BIOETHICS

BIOETHICS . Bioethics as a discipline clearly did not begin fully developed, and its origins are somewhat unclear. Very remote origins can be traced to late medieval discussions in Roman Catholicism concerning what means were required to preserve life in the face of illness. These discussions, commented on by the majority of theologians, initiated the famous distinction between ordinary and extraordinary means of preserving life. The assumption was that all had an obligation to preserve their own lives because life was a gift of God and while humans exercised stewardship over life, they had no dominion over it. Thus the question became "does proper stewardship mandate doing everything possible to preserve life?" The clear consensus throughout the Middle Ages was that it did not: one did not need to be a hero and submit to any number of painful and marginally useful treatments, nor did one have to bankrupt one's self or one's family, nor did one have to move to a better climate, or seek out the best and most healthful foods. If one would be embarrassed by a physical examination, one could decline the exam. Thus began a long conversation over the problem of the ethical management of one's death.

In various religious communities this tradition continued in pastoral counseling: the provision of theological guidance to those in various crises, spiritual, moral, or medical. Pastoral counseling in some form was an element of all denominations, more formal in some and more individualized in others. But the reality of religious institutions both reflecting on and expressing their concern for the sick and dying ensured that questions of significance related to medical practice would be an important part of the tradition.

Thus in the United States, the real locus of the beginning of bioethics as a discipline, when questions about the application of new technologies in medicine began to come to the fore, particularly issues of death and dying—the use and removal of ventilators, the distribution of the scarce resource of the kidney dialysis machine—theologians were receptive and, because of the religious bioethics tradition, did not have to begin from square one. A conversation was already in place and new questions could be brought in and the conversation furthered.

The first formal structuring of bioethics took place at the Hastings Center—founded in 1971 and originally known as the Institute for the Study of Ethics and the Life Sciences. While these developments occurred under the direction of the center's founders, a philosopher and a psychiatrist, the majority of the individuals in the first groups invited to meetings were theologians or people in religious studies, or clergy. While the perspectives brought to the table were sectarian, the discussions were surprising ecumenical and nondoctrinaire. This mix of participants also characterized the first Presidential Bioethics Commission.

Philosophers were also part of this early mix but their entry was more difficult, perhaps because many philosophers were, at that time, trained in the analytic tradition and were more interested in problems of theory. Thus the turn to practice was a little complicated and was not fully validated until the development of the field called applied philosophy, another birth accomplished only under difficult circumstances. While theory has always been part of theological reflection, people in theology and the ministry in particular were used to discussion of cases and were immediately attuned to the specifics of the problems brought to bioethics.

Following the foundation of the Hastings Center and then of the Kennedy Institute of Ethics, bioethics saw a blossoming of undergraduate courses and bioethics centers nationwide. These centers were staffed by individuals who had theological or philosophical training, but were typically not versed in the sciences or the new developments in medicine and technology. Thus one of the first functions of both of these bioethics centers was to offer summer courses in the new field to get people scientifically and technically up to speed. Eventually these people found their way into medical schools and programs in medical ethics and medical humanities became an established part of the medical curriculum.

These developments were quickly followed by the creation of graduate courses, journals, conferences, graduate programs, and a professional society: the American Society of Bioethics and Humanities. This society, as the premier professional bioethics organization, is reflective of major changes in the field. Only a minority of the society's members comes from theology or religious studies backgrounds. The majority comes from the social sciences, medicine, literature, anthropology, and so on. Although there have been sessions on religion at the society's meetings, they are not a standard feature of conventions. People in theology or religious studies seem to do much of their professional work in bioethics through special sessions or programs in associations such as the American Academy of Religion, the Society of Christian Ethics, the Society of Jewish Ethics, and other denominational professional societies.

While many individuals at work in the field of bioethics are theologians or in the field of religious studies, the discipline seems to have moved from these to other academic disciplines as new questions are examined and new discussions established. This shift may also reflect a growing secularization and pluralism within American culture and a greater interest in the public policy dimensions of bioethical debates, debates in which religious perspectives are seen as particularly divisive. Thus the religious perspective, though the inspiration for many of the early discussions in bioethics, has now moved to the side as new disciplines bring their perspectives forward.

A Shift in Context

Probably one of the largest shifts in bioethics has been from clinical perspectives to public policy issues. The early decades of bioethics were centered on the clinical experience of the physician-patient relationship. In part this was because of the case-oriented nature of bioethics' theological background, but it was also because the physician-patient relationship was the dominant locus of the practice of medicine. Here the discussion, from both theological and philosophical perspectives, centered on the values of the patient and the physician, how they complemented each other, how they clashed, whose would take priority, and how were both of their value sets to be respected in practice. In these discussions, principles were appealed to as well, whether theological or philosophical. But the focus of the discussion was always the individual patient and the individual physician. Both theology and philosophy were comfortable with this framework.

