I. INTRODUCTION

Bioethics was flourishing in most of the countries of late-twentieth-century Europe. However, as a field of ethical reflection and an instrument of public policy, bioethics is hardly uniform across the continent. The development of medical science and technology, as in many countries throughout the world, has stimulated an interest in the attendant ethical issues. Yet the ways various countries have experienced that development differ, as have their ethical responses. Although influenced by social and political events, and by philosophical, literary, religious, and cultural ideas common to the European milieu, various countries and cultures have contributed in unique ways to the formulation of bioethical ideas. There is now a European Association of Bioethics, and in its deliberations, the commonalities of European bioethics can be found, as well as the distinct accents of the various national participants. This introduction will state some of the common themes; the articles that follow will emphasize national and regional distinctions.

Role of Medical Science and Technology

An important prerequisite to twentieth-century discussions and positions was the establishment in the nineteenth century of a natural scientific basis of medicine. Impressive progress in diagnosis and treatment, coupled with this development, led to new ethical problems. Concurrent with this process was an anthropological reduction—a loss of humanistic dimensions in the natural sciences and medicine leading to various attempts at balance and correction in the early twentieth century.

Philosophical Influences

Anthropological medicine and philosophical or existential psychiatry are important twentieth-century reactions to the one-sided natural scientific orientation of medicine. Various philosophical directions, associated with the names of Edmund Husserl, Martin Heidegger, Karl Jaspers, Jean-Paul Sartre, Maurice Merleau-Ponty, Gabriel Marcel, and José Xavier Zubiri, have influenced medicine. Theology has also made important contributions. An independent, intramedical discussion of methods and theory, beginning in the late nineteenth century, and the integration of psychology and sociology into medicine in the last few decades, have also affected contemporary European bioethics.

The situation of medical history in the medical faculties of the universities of Europe presents a different picture. The grand tradition of the presentation of history and theory, including the study of medical ethics, as part of the formal education required of medical students during the preclinical and clinical years was abandoned in the empirical, scientific nineteenth century. Only in Germany was it possible to establish a chair for medical history in almost every medical faculty.

These impulses and initiatives sought to bridge the separation between the natural sciences and humanities. The history of the patient was considered to be as important as the history of the illness. The ethical dimension was recognized anew in the understanding of disease, the concept of treatment, and the physician–patient relationship.

After 1900, discussions of the concept of cause led to a new appreciation of the anthropological dimensions of medicine. The concept of monocausality has been countered by that of multiconditionalism: Disease cannot be explained by one cause but by several causes. Constitution and disposition (i.e., the physical conditions of the individual) supplement the principle of exogenous infection; cause (causa efficiens) and aim (causa finalis) should not mutually exclude one another. Physical as well as mental illness can fulfill a purpose or meaning, can represent freedom in unfreedom, in the type of coping with these damages.

Literary Influence

The arts—in particular literary texts—also proffer important influences and models. Medical ethics has profited and will continue to profit from a unification with medical humanities. Novels and stories describe the attitudes and behavior of the patient as well as the physician in detail, drawing the reader into the context of the hospital as well as the wider social environment. Such literary depictions and interpretations, in providing examples, can play an important role in medical training. The scientific pleas for euthanasia at the beginning of the twentieth century find their supplementation or preparation in the literature of the nineteenth century. The texts of Guy de Maupassant, Henrik Ibsen, Theodor Storm, Anton Chekhov, and Hjalmar Söderberg describe conflicts in which the killing of a suffering and dying person is suggested; at the same time, there are warnings against active euthanasia. Normative opinions that equate health with the positive and illness with the negative are relativized or even reversed in the works of Marcel Proust, Thomas Mann, Robert Musil, Virginia Woolf, and many other writers. Health should also be understood as the ability to live with illnesses and disabilities, which may harbor opportunity and challenge. The patient has rights and duties, as does the physician; both can exhibit virtues. Their relationship manifests both asymmetry and symmetry such as differences in medical knowledge and experiences of pain and disease.

