Ruth Macklin

39 Regulating Experimentation in Research and Medical Practice 469Paul Ulhas Macneill

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contents

40 Research Using Preimplantation Human Embryos 487Mary Warnock and Peter Braude

41 The Moral Status of Animals and Their Use As Experimental Subjects 495Bernard E. Rollin

PART XII Ethical Issues in the Practice of Health Care 511

42 Confidentiality 513Raanan Gillon and Daniel K. Sokol

43 Truth-telling 520Roger Higgs

44 Informed Consent and Patient Autonomy 530Robert Young

45 Patients Doubtfully Capable or Incapable of Consent 541Carl Elliott

46 Ethics in Nursing Practice 551Janet L. Storch

47 Global Trends in Nursing Ethics 563Verena Tschudin

Part XIII The Teaching and Practice of Bioethics 571

48 Ethics Committees and Ethics Consultants 573Jonathan D. Moreno

49 Teaching Ethics in the Health Professions 584Lynn Gillam

Index 594

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Contributors

John D. Arras, University of Virginia

Margaret Pabst Battin, University of Utah

Joseph Boyle, University of Toronto

Peter Braude, King’s College London

Dan W. Brock, Harvard Medical School, Boston

Alexander Morgan Capron, University of Southern California, Los Angeles

Ruth Chadwick, Cardiff University, Wales

James F. Childress, University of Virginia

Angus Clarke, Cardiff University, Wales

Jan Crosthwaite, University of Auckland, New Zealand

Norman Daniels, Harvard University, Boston

Govert den Hartogh, University of Amsterdam, The Netherlands

Carl Elliott, University of Minnesota, Minneapolis

Segun Gbadegesin, Howard University, Washington, DC

Lynn Gillam, University of Melbourne

Raanan Gillon, Imperial College London

Eric Gregory, Princeton University

R. M. Hare, Deceased

John Harris, University of Manchester

Roger Higgs, King’s College School of Medicine and Dentistry, London

Nils Holtug, University of Copenhagen

Eike-Henner W. Kluge, University of Victoria, Canada

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contributors

Michael Kottow, University of Chile, Santiago

Donald W. Light, University of Medicine and Dentistry of New Jersey

Christopher Lowry, The Chinese University of Hong Kong

Florencia Luna, University of Buenos Aires

Ruth Macklin, Albert Einstein College of Medicine, Bronx, New York

Jeff McMahan, Rutgers University, New Brunswick

Paul Ulhas Macneill, University of Sydney

Rita C. Manning, San José State University, California

Sarah Marchand, St Paul, Minnesota

Jonathan D. Moreno, University of Pennsylvania

Justin Oakley, Monash University, Australia

Kevin Outterson, Boston University, Boston

Gregory Pence, University of Alabama at Birmingham

Laura M. Purdy, Wells College, Aurora, New York

James Rachels, Deceased

Janet Radcliffe Richards, University of Oxford

Bernard E. Rollin, Colorado State University

Julian Savulescu, University of Oxford

Udo Schüklenk, Queen’s University, Kingston, Ontario

Michael J. Selgelid, The Australian National University, Canberra

Daniel K. Sokol, Imperial College London

Bonnie Steinbock, State University of New York

Brian Stoffell, Flinders University, South Australia

Janet L. Storch, University of Victoria, Canada

Peter A. Sy, University of the Philippines, Quezon City

Michael Tooley, University of Colorado at Boulder

Verena Tschudin, University of Surrey, UK

Wibren van der Burg, Erasmus University, Rotterdam

Mary Warnock, Axford, Wiltshire, UK

Mary Anne Warren, San Francisco State University, San Francisco, California

Daniel Wikler, Harvard University, Boston

Dr Robert Young, La Trobe University, Melbourne

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xiii

Acknowledgments

For encouraging us to take on the first edition of this project, we wish to thank AlynShipton – although we had some doubts along the way that we would ever finish whatturned out to be a mammoth task.

In revising the book, we were ably assisted by Brent Howard. Our contributors will bewell aware of the thoroughness with which he went through each essay, and of hisability to make valuable suggestions for improving not only the style, but also in manycases the substance of the argument. Sadly, Brent’s health problems meant that he couldnot assist us with the last few essays, and he did not live to see the volume in print.Thank you, Brent.