The problem now is that both the field and the critical questions in bioethics have moved from a primary emphasis on the physician-patient dyad to how that dyad is understood within the context of a variety of public policy issues, relating to such complexities as the variety of health insurance plans, hospital organization, research agendas, the funding of public and private health-care delivery systems, and the requirements of care for a variety of specialized populations: the newborn, the disabled, the incompetent, the aging. A major focus is now on what could be termed institutional bioethics, in that the questions have to do with issues of justice within the system of health care itself and with what services are available and to whom and how are they delivered.

Needless to say, such questions give rise to a variety of competing values-based positions regarding priority of needs, equitable distribution of resources, and ease of access to various programs. While religious communities are both providers of health care and participants in these discussions, the public debate is complicated by the presence of a variety of competing actors: insurance companies, HMOs, advocacy groups for various diseases and programs, and the Social Security, Medicare, and Medicaid programs to name just a few. While all recognize that values are at the center of the debate, the pluralistic nature of U.S. society is a complicating factor precisely because of the competition of values originating from so many different communities.

While it is the case that a variety of forms of national health care exist in many other countries, many of these plans are beginning to experience crises stemming from the need for increased funding, a demand for improved services and better and more rapid access to them, and the pressures put on such systems by the needs of an expanding population of aging citizens. Additionally, due to recent immigration into Europe, the problems associated with pluralism are beginning to be experienced there, and this will undoubtedly have an impact on various national health-care systems. Many of the debates in the United States will soon be part of the discussion in Europe.

Embryonic Stem Cell Research: American Perspectives

One particularly contentious debate in the field of bioethics concerns the question of at what developmental stage human life becomes subject to morally and legally mandated protections. In the United States, this debate was brought into focus by the 1973 U.S. Supreme Court case Roe v. Wade. This decision decriminalized abortion in the first trimester, permitted some state regulation of abortion within the second trimester, and permitted more regulation in the final trimester. It set off both a firestorm of debates and about 1.3 million abortions per year in the United States, though these figures vary by the year. The debate has been complicated by the introduction of a variety of fetal diagnostic technologies, including preimplantation genetic diagnosis, and of prenatal technologies such as amniocentesis and ultrasound. Additionally, part of the practice of in vitro fertilization (IVF) is the freezing of embryos not immediately used to achieve a pregnancy. Their status and disposition has been the subject of moral, religious, clinical, court, and public policy debates. Finally, given the possibilities of embryonic stem cell research, new questions are being raised: can human embryos be generated expressly for research purposes, are human embryos generated by cloning morally the same as those generated in the customary way, and might frozen embryos be used in this research? The public policy of the Bush administration enunciated in August 2002 was a political finesse that permitted federally supported research on already existing lines of cells derived from embryos, but prohibited the creation of any new cell lines for research from either embryos in storage in IVF clinics or embryos generated expressly for such research. Originally scientists thought that there might be some sixty-three such cell lines available for research but the actual number of useable lines is around ten. Many hailed this decision as an appropriate compromise that permitted some research to go forward but also protected human life by prohibiting the future destruction of embryos for this project. Additionally, in 2003 and 2004, the states of California and New Jersey passed legislation permitting embryonic stem cell research, thus setting a precedent for other resolutions regarding the permissibility of such research as well as the funding of it.

In general, religious communities in the United States have varied considerably in their reaction to this solution. The most conservative is the Roman Catholic community, which prohibits absolutely any direct abortion or any procedure that involves killing the embryo, though it does permit research designed to benefit the fetus. This leads to the position that any research predicated upon the destruction of human embryos is totally prohibited, regardless of whether the cell lines are already in existence or generated and destroyed for a specific research project. This position is shared by the Orthodox Bishops of America for precisely the same reason: the sacredness of human life from its inception. The other religious denominations typically approve of some abortions under certain circumstances, though this moral approval is given reluctantly.

Many other denominations tend to be conservative on the use of the embryo in research, typically arguing against the embryo's being reduced to an object and its possible commodification. Officials in the Methodist Church have suggested a moratorium on embryonic stem cell research and already deplore the use of research that produces what they call waste embryos. The Presbyterian Church, which both recognizes the moral status of the embryo/fetus and also supports a woman's right to abortion, affirms the use of fetal tissue and embryonic stem cells from surplus embryos from IVF for research that could lead to lifesaving breakthrough in medicine. They require a proportion between the significance of the research and the destruction of the embryo.