Political Influences

Ethical discussions of medical issues took place in all European countries even before World War II. Numerous essays and monographs were published on the ethics of the physician, ethics in research, and the ethics of patients, as well as the ethics of the family and of society. In 1901, the first Congrès International de Médecine Professionelle et de Dèontologie Médicale took place in Paris. Many conventions on the subject of forensic medicine had already taken place. Bioethics in Europe is not uniform; different accents can be found in theory and practice. The differences are based on each country's respective artistic traditions as well as on the respective political and economic situations and legal regulations.

Undoubtedly, World War II and, after its end, the Nuremberg Code were turning points in bioethics. On the one hand, an increased tendency toward international uniformity in bioethics was reflected in such international declarations as, for example, Helsinki (1964) and Tokyo (1975), and in the introduction of ethics committees. On the other hand, the multitude of differing orientations retains its validity, even gaining a new weight through the presence of foreign labor and long-term migration in the European countries. Radical political changes in Eastern Europe and Germany through the collapse of communism made manifest the continuity of ethical opinions and social conditions that had been thought to be relics of the past; these hold new meaning for bioethics in the future.

Problems in bioethics must be solved on many levels, particularly in the Eastern European countries. At the center stands the task of finding a convincing ethical or humanistic solution for the vacuum of ideals left by the collapse of communism and the pressure of technical-scientific progress. Here, as is generally the case in the realization of ethical principles, the applicable legal regulations are of decisive importance. When moral principles are weak, laws can offer protection.

Medical Ethics and Bioethics

Because of the plurality of traditions that make up contemporary European bioethics, it is not possible to isolate a single path of development. The word bioethics itself denotes many things. Bioethics has been used to propose norms in the practices of modern biomedicine, norms of a religious-ethical nature, and norms of legal or philosophical ethics. Sometimes, under the new label bioethics, the method and arguments of already consolidated disciplines (moral theology, law, ethical guidelines for health professionals, moral philosophy) are easily recognizable, enriched only by the content of new problems.

In the different European cultural contexts, bioethics has had to confront a strong tradition of medical ethics that was developed and defended by physicians as their exclusive property. The proprietary claims of health professionals on medical ethics have produced ambivalent results. The independence of medical ethics has sometimes been able to protect the profession from the pressures that totalitarian ideology exerts on physicians to conform their behavior to the values imposed by the regime. Under the fascist and Nazi regimes (Italy and Germany) and in countries ruled by communism, medical ethics was denied an independent status in order to subordinate it to particular ideological visions (including racism, eugenics, the class struggle, and the dictatorship of the proletariat). In such situations, medical ethics' independence from the values that regulate the society created space for an ethics tied to philanthropic and universalistic ideals.

Nevertheless, the medical ethics elaborated by professional physicians can also obstruct the rise of formulations better adapted to the changing cultural situation. This is evident in many European countries by the many physicians who turn to traditional medical ethics, inspired by the ideals of Hippocratic medicine and strongly anchored in a paternalistic attitude toward the sick person, in order to oppose the medical models that are centered on the value of individual autonomy and the practice of informed consent.

The thrust toward bioethics is characterized, if compared with the strong tradition of an ethics developed by the medical profession itself, by the need for a civil ethics or an ethic of ordinary life elaborated in many voices. Bioethics is differentiated from medical ethics in being a consensual reformulation of rights and obligations in the context of medical practice and healthcare. This includes the professional obligations of physicians, but does not derive only from these. A further characteristic trait of bioethics in regard to civil or general ethics is the minimal ethical consensus, which obliges all citizens, in contrast to the maximal ethical consensus, which focuses on individual preferences.