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Part I

Introduction

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3

1

What Is Bioethics? A Historical Introduction

HELGA KUHSE AND PETER SINGER

Since the 1960s ethical problems in health care and the biomedical sciences have grippedthe public consciousness in unprecedented ways. In part, this is the result of new andsometimes revolutionary developments in the biomedical sciences and in clinicalmedicine. Dialysis machines, artificial ventilators, and organ transplants offer the pos-sibility of keeping alive patients who otherwise would have died. In vitro fertilizationand related reproduction techniques allow a range of new relationships between par-ents and children, including the birth of children who are not genetically related to thewomen who bear them. The development of modern contraceptives, prenatal testing,and the availability of safe abortions have given women and couples increased choicesabout the number and kinds of children they are going to have. Groundbreakingdevelopments in genetics and the possibility of genetic enhancement add a further dimen-sion to these choices. Technological breakthroughs, however, have not been the onlyfactor in the increasing interest in ethical problems in this area. Another factor hasbeen a growing concern about the power exercised by doctors and scientists, whichshows itself in issues about “patients’ rights” and the rights of the community as a wholeto be involved in decisions that affect them. This has meant greater public awarenessof the value-laden nature of medical decision-making, and a critical questioning of thebasis on which such decisions are made. It has become patently obvious during the pastthree or four decades that, to give just one example, someone has to decide whetherto continue life-support for patients who will never regain consciousness. This is nota technical decision that only doctors are capable of making, but an ethical decision,on which patients and others may have views no less defensible than those of doctors.

It was in the climate of such new ethical issues and choices that the field of inquirynow known as “bioethics” was born. The word was not originally used in this sense.Van Rensselaer Potter first proposed the term for a “science of survival” in the ecologicalsense – that is, an interdisciplinary study aimed at ensuring the preservation of the biosphere (Potter 1970). This terminology never became widely established, however,and instead “bioethics” came to refer to the growing interest in the ethical issues arisingfrom health care and the biomedical sciences. It is to bioethics in this latter sense thatthe present volume forms a Companion.

Although the term itself is new, and the prominence of bioethics owes much to recentdevelopments in the biomedical sciences, bioethics can also be seen as a modern

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version of a much older field of thought, namely medical ethics. Undoubtedly,bioethics claims medical ethics as part of its province, but in many ways it takes a distinctly different approach. Traditionally, medical ethics has focused primarily on thedoctor–patient relationship and on the virtues possessed by the good doctor. It has alsobeen very much concerned with relations between colleagues within the profession,to the extent that it has sometimes seemed to exemplify George Bernard Shaw’sremark that “all professions are conspiracies against the laity.” Bioethics, on the otherhand, is a more overtly critical and reflective enterprise. Not limited to questioning theethical dimensions of doctor–patient and doctor–doctor relationships, it goes wellbeyond the scope of traditional medical ethics in several ways. First, its goal is not thedevelopment of, or adherence to, a code or set of precepts, but a better understandingof the issues. Second, it is prepared to ask deep philosophical questions about the natureof ethics, the value of life, what it is to be a person, the significance of being human.Third, it embraces issues of public policy and the direction and control of science. In all these senses, bioethics is a novel and distinct field of inquiry. Nevertheless, itshistory must begin with the history of medical ethics.

Medical Ethics

Medical ethics has a long and varied history (Reich 1995: 1439–646). While it is oftenthought that it had its beginning in the days of Hippocrates, in ancient Greece, it is infact much older. Even tribal societies, without a written language, already had moreor less well-articulated values that directed the provision of health care by shamans,exorcists, witches, sorcerers, and priests, as well as by midwives, bonesetters, and herbal-ists. One of the earliest written provisions relating to the practice of medicine is fromthe Code of Hammurabi, written in Babylon in about 1750 bc. It stipulates that if adoctor uses a bronze lancet to perform a major operation on a member of the nobilitythat results in death or leads to the loss of an eye, the doctor’s hand will be cut off(Pritchard 1969). Other early provisions of medical ethics were embedded in a religioustradition. A monument in the sanctuary of Asclepius, for example, tells doctors to be“like God: savior equally of slaves, of paupers, of rich men, of princes, and to all a brother,such help he would give” (Etziony 1973); and the Daily Prayer of a Physician, oftenattributed to the twelfth-century Jewish doctor Moses Maimonides (but now thoughtto date from the eighteenth century), condemns not only “thirst for profit” but also “ambi-tion for renown and admiration” (Veatch 1989: 14).

