BIOETHICS

Bioethics is an interdisciplinary field of study dealing with practical ethical issues roughly at the intersection of morality, medicine, and the life sciences. Within philosophy, bioethics is one of several different areas of applied ethics, a domain within general normative ethics. The term "bioethics" was coined in 1970, but the development of bioethics as a discipline may be dated to the late 1960s or early 1970s, depending on which historical markers are used.

The scope of bioethics as a discipline is not entirely fixed, it is important to note. At least three competing visions are available. On the most restricted view, bioethics simply reduces to biomedical ethics, which encompasses ethical issues relating to the practice of medicine broadly understood and the pursuit of medical research. Even on this restricted view of bioethics, the scope extends to the ethics of our use of nonhuman animals in biomedical research, for example. On the second understanding, bioethics encompasses, in addition to biomedical ethics, ethical issues related to the life sciences and technologies. On this understanding, also included is consideration of environmental issues, for example, issues such as genetic modification of plants or the use of cloning technologies to revive extinct species of animals or plants. According to the widest view, bioethics includes the biological aspects of environmental ethics, issues related to nonhuman-animal use, and biomedical ethics. On this understanding, the ethical dimensions of vegetarianism and how global warming affects biotic communities are also bioethical issues. Interestingly, this widest understanding of the term is closest to the meaning given by biochemist Van Rensselaer Potter, who originally coined the term. However, it also offers the least common understanding of the term within the discipline. The second sense probably offers the most common understanding within the discipline, while most people working in the field of bioethics work on issues in biomedical ethics, the first sense. This entry will explore issues related to all three senses of bioethics.

Locating Bioethics within Philosophical Ethics

Ethics is the philosophical study of morality. It is to be distinguished from the empirical study of moral norms and practices. This second area of investigation is sometimes also called simply "ethics," but to distinguish it from philosophical ethics, it may more felicitously be called descriptive ethics. As a philosophical discipline, ethics may be further divided into metaethics, general normative ethics, and various areas of applied ethics. Metaethics is concerned primarily with reflections on ethics itself. Some issues within metaethics include the meaning of moral terms like "ought," "right," and "virtue"; the metaphysical status of moral norms; the proper grounds for justifying moral claims; and the nature of moral knowledge.

Normative ethics, by contrast is concerned in general with positive guidance to living morally. Normative ethics concerns questions about how to act, what kind of character to develop, and what values to live by. Within normative ethics generally, various ethical theories have been developed as guides in answering these questions. Normative moral theories lay out the structure for particular fundamental sources of normative moral value. Examples include utilitarianism (a type of consequence-based ethics), deontology (a duty-based ethics), and virtue ethics (a character-based ethics). However, normative ethics may also proceed without any particular theoretical structure and may engage directly with the various issues at stake in practical moral living.

Applied ethics is normative ethics at the level of engagement with various specific topics in practical moral life. As such, applied ethics may proceed by following some more general normative theory, by following some methodology or theory particular to the area of study, or without following any specific theoretical or methodological underpinning. The term "applied ethics" implies that general normative theories are simply interpreted in light of specific moral problems to generate practical moral answers; however, this is seldom actually the case. A better term might be "practical ethics."

Bioethics, then, is a type of practical ethics. It is on the same philosophical level as business ethics, environmental ethics generally (unless understood as a subset of bioethics), cyberethics, and a host of other specific fields dealing with particular areas of complex lived morality. The division into areas of practical ethics may not be particularly neat. As already discussed, bioethics may be understood as distinct from, or inclusive of, environmental ethics. Other areas of practical ethics, such as professional ethics, overlap with various other fields (for example, business ethics, legal ethics, and medical ethics).

History and Social Context

Many of the specific issues addressed in bioethics have historical roots. The issue of physician-patient confidentiality was addressed in the Hippocratic oath. The bioethics of how we treat animals has roots in the work of such historical figures as Porphyry (232–309) in his treatise On Abstinence from Animal Food (discussed in Sorabji 1993). More recently, the requirement that human subjects voluntarily consent to medical research was spelled out in the Nuremberg Code (International Military Tribunal 1949), following the "doctors trial" for atrocities committed as part of the holocaust.