Judaism affirms the traditional doctrine of stewardship by acknowledging that our bodies are on loan to us from God. This then generates a corresponding obligation to seek cures for diseases. However, in Judaism, as in Christianity, one finds a variety of positions. The more liberal position argues that because abortions are permitted, based on the Talmudic teaching that for the first forty days the fetus is as water, one could argue that the destruction of the fetus is not murder. Such destruction would be possible as one way of fulfilling the obligation to seek cures for serious diseases. Other experts within Judaism are more conservative in their position on abortion. Therefore, they do not support the destruction of embryos for research. Because of their concern for protecting human life, these experts would limit such research with stringent regulations. Still others respond that such limitations on research, though intended to protect human life, also erect barriers to curing disease, relieving pain and suffering, and promoting health.

Public policy implications

This debate has complicated the public policy process of deciding on whether embryos can be used in research in at least two ways. First, there is great controversy over who is appointed to various commissions. Second, there is debate within the commissions themselves. And both are subsets of the critical litmus test in U.S. politics: one's position on the moral status of the human embryo. The goal in appointing national commissions is to achieve balance or adequate representation of particular positions, especially those that represent the main constituencies of the one doing the appointing. That process then creates problems for the commission in its deliberations, frequently manifest by lopsided votes or minority reports, or by the final recommendations not being accepted or being left to languish. The main problem is that the politicization of the process inhibits genuine debate and research that might prove profitable for the country as a whole. Additionally, while the individuals chosen for such panels or commissions are generally qualified, the main criterion guiding their selection is their advocacy of a particular viewpoint.

Embryonic Stem Cell Research: European Perspectives

In Europe the situation is somewhat different and is a function of the developing policies of the European Union (EU) and of how the legislation of individual countries within the EU relate to them. The situation is also complicated by the political situations and religious traditions of various countries. And the situation is very dynamic.

The nub of the issue is the question of whether human embryos can be generated for research or whether only surplus embryos from IVF clinics can be used. In November 2003, the European Parliament, in a 298-242 vote with 21 abstentions, voted to permit the use of EU funds for experimenting on human embryos that were no older than fourteen days and were from IVF clinics. In the Parliament's Environmental Committee, amendments to ban human embryonic stem cell research were blocked. The European Union Industry Committee, in a 28-22 vote with 2 abstentions, permitted the use of such cells for research under strict conditions. In addition, this committee stated that the funding should depend both on the contents of the research proposals and the legal framework of the individual country. Additionally, the committee ruled that priority should be given to adult stem cells; it also permitted the funding of research using embryonic or fetal cells from spontaneous or therapeutic abortions. In December 2003, the EU voted not to permit the use of EU money on research using new human embryos.

With respect to individual members of the EU early in the twenty-first century, Belgium, Denmark, Finland, Greece, the Netherlands, Sweden, and the United Kingdom permit taking cells from surplus embryos for research. However, Austria, Germany, France, Ireland, and, under some circumstances, Spain prohibit such obtaining of these cells. Luxembourg, Italy, and Portugal have no specific legislation as of 2004. Nonetheless, Italy is proposing legislation to prohibit any research on generating embryos for research and the destruction of human embryos. Spain, however, appears to be ready to permit obtaining cells from surplus embryos from IVF if donor consent is obtained. Germany permits the use of human embryos for research only if the cells have been imported and if the research is critical and no alternatives to human embryonic stem cells are available.

Background

In Europe in general, there has been relatively strong resistance to a variety of forms of genetic engineering, whether applied to humans, animals, or crops. This movement has been particularly strong in Germany, an understandable position given the eugenic dimension of the National Socialist Party. Other countries, including Ireland, have constitutions that give strong protection to early human life. England permits both cloning for therapeutic purposes (generating embryos for therapy in the donor of the cell) and the use in research of human embryos and cells from them so long as embryos are no more than fourteen days old.

The Commission of European Bishops' Conferences has criticized the actions of the EU with respect to stem cell research. The conference recommends the prohibition of EU funds for research on human embryos and embryonic stem cells primarily because of the intrinsic value of human life at all stages of development. Thus such material should not be used for research, regardless of any good ends to which the research might be put. Additionally the bishops argue that there is yet to be found any clear evidence for any therapeutic benefits from such research.