The ancient ethical codes were often expressed in the form of oaths. The best-knownmedical oath in the Western tradition is the Oath of Hippocrates, commonly assumedto be from the fifth century bc, and often regarded as the very foundation of Westernmedical ethics. Despite the oath’s continuing appeal, its origins are clouded in mystery.Around 500 bc many different schools of medical practice coexisted, each of them reflecting somewhat different medical, philosophical, and religious beliefs. One of thesemedical schools, on the island of Cos, was headed by the physician Hippocrates. TheHippocratic School produced a large body of writings on medicine, science, and ethics.The date of the oath, however, is unknown, with estimates ranging from the sixth cen-tury bc to the beginning of the Christian era (Edelstein 1967). The oath’s significance

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what is bioethics? a historical introduction

in the history of Western medical ethics is twofold. In affirming that “I will use dieteticmeasures to the use and profit of the sick according to my capacity and understand-ing. If any danger and hurt threatens, I will endeavor to avert it,” the oath establishesthe principles of beneficence and nonmaleficence, that is, that doctors must act so asto benefit their patients and seek to prevent harm. In addition, the oath’s prohibitionon giving a potion to produce an abortion, or giving any poison to end the life of a patient,is consonant with the view of the sanctity of human life that has dominated medicalethics under Christendom. Other aspects of the oath – like the injunction to honor one’s teacher like a parent, “to share his fate and if occasion arise supply him with thenecessaries of life” – are less frequently referred to in modern discussions of medicalethics.

While some scholars hold that the increasing importance of the Hippocratic Oath islinked to the rise of Christianity, this is disputed by others who believe that there aresignificant differences and tensions in the ethical precepts on which Hippocratic andChristian medicine were built. One obvious difference lies in the two traditions’ reli-gious commitment. At different times, various modifications were thus introduced tomake the Hippocratic Oath acceptable to Christians. One of the earliest of these datesfrom the tenth or eleventh century. It is entitled “From the Oath According toHippocrates Insofar as a Christian May Swear it.” This oath no longer requiredChristian doctors to swear to Greek gods and goddesses; rather, those taking the oathaddressed themselves to “God the Father of our Lord Jesus Christ” ( Jones 1924: 23).

Perhaps one of the most significant moral influences of Christianity relates to its emphasis on love for one’s neighbor and compassion for the ill. Religious institutions,such as monasteries, began to set up “hospitals” for the ill and destitute, and Christianteaching emphasized that doctors must cultivate the virtues of compassion and charity. A treatise, probably dating from the early twelfth century, exhorts doctors notto heal “for the sake of gain, nor to give more consideration to the wealthy than to thepoor, or to the noble than the ignoble” (MacKinney 1952: 27), and in the thirteenthcentury Thomas Aquinas considered it a sin if a doctor demanded an excessive fee, orif he refused to give gratuitous treatment to a patient who would die for want of it.

If greed and lack of charity were regarded as sins, so were other practices as well.Navarrus, a leading sixteenth-century canonist, provided a clear statement that condemned euthanasia as sinful, even if motivated by pity. In this, he followed StAugustine’s earlier pronouncement, in The City of God, that Christians must notchoose suicide to escape illness; and Thomas Aquinas’ condemnation of the practiceon the grounds that it was unnatural and a usurpation of God’s prerogative to giveand take life.

When it came to another topic still central to contemporary bioethical debate – thatof abortion – the historical position of the Church has been somewhat ambiguous. Whilethe practice was standardly condemned in the early Christian literature, its wrongnesswas often regarded as a matter of degree. Following Aristotle, various thinkers –including Thomas Aquinas – thought that only the abortion of an animated fetus constituted homicide. Animation was presumed to occur at 40 days for male fetuses,and 90 days for female fetuses. By and large, this view remained dominant until 1869,when Pius IX declared all direct abortions homicide, regardless of the fetal stage of development.