Despite these and multiple other sources of historical precedence, the discipline of bioethics coalesced only in the very late 1960s to early 1970s. The social forces behind this formation into a specific disciplinary field include a growing social awareness of issues of medical paternalism and some unethical practices in medical experimentation; the consumer, feminist, and civil rights movements; the increased institutionalization of health care and with it a growing concern for issues of allocation; advances in biotechnology and biomedicine; growing awareness of issues of sustainable economic growth and environmental impact; and rising awareness of the conditions of animals in newly evolving factory farms.

Since its inception, bioethics has taken deep root in academia, professional education, public policy, the law, and public deliberation. Bioethics courses are offered to undergraduates as part of humanities and science curricula and to medical and other health-professional students. A variety of centers for bioethics research have been established, and numerous government commissions dealing with bioethical issues have been formed and have had varying impact on public policy. A U.S. commission of high impact was the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the source for the Belmont Report (1979), spelling out the ethical principles guiding experimentation on human subjects. Those working in bioethics have extensively scrutinized legal cases, such as the 1989 U.S. Supreme Court case regarding Nancy Beth Cruzan, whose parents sought to withdraw life support after Ms. Cruzan fell into a persistent vegetative state. The law has also been influenced by bioethical analysis, for example by the inclusion of those working in bioethics as expert witnesses in trials. Finally, as biomedical ethical issues and advances in the life sciences have received more attention by the mass media, public arenas for debate over these issues has also grown.

The Discipline

Bioethics as a discipline crosses over other disciplinary boundaries, both within and outside of philosophy. Here the focus is on the philosophical aspects of the discipline. Nonetheless, some general remarks about the discipline as a whole are necessary in order to view the philosophical area of bioethics in context. This is important also because there is controversy within the field of bioethics, as has been seen, about what counts as bioethics, but also about the extent to which it is a unified discipline, and about exactly which general methodologies and areas of expertise are relevant.

It is uncontroversial that moral philosophy plays a central role within bioethics, and also that other areas of philosophical study are implicated by the topics relevant to bioethics. For example, political philosophy is central to issues of distributive justice in access to health care and to public-health measures affecting human health, as well as in adjudicating questions of public, institutional, and governmental decision-making about controversial bioethical issues such as use of stem cells and cloning of human somatic cells. In addition to addressing general issues of the relationship between the law and practical morality, philosophy of law is also relevant to determining how case law and legislative law relate to ethical decision making. Finally, although the connection is less widely recognized, philosophy of science is crucial to the investigation of some central conceptual issues in bioethics, for example, the nature of the scientific facts that often play a central role in practical ethical decisions and the meaning of the concept of human health often invoked in such ethical distinctions as that between using genetic technologies for enhancements versus using them therapeutically. Even the question of what counts as a biological kind or species is central in determining whether legitimate ethical distinctions can be made between human beings and other nonhuman animals for how we treat them, and in dealing with ethical issues related to the transhuman movement for improved humans.

While philosophy is the right place to look for expertise in clarifying the issues involved in answering moral questions and for theoretical structures intended in part to answer those questions, it is not clear that philosophy is the right place to look for positive answers to specific practical moral questions. We might then delineate two kinds of ethics expert: academic and directive. The broader issue is whether expertise in academic bioethics provides any expertise in directive ethics. There is no clear consensus within the discipline on this issue.

Outside of philosophy, disciplines relevant to bioethics include the social sciences, law, and medicine, as well as those within what has been termed the medical humanities. With such a wide range of participants, it is not surprising that there are disagreements over the scope of bioethics, the relevance of different fields to the discipline, the training necessary to qualify as a member of the discipline, the kind of expertise that such members have, and the legitimacy of the very term "discipline" in describing this diverse range of fields, methodologies, and topics of interest. What is certain, however, is that enough overlapping consensus exists to create a discipline identifiable to its members and to the general public.

Methods in Bioethics

How do moral philosophers and others working in bioethics go about dealing with the complex moral issues at the heart of many bioethical issues? The answer to this question is quite complex. Three basic approaches are available. The first approach applies established general normative theories to particular issues in bioethics. The second embraces one or several methodologies specifically developed for bioethical issues. The third method either avoids or rejects outright specific methodologies outside of basic philosophical and critical-thinking skills. These methods will be discussed in turn.