The cultural and religious situation in Europe is moving from positions of relative homogeneity to that of pluralism. This is due to population changes resulting from immigration, the changing status and level of political power of the Catholic Church in historically Catholic countries, and pressure from various groups, both governmental and private, to advance the participation of the EU in genetic research. At stake are religious and cultural values as well as vast economic consequences. The final resolution of the specific issue of the use of human embryos in research as well as the larger question of the reconfiguration of religious and cultural values in the EU is yet to be determined. But this resolution will present a major case study in how such resolutions are brokered.

Conclusions

The beginnings of bioethics occurred within the context of religion broadly understood. Various denominations had pursued bioethical questions for long periods of their history, but typically within the context of pastoral counseling or the resolution of particular cases at the bedside. As bioethics became more of an academic discipline, the orientation shifted from a religious perspective to a more philosophical one. However, as public policy issues related to bioethics began to be debated, religious issues came to the fore once again, both in terms of the content of policy proposals and in terms of the selection process that determined the membership of bioethics committees.

In the United States at the present time, there is a significant debate over the place of religion in discussions of public policy. But the terms of the debate are far from clear. Some buttress their arguments by appealing to the so-called traditional Christian heritage of the United States. Others point out the difficulties of that position in light of the United States' current religious heterogeneity. Yet others argue that religion is being marginalized in favor of a secularized society through attempts to eliminate religious voices from the debate. Others still argue that religious positions or institutions are being favored by the government through voucher programs and public funding of some religiously based charities. Just who is on what side of the debate seems occasionally to vary from case to case, the result being an increasing cacophony in the public arena.

What is clear is that, in Western culture, religion is important for many citizens and that believers expect some degree of coherence between their beliefs and their social life. Religion is not simply a private belief system; it has personal and social behavioral implications. Additionally, we assume that religious bodies, as well as individual representatives of those bodies, have the right to participate in public debate over public policy. And while in theory many will agree that one's religious beliefs should not be a litmus test for participation in office or committees, those beliefs are in fact becoming increasingly important in nominating processes and elections.

Nonetheless, bioethics should not shed or attempt to eliminate its religious heritage. That heritage has been exceptionally helpful in the analysis and resolution of many questions in bioethics. What needs to be added to this heritage is a new chapter of ecumenical reasoning and of dialogue between all religious traditions. What is also needed is a focused reflection on the process of conducting public policy debates, with respect to the religious traditions represented, to the merging of these traditions, and to the public presentations of the positions of these traditions. The contribution of these traditions to the public debate is important not only because of the inherent value of their positions, but also because religious viewpoints may bring out or highlight facets of the public policy debate that might be missed or undervalued by others. Such a contribution will be made, however, only when the religious traditions can articulate these positions in a language and style accessible to a broad public. This is the challenge for the new religiously based bioethics.

Bibliography

Catholic News Service. "European Bishops Oppose EU Funding of Stem-Cell Research." Available at www.cwnews.com/news.

CellNews. "EU to Fund Stem-Cell Research Despite Split." Available at www.geocities.com/giantfideli.

Cole-Turner, Ronald, ed. Beyond Cloning: Religion and the Remaking of Humanity. Harrisburg, Pa., 2001.

Council of Europe. "Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention of Human Rights and Biomedicine." Available at www.conventions.coe.int/treaty/en/treaties.

Davis, Dena S., and Laurie Zoloth, eds. Notes from a Narrow Ridge: Religion and Bioethics. Hagerstown, Md., 1999.

Hanson, Mark J., ed. Claiming Power over Life: Religion and Biotechnology Policy. Washington, D.C., 2001.

Holland, Suzanne, Karen Lebacqz, and Laurie Zoloth, eds. The Human Embryo Stem Cell Debate: Science, Ethics, and Public Policy. Cambridge, Mass., 2001.

Mackler, Aaron L. Introduction to Jewish and Catholic Bioethics: A Comparative Analysis. Washington, D.C., 2003.

Peters, Ted. For the Love of Children: Genetic Technology and the Future of the Family. Louisville, Ky., 1996.

Post, Stephen G., editor-in-chief. The Encyclopedia of Bioethics. 3d ed. New York, 2003.

Shannon, Thomas A., and James J. Walter. The New Genetic Medicine: Theological and Ethical Reflections. Lanham, Md., 2003.

Verhey, Allen, ed. Religion and Medical Ethics: Looking Back, Looking Forward. Grand Rapids, Mich., 1996.

Walter, Jennifer K., and Eran P. Klein, eds. The Story of Bioethics: From Seminal Works to Contemporary Exploration. Washington, D.C., 2003.

Thomas A. Shannon (2005)