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Over the millennia, many different religious groups have attempted to formulate thecentral virtues and duties of doctors in various ways, and to articulate their particu-lar responses to issues within medical ethics. The Roman Catholic Church is thus not the only Christian Church to have well-developed views on a range of issues in medical ethics; there are a number of Protestant Churches with distinct positions aswell. In addition, there are of course extensive non-Christian religious teachings.Jewish and Islamic medical ethics, for example, articulate the duties and responsibil-ities of Jewish or Islamic doctors, and in East Asia and the Indian subcontinent, traditions of medical ethics are intertwined with Taoism, Confucianism, Buddhism,Shintoism, and Hinduism.

Over the centuries, medical practitioners themselves continued to reflect on the qualities that the virtuous doctor should possess, in particular in his relationship withpatients. While these reflections were typically intertwined with prevailing religious trendsand teachings, the seventeenth and eighteenth centuries brought some changes. JohnGregory, a prominent eighteenth-century Scottish doctor-philosopher, drew on prevailingEnlightenment philosophies to articulate his view that doctors must be “sympathetic,”in the sense developed by the great Scottish philosopher David Hume. In other words,the doctor was to develop “that sensibility of heart which makes us feel for the distressesof our fellow creatures, and which, of consequence, incites us in the most powerful manner to relieve them” (Gregory 1817: 22).

Gregory’s reflections on the role of doctors and the doctor–patient relationship arestill highly relevant today. Not only was he possibly the first doctor who sought to developa universal moral basis for medical ethics – one that was free from narrow religiousand parochial concerns – but his view of the central role played by care and sympathyin the doctor–patient relationship may also be read as one of the first articulations ofan “ethics of care.” In recent times, care approaches to ethics have played an impor-tant role in feminist and nursing approaches to ethics.

Nursing Ethics

Medical ethics has not been the only source of ethics relating to health care. Pro-fessional nursing had its beginning in nineteenth-century England, where FlorenceNightingale established the first school of nursing and laid down some of the ethicalprecepts that would shape the practice of nursing for a long time. Emphasis was placedon the character of the nurse. Above all else, a good nurse must be a good woman, asFlorence Nightingale put it.

By the early 1890s nurses had begun seriously to discuss ethical issues in nursing.In 1899 the International Council of Nurses was established, professional journals, suchas The American Journal of Nursing, sprang up and in 1901 Isabel Hampton Robb, a leaderof nursing at the time, wrote one of the first books on nursing ethics, entitled NursingEthics for Hospitals and Private Use (Robb 1901). The vast majority of nurses arewomen and, until fairly recently, the vast majority of doctors have been men. Not surprisingly, the relationship between doctors and nurses reflected the different rolesof women and men, and their relative status in society. One of the manifestations ofthis was the assumption that the primary responsibility of nurses was to doctors rather

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than to patients, and that nurses had to show absolute obedience to their medical colleagues. As one American nursing leader put it in 1917: “The first and most helpful criticism I ever received from a doctor was when he told me that I was supposed to be simply an intelligent machine for the purpose of carrying out his order”(Dock 1917: 394).

The view that the nurse’s primary responsibility was to the doctor prevailed untilthe 1960s, and was still reflected in the 1965 version of the International Code ofNursing Ethics. Item 7 of the Code states: “The nurse is under an obligation to carry outthe physician’s orders intelligently and loyally.” The revival of feminist thinking in thelate 1960s paralleled the developing self-consciousness and self-assertiveness ofnurses, and in the 1973 International Council of Nurses’ Code for Nurses, the nurse’s “primary responsibility” is no longer seen to be to doctors but to patients – “to thosepeople who require nursing care.”

This questioning by nurses of their traditional role and their relationship with doctors and patients eventually converged with a movement by feminist philosophersthat challenged the traditional (and therefore male-dominated) view of ethics as a mat-ter of abstract, impartial, and universal principles or rules. Instead of this conceptionof ethics, feminist philosophers like Nel Noddings (1984) conceived of ethics as a fabric of care and responsibility arising out of personal relationships. Building on this“female” approach to ethics, both philosophers and nurses sought to construct a newethics for nurses based on the concept of care. Jean Watson, a nurse and a prominentproponent of a nursing ethics of care, applies to the nursing situation Noddings’s viewthat an ethics of care “ties us to the people we serve and not to the rules through whichwe serve them” (Watson 1988: 2).