A second issue that bioethics in Europe must face is its relationship with religious ethics. The weight of religious ethics relative to the moral problems posed by the corporality of man (sexuality, procreation, disease, health, death) and healthcare varies according to cultural context and type of religious communities in the society. In societies in which a single religion dominates, especially of the Catholic tradition (Ireland, Poland, Italy, Spain), religious ethics tends to superimpose itself onto bioethics, shaping it to its own norms. In countries in which a tradition of pluralism prevails, the two normative contexts—religious ethical and bioethical—are more clearly distinct.

Where religious ethics is seen as antithetical to secular ethics, a clear polarization can appear in the society; possible examples are Ireland, Poland, or Portugal, with their Catholic tradition. Justification of ethical judgment then consists of making reference exclusively to one set of values instead of another. This happens, for example, when clinical decisions are evaluated exclusively in terms of values considered to be absolute: sacredness of life versus quality of life, benefit of the medical act versus self-determination of the patient, and so on.

A third issue in the contemporary development of bioethics in Europe relates to the challenge of universalism. Developments in the ethics of medicine and biological sciences reveal two opposing challenges for bioethics: the need to be rooted in the particular, with respect to the cultures, traditions, and local communities of belonging, and the need to refer itself to universal values. Universalism is an intrinsic dimension of ethical rationalism. At the same time, universalism is necessary to ensure normative rules and moral obligations. The directives, for example, of "Good Clinical Practice for Trials on Medical Products in European Community" (1991) have had the aim of producing one practice of experimentation in this field. In Europe, in fact, the crowded national frontiers would easily create "enclaves" where biomedical practices prohibited beyond these frontiers would be legitimate. An international consensus has to be created to prevent a "tourism" in medical research.

The various bioethics developing in Europe face the challenge of particularism as much as that of universalism. The best forms of European bioethics are clearly those that are trying to respond to both these challenges.

Recommendations of the Council of Europe

The most relevant innovation for the history of bioethics in Europe is the approval of a "Convention for the Protection of Human Rights and Dignity of Human Being with regard to the Application of Biology and Medicine" by the Council of Europe. After almost five years of work and lively discussions, the steering Committee on bioethics of the Council of Europe (CDBI) presented a text which was approved by the Council of ministers in Oviedo (Spain), on April 4, 1997. The Convention is therefore known as the Oviedo Convention or "Convention on human rights and bio-medicine." Its main purpose is to reinforce the idea that, since Europe is becoming more and more integrated from a cultural point of view as well as economically and politically, it is necessary to find a common orientation also on the subject of bioethics.

Eighteen out of the forty countries of the Council of Europe have signed the Convention. The parliaments of the signatory States are now called upon to ratify this Convention, thus agreeing to bring national legislation into line with the principles enunciated in the agreement. Indeed, unlike "Recommendations" of the Council of Europe and "Treaties," which are a mere expression of principles, the instrument of the Convention is particularly effective because it is binding on those states that ratify it, obliging them to apply its standards within their individual sets of laws. This means that the Convention is not an "exhortation," to the individual states, but has a normative value. As of September 2002, thirteen countries have also ratified the Convention they signed.

The choice made with the Convention was to focus on principles and rules that can help create a consistent set of laws, real European common rights in the bioethics area: the prevalence of human beings over science, respect for individual independence, protection of integrity and dignity, confidentiality of medical and genetic information, noncommercialization of the human body. In the Convention no position has been taken on widely debated topics, including medically assisted procreation, the cloning of embryos, or genetic engineering. The most controversial aspects of bioethics are expanded upon in additional protocols. Two of them have been drawn up so far: on the Prohibition of Cloning Human Beings (January 12, 1998) and on Transplantation of Organs and Tissues of Human Origin (January 24, 2002).

The essential elements of the Convention are: the primacy of the human being (article 2: "The interest and welfare of the human being shall prevail over the sole interest of society or science"); equitable access to healthcare (article 3: "Parties taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to healthcare of appropriate quality"); the central role of information and consent (article 5: "An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks").

dietrich von engelhardt

sandro spinsanti (1995)

revised by authors