General Normative Theories

Perhaps surprisingly, the least common approach to bioethics is the approach of applied ethics, that is, the application of general normative theories to specific moral problems in bioethics. Nevertheless, there is some substantial work in bioethics that proceeds roughly along these lines. Examples include Peter Singer's utilitarian approach to the ethics of how we treat animals (2002), Tom Regan's deontological approach to that same issue (1983), and Rosalind Hursthouse's essay on abortion from a virtue-ethical perspective (1991). Of work that follows this general model, the most commonly appealed- to theories are the three just mentioned: utilitarianism, deontology, and virtue ethics. These theories are actually umbrella categories under which fall a number of specific theories.

Even the work in bioethics that falls into this first category is not really simply straightforward application of normative theories to particular bioethical problems. Rather, some particular vision of a general theoretical structure is rendered, and the bioethical problem is interpreted in light of that theoretical structure. This might involve, among other things, modifying the theory to fit the issue and arguing for some particular interpretation of the practical implications of the theory over others.

Some theories lend themselves more readily than others to application to specific moral problems. However, even the application of these theories requires extensive interpretation. For example, according to hedonistic act utilitarianism, the right action is the one that maximizes pleasure (or minimizes pain) for all those affected. In principle, then, the answer to the question "Which action is right?" is a matter of calculation of hedonistic utility output. Yet we still need to know which outcomes count as pleasures and pains, of what strength and type, and for what range of beings. (Does the calculation include sentient nonhuman animals? Future persons?)

Despite the term "applied ethics," then, normative moral theories are at a level of abstraction not conducive to straightforward application to particular moral problems. Making matters more difficult, normative theories conflict with one another, sometimes in ways that imply different practical recommendations. In such cases one has to decide which theoretical approach is the best before tackling the moral problem at hand. Moral theories are still helpful in making practical moral decisions, since they provide essential analysis of basic moral values, coherent frameworks for understanding moral issues, and general justificatory strategies for particular approaches to morality. Yet it is not even clear that a proper goal of normative moral theory is to generate specific moral directives. On a virtue-ethical view, for example, moral guidance in specific practical contexts flows from a virtuous character, not from abstract theoretical principles.

Methods Specific to Bioethics

In part because of the problems associated with the application of general normative theories of morality to problems in bioethics, a number of methodologies specific to bioethics have been developed since the inception of the discipline. It is important to note at the outset that these methods have been developed largely for biomedical ethics rather than for bioethics in the broader sense embraced in this entry. Among these methods, the most well known is the principles-based approach developed largely by Tom Beauchamp and James Childress in successive editions of Principles of Biomedical Ethics (2001) but also inspired by the more general approach to ethics favored by earlier philosophical figures such as W. D. Ross (1930). The principles approach relies on a variety of prima facie norms, the most prominent of which are four principles: beneficence, nonmaleficence, justice, and respect for autonomy. The source of these principles is supposedly common morality. No single principle is a trump principle, since each may be overridden by considerations deriving from the others in specific contexts. How the principles are spelled out in specific situations and which one(s) hold sway in case of conflict is determined by a process of specification and balancing.

Another influential approach is the casuistic approach revitalized from ancient and medieval roots by Albert Johnson and Stephen Toulmin in The Abuse of Casuistry: A History of Moral Reasoning (1988). For casuists, general ethical principles stem only from the analysis of paradigm cases. These paradigm cases offer clear moral outcomes and create a set of initial presumptions about how to resolve other cases. These presumptions hold sway unless we come across exceptional circumstances. When such exceptional circumstances arise, we must go through a process of analogical reasoning, which includes identifying the ethical values at issue, the alternate courses of action, the morally relevant ways in which cases of the sort at issue can differ (the casuistic factors), and the relevant paradigm case(s) (Strong 2000).

A third approach, narrative bioethics, is a relative newcomer but has close ties to antitheoretic trends in normative moral philosophy generally. Insofar as narrative bioethics is not a single approach, it is hard to specify exactly what it amounts to methodologically. However, a couple of themes can be drawn out to give a flavor for this type of approach. First is the ethical significance of the various narrative voices involved in ethically complex situations. In opposition to casuistry, which relies on some single paradigm case and thereby a neutral voice, narrative bioethics focuses on telling the story from the viewpoints of all the participants. In this way we can see that the neutral voice in the paradigm cases (the physicians, lawyers, and/or judges) may in fact be the most powerful voice. Further, narrative bioethics focuses not on principles as a way of solving ethical quandaries, but rather on the different ways of telling the story and the comparative choices supported by these ways. Thus the stories themselves have normative impact.