Bioethics

Perhaps the first “modern” work of bioethics was Joseph Fletcher’s Morals andMedicine, published in 1954. Fletcher was an American Episcopalian theologianwhose controversial “situation ethics” approach to ethical questions had more in com-mon with consequentialist ethics than with traditional Christian views. In keeping withthis, he later abandoned his religious belief. Although Fletcher did much to stimulateearly discussions of ethical issues in medicine, it was only in the 1960s that bioethicsreally began to take shape as a field of study. This period was one of important culturaland social changes. The civil rights movement focused attention on issues of justiceand inequality; the Cuban missile crisis and the Vietnam War led to a renewed questioning of war and nuclear weapons; and the resurgence of feminism, coupled withthe availability of safe abortions and modern contraceptives, raised questions about women’s reproductive rights. For much of the late 1960s and early 1970s, universityauthorities were besieged by students, initially in opposition to the Vietnam War, butlater also demanding that their courses be relevant to the larger social issues of theday. These changes had their effect on the practice of philosophy too, sparking arenewed interest in normative and applied ethics. While the prevailing orthodoxyamong English-speaking moral philosophers throughout the 1960s was that philo-sophy deals with the analysis of moral terms rather than with practical issues, this

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attitude began to shift in the 1970s. Increasingly, moral philosophers began toaddress themselves to such practical ethical issues as abortion and euthanasia, the ethicsof war and of capital punishment, the allocation of scarce medical resources, animalrights, and so on. They frequently dared to question what had not been questioned before.Since some of these issues related to practices in health care and the biological sciences,this movement in philosophy helped to establish bioethics as a critical discipline.

The other major impetus to the growth of the field was the development of new medical technology that threw up questions no one had needed to answer before. Oneof the first high-profile bioethics issues in the United States shows this clearly. The firstmachines that could dialyze patients who had suffered kidney failure dramatically savedthe lives of patients who would otherwise have been dead in a matter of days; but themachines were very expensive, and there were many more patients who were suffer-ing from renal disease than there were machines. In 1962 the artificial kidney centrein Seattle, Washington, set up a committee to select patients for treatment. Its life-and-death decisions earned it the name of “the God committee,” and focused attentionon the criteria it used. A study that showed a bias toward people of the same socialclass and ethnic background as the committee itself eventually led to further discus-sion about the best way to solve such problems.

Of all the medical breakthroughs of this period, the most widely publicized was thefirst heart transplant, performed by the South African surgeon Christiaan Barnard in1967. The patient’s death 18 days later did not dampen the spirits of those who haileda new era of medicine – with its attendant ethical dilemmas. The ability to perform hearttransplants was linked to the development of respirators, which had been introducedto hospitals in the 1950s. Respirators could save many lives, but not all those whosehearts kept beating ever recovered any other significant functions. In some cases, theirbrains had ceased to function altogether. The realization that such patients could be a source of organs for transplantation led to the setting up of the Harvard Brain Death Committee, and to its subsequent recommendation that the absence of all “discernible central nervous system activity” should be “a new criterion for death”(Rothman 1991). The recommendation has subsequently been adopted, with somemodifications, almost everywhere.

If the availability of respirators and other powerful life-extending technology raisedquestions about the time when a patient should be declared dead, it also brought tothe forefront questions about the proper limits of employing this technology inattempts to save or prolong a patient’s life. While it had generally been accepted thatcompetent patients must not be treated against their will, the situation of incompetentpatients was far less clear. This was true not only with regard to patients who had beenrendered incompetent by illness, accident, or disease, but also the treatment of seriouslydisabled or premature newborn infants. The question was simply this: if a patient isunable to say “no,” does this mean that his or her life must always be prolonged foras long as possible, even if the patient’s prospects are very poor?

In 1973 a leading US medical journal, the New England Journal of Medicine, publisheda study by two pediatricians on the ethical dilemmas they encountered in the specialcare nursery (Duff and Campbell 1973). The doctors, Raymond Duff and A. G. M.Campbell, did not think that all severely ill or disabled infants should receive life-prolonging treatment. They thought it important to break down “the public and

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professional silence on a major taboo,” and indicated that out of 299 infants in the special-care nursery, 43 had died as a consequence of a non-treatment decision. A cen-tral question was whether these non-treatment decisions were morally and legally sound.

Questions about the limits of treatment for those who are unable to decide for themselves were raised not only in the United States but in other countries as well.Australian and British doctors, for example, had begun publishing their views on theselective non-treatment of infants born with spina bifida, and thereby contributed toan ongoing debate about the appropriateness of a “quality of life” or a “sanctity of life”approach in the practice of medicine (Kuhse and Singer 1985).