While none of these approaches offers a general normative theory for bioethics, the principles-based approach comes closest, whereas the narrative and casuist approaches offer methods to deal with bioethical issues but eschew theory. A final approach offers a general theory of practical morality with particular focus on bioethics issues. This is the theory offered by Bernard Gert, Charles Culver, and K. Danner Clouser in Bioethics: A Return to Fundamentals (1997). On their view, morality is a public system whose purpose is to minimize the amount of evil suffered by those protected by it. In opposition to the principles-based view of bioethics, this view has more specific moral rules as fundamental touchstones.

Despite the availability of these various methods, much work in bioethics actually proceeds without a specified method or by a piecemeal approach. This kind of no-method method can be criticized for its ad hoc nature and for its lack of any specific justificatory framework. Even without specific appeal to some particular methodological framework, bioethical analysis at its best avails itself of a number of useful tools in approaching areas of ethical conflict, including gathering and sifting through morally relevant factual information; providing conceptual clarity on the moral concepts at issue; engaging in casuistic reasoning (without necessarily embracing casuistry as a methodology); and offering analysis, critique, construction, and revision of moral arguments.

Themes in Bioethics

As already discussed, bioethics as understood here includes at least biomedical ethics and ethical issues related to advances in the life sciences and life-science technologies, but may be broadened to include environmental ethics and ethics related to our treatment of nonhuman animals generally. The specific topics in bioethics are numerous and change in character and focus over time as the field advances. Each anthology of bioethics lists and groups the topics somewhat differently. A small sampling of these topics from four well-known anthologies includes justice in access to health care, mother-fetus relations, research involving human subjects, reproductive technologies, eugenics, genetics, health-care policy, physician-assisted suicide and euthanasia, medical confidentiality, the physician-patient relationship, informed consent, research involving animal subjects, definitions of death, human cloning and stem-cell research, and organ donation. Most of these topics include subtopics and may also be subsumed under more general headings. Developing any additional list of specific topics in bioethics here would be unhelpful; more useful is to focus on a few general philosophical issues at the overlap of a variety of topics in bioethics.

Moral Status

A key issue in several central topics in bioethics is the moral status of various animal species, the environment, and human beings in various life stages. The issue of moral status is in part a question about how far the moral community extends, that is, what the scope is of those entities considered to have direct moral value. An answer to the scope question does not resolve the issue entirely, since there may be different degrees of moral status. For example, we might think that both pigs and adult human beings have some direct moral status, but still that the adult human being has more moral status.

One way in which the issue of moral status has been addressed is through the concept of personhood. This concept introduces a normative category for those kinds of beings with full moral status, namely persons. In the philosophical debate, persons are not simply all and only human beings. Rather, it is normally assumed that some capacities are required to attain the status of a person. These capacities must be judged by their moral relevance, and not simply along species lines. Some morally relevant capacities might be the ability to feel pain and to have pleasure, the ability to engage emotionally with others, the ability to act intentionally, and the ability to make rational choices. If the level of capacity required for personhood is drawn at the more basic abilities, then the category of persons will include many animals and most human beings. Alternately, if the line is drawn at the higher abilities, for example at the capacity for autonomous actions and choices, then many human beings and most animals will not be persons.

Within biomedical ethics, the issue of moral status is of crucial significance for topics such as abortion and for issues at the beginning and end of life, for example, issues of the moral acceptability of discontinuing life support for severely impaired newborns or humans in persistent vegetative states. For those wanting to extend full moral status to fetuses and severely impaired postnatal human beings, a problem arises of how to ground that moral status. If it is grounded in the particular capacities or potential capacities of those beings, then a relevant question is whether the same moral status should also be extended to some nonhuman animals.

A central question in environmental ethics is the moral status of the environment in general and of particular ecosystems or other entities. Do two-hundred-year-old oak trees have sufficient moral status that it is wrong to cut them down independently of their effect on human beings or animals with moral status? Establishing the source of such moral status has been a source of difficulty within the field. Yet reflecting on questions like this may bring to light some of the limitations of a capacities-based approach to moral status. Moreover, even if oak trees, nonhuman animals, and human fetuses do not have individual moral status, it does not follow that we can ignore their well-being. Indeed, through such ethical resources as virtuous habits of character, the relationships of persons to other beings, and the effects of our treatment of such beings on other persons, we can establish a wide range of protections for nonpersons.