It was not until 1976 that a landmark US case – that of Karen Ann Quinlan – lentsupport to the view that doctors had no legal duty to prolong life in all circumstances.Karen Ann Quinlan, who had become comatose in 1975, was attached to a respir-ator to assist her breathing. Her condition was described as “chronic persistent vegetative state.” When the treating doctor refused to honor the family’s wishes thatKaren be removed from the respirator, the case eventually came before the New JerseySupreme Court, which decided that life-support could be discontinued without the treat-ing doctor being deemed to have committed an act of unlawful homicide. The case hadimplications for future thinking about various issues relating to medical end-of-life decisions, such as the moral and legal relevance of the distinction between so-calledordinary and extraordinary means of treatment, the role of parents or guardians in medical end-of-life decisions, the validity or otherwise of a now incompetent patient’spreviously expressed wishes regarding life-sustaining treatment, and so on.

Important ethical issues had already been raised in the United States with regard tothe ethics of human experimentation by writers such as Henry K. Beecher (1966). Ithad become known that patients at the Jewish Chronic Disease Hospital in Brooklynhad been injected with live cancer cells, without their consent; that, from 1965 to 1971,mentally retarded children at Willowbrook State Hospital in New York had been inoculated with the hepatitis virus; and that a 1930 study aimed at determining the“natural history” of syphilis in untreated black men continued in Tuskegee, Alabama,until the early 1970s.

The public attention directed at these cases led to important changes in the scrutinythat US agencies henceforth directed at medical research. In 1973 the US Congress established the National Commission for the Protection of Human Subjects ofBiomedical and Behavioral Research, whose members were charged with the task of drawing up regulations that would protect the rights and interests of subjects ofresearch. While the Commission’s role was only temporary, its influence was not. Mostof the Commission’s recommendations became regulatory law, and one of its reports– the Belmont Report – clearly articulated the ethical principles that should, in theCommission’s view, govern research: respect for persons, beneficence, and justice.Subsequently, principles such as these have been influential in bioethics through theirincorporation into a widely used bioethics text, now in its sixth edition – Principles ofBiomedical Ethics (Beauchamp and Childress 2009).

By the end of the 1960s, mounting ethical problems in medicine, research, and thehealth-care sciences had already led to the establishment in the United States of the first institutions and centers for bioethics. One of the best known of these centers– the Institute of Society, Ethics and the Life Sciences (the Hastings Center) – was founded

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by Daniel Callahan and Willard Gaylin in 1969, and its publication, the HastingsCenter Report, was one of the first publications exclusively directed toward the newlyemerging discipline of bioethics.

Almost from the beginning, bioethics was an interdisciplinary enterprise. Whileethics had been the near-exclusive domain of moral philosophers and religiousthinkers, bioethics crossed the boundaries not only of medicine, nursing, and thebiomedical sciences, but of law, economics, and public policy as well. Bioethics in thisbroad, interdisciplinary sense has since become firmly established as a field of inquiryand of learning – first in the United States, and since then in many other countries aswell. It is now taught at universities at both undergraduate and postgraduate levels,and many nursing and medical schools regard bioethics as an integral part of their curriculum. Today there are many bioethics research centers throughout the world,and bioethicists are often consulted by government commissions, law reform bodies,and professional organizations. Many countries have their own national bioethicsassociations and the International Association of Bioethics (IAB) links bioethicistsfrom all parts of the world. A number of highly regarded scholarly bioethics journalsemanate from different continents, and international congresses on bioethics are nowa frequent phenomenon. In short, while bioethics had its beginning in the United States,it is now a global field of inquiry.

Bioethics is now also becoming more global in its focus. As Michael Selgelid pointsout in his contribution to this volume (chapter 36), 90 percent of medical researchresources are spent on diseases that account for only 10 percent of the global burdenof disease – the diseases that people in rich countries are likely to suffer from. This isin part because pharmaceutical corporations have no incentive to develop drugs to treatpeople who will not be able to afford to buy them, and in part because the governmentresearch funds of rich nations are also mostly directed toward finding treatments forthe diseases that afflict the citizens of those nations. There is, therefore, comparativelylittle research into finding treatments for the diseases from which people in poorer nationsare likely to suffer. That fact itself, of course, poses an ethical question – do the peopleof the rich nations, through their governments or through private philanthropy, havean obligation to reverse this imbalance? Bill and Melinda Gates clearly believe there is.The website of the Gates Foundation says that one of their key values is “All lives – nomatter where they are being led – have equal value” and the research they are fundingis directed against diseases like malaria, which kill millions of people every year, virtu-ally all in developing countries.