Distributive Justice

A very different core topic within bioethics focuses on questions of distributive justice, that is, what the proper distribution is of social resources and burdens. Looking more closely at this issue gives a sense of the different types of theoretical resources brought to bear in bioethics and also shows how the discipline has developed. Issues of distributive justice are usually approached not from the perspective of general normative moral theory, although they may be, but from theories in political philosophy. Examples of theories constructed to deal generally with issues of distributive justice are John Rawls's A Theory of Justice (1971) and the libertarian theory found in Robert Nozick's Anarchy, State, and Utopia (1974). However, as with normative moral theories, these general approaches to the distribution of social resources and burdens are often not well suited to the specific practical issues involved in bioethics.

To deal with issues of distributive justice at a level directly relevant to bioethics, a number of specific views have been developed. Many of these are varieties of egalitarianism, a general view in distributive justice focusing on the moral foundations for an equal distribution of social goods and resources. A major question for egalitarian theories in bioethics is what should be equally distributed: health care, health outcomes, satisfaction with health? Other views of the ethically proper way to allocate health care rely on formal mechanisms, such as cost-effectiveness analysis, which has theoretical roots in utilitarianism. The least common approach to issues of distributive justice in bioethics is libertarianism, although this view has had some supporters.

The evolution of the particular topics involved in distributive justice in bioethics gives a sense of how the discipline has changed over time. Initially, there was little focus on issues of distributive justice except for the discussion of the just distribution of the burdens of research on human subjects. While the issue of research on human subjects has retained significance, with the growth of patient activism and the perception of promising new interventions the distributive focus shifted from protection from the burdens of research to assurance of equitable access to research protocols. As the ramifications of institutionally centered health care and various health-insurance mechanisms grew, issues of distributive justice in health care became focused on questions of access. Such questions as whether there is a right to health care came to the fore. These questions have remained significant, particularly in the United States, where the number of uninsured persons continues to rise along with the costs of health care.

To complicate matters further, an additional twist has been added into the mix, which is that health inequalities appear to be tied less to health-care access than to relative social and economic status. While providing equitable access to health care may retain moral significance as a matter of distributive justice, providing such access may make a relatively small dent in the problem of health inequality.

Other Themes

In addition to the problem of moral status and topics in distributive justice, a number of other philosophical issues lie at the core of various specific topics in bioethics. While it is impossible to discuss all these topics here, several significant questions should be noted. One set of issues focuses on the science side of bioethics. First, what is the role of scientific facts in moral decision making? In this area, relevant questions might be, "How significant is an understanding of the biological developmental stages of human fetuses to the morality of abortion?" And, "What difference does it make to issues of distributive justice whether some genetic predispositions to disease significantly lower some persons' life expectancies?" Second, how do advances in the life sciences affect ethical issues? In this area the main issue is whether advances in the life sciences actually create the need for new ethical concepts and models or whether they simply create an opportunity to reinterpret established ethical debates. Fields where this question is especially relevant include human-somatic-cell cloning and assisted-reproduction technologies. A general underlying question with regard to these and other issues at the overlap of science and ethics is the moral relevance of naturalness.

Another set of core issues has to do with the development of role ethics as a way of understanding the specific obligations of physicians, other health-care workers, researchers, and scientists to particular populations. Here the main philosophical issue is whether individuals incur some obligations simply by occupying particular social roles or whether all obligations are versions of more general social obligations. The question is not whether physicians, for example, have a specific duty to protect the privacy of some medical information. All agree that this is the case, in addition to agreeing on a number of other specific duties that physicians have to their patients. The question is rather whether this duty is the product simply of occupying a specified social role or whether it is a duty that anyone with the requisite expertise in the particular relationship would also have. If there are obligations that are completely role dependent, then one can expect that some of these may conflict with other moral obligations, thus creating the potential for moral dilemmas. By contrast, if role obligations are contextual renderings of general moral obligations, then no such conflict can be expected.

Bioethics is a relatively young discipline that has already had a dramatic impact on academic curricula, public policy, public awareness of ethical issues, health care practices, and health sciences research. Continued advances in the life and health sciences on the one hand and continued disparities in health and health care on the other hand make it likely that bioethics as a discipline will continue both to grow as a field and to evolve in focus and methodology.

See also Environmental Ethics; Medical Ethics; Science, Research Ethics of.

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Rebecca L. Walker (2005)