But there has also been a 10/90 problem in bioethics itself – in fact, until the 1990s,probably much less than 10 percent of the work of bioethicists was focused on bioeth-ical issues raised by 90 percent of the global burden of disease. This is now changing.Developing World Bioethics, a journal devoted to bioethical issues relating to the developing world, is one example of this change. The IAB has made a deliberate effortto encourage bioethics in developing countries. As discussed elsewhere in this volume,much more attention is being paid to bioethical issues raised by infectious diseases, includ-ing, but not limited to, HIV/AIDS. In this revised edition, we have also increased thenumber of articles dealing with global bioethical issues and issues that particularly face developing countries. It remains true, unfortunately, that the majority of articlesdealing with specific issues focus on bioethical issues in affluent countries. That

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reflects the state of the field today – although it is moving in the right direction, as faras increasing its focus on problems outside affluent nations is concerned, it is movingslowly and there are still very few people working in bioethics in developing countries,and writing about the issues those countries face.

References

Beauchamp, T. L. and Childress, J. F. (2009) [1979]. Principles of Biomedical Ethics, 6th edn. New York: Oxford University Press.

Beecher, H. K. (1966). Ethical and clinical research. New England Journal of Medicine 274:1354–60.

Dock, S. (1917). The relation of the nurse to the doctor and the doctor to the nurse. AmericanJournal of Nursing 17.

Duff, R. S. and Campbell, A. G. M. (1973). Moral and ethical problems in the special-care nursery. New England Journal of Medicine 279: 890–4.

Edelstein, L. (1967). The Hippocratic Oath: text, translation and interpretation. In O. Temkinand C. L. Temkin (eds.), Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, MD:Johns Hopkins Press, pp. 3–63.

Etziony, M. B. (1973). The Physician’s Creed: An Anthology of Medical Prayers, Oaths, and Codes ofEthics Written by Medical Practitioners Throughout the Ages. Springfield, IL: Charles C. Thomas.

Fletcher, J. (1954). Morals and Medicine: The Moral Problems of the Patient’s Right to Know the Truth,Contraception, Artificial Insemination, Sterilization, Euthanasia. Boston: Beacon.

Gregory, J. (1817). Lectures and Duties on the Qualifications of a Physician. Philadelphia: M. Carey.Jones, W. H. S. (1924). The Doctor’s Oath: An Essay in the History of Medicine. New York:

Cambridge University Press.Kuhse, H. and Singer, P. (1985). Should the Baby Live? The Problem of Handicapped Infants.

Oxford: Oxford University Press.MacKinney, L. C. (1952). Medical ethics and etiquette in the early Middle Ages: the persistence

of Hippocratic ideals. Bulletin of the History of Medicine 26: 1–31.Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Education. Berkeley:

University of California Press.Potter, V. R. (1970). Bioethics, science of survival. Biology and Medicine 14: 127–53.Pritchard, J. B. (1969). Ancient Near Eastern Texts Relating to the Old Testament, 3rd edn.

Princeton, NJ: Princeton University Press.Reich, W. T. (ed.) (1995). Encyclopedia of Bioethics. London: Simon & Schuster and Prentice Hall

International.Robb, I. H. Hampton (1901). Nursing Ethics for Hospitals and Private Use. Cleveland, OH: J. B.

Savage.Rothman, D. (1991). Strangers at the Bedside. New York: Basic Books.Veatch, R. M. (1989). Medical Ethics. Boston: Jones and Bartlett.Watson, J. (1988). Introduction: an ethic of caring/curing/nursing qua nursing. In J. Watson

and M. A. Ray (eds.), The Ethics of Care and the Ethics of Cure: Synthesis in Chronicity. New York:National League for Nursing.

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Part II

Questions About Bioethics

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a companion to bioethics...a companion to bioethics second edition edited by helga kuhse and peter...

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