Medical Ethics, History of Australia and New Zealand
MEDICAL ETHICS, HISTORY OF AUSTRALIA AND NEW ZEALAND•••
Medical ethics in Australia and New Zealand (Australasia) evolved slowly until the early 1980s, when major advances in reproductive technologies prompted widespread public discussion of bioethical issues surrounding human conception.
In the early decades of the twentieth century, ethical debates centered on issues of professionalism in the delivery of medical services, such as the permissibility of advertising by individual practitioners and the setting of standard fees to avoid "undercutting" by competitors. The branches of the British Medical Association (BMA) that had been set up in the colonial Australian states were federated in 1912, when a unified code of professional ethics, dealing mainly with the regulation of advertising and etiquette toward patients, was introduced (Egan). After World War I, medical schools in Australasian universities began to include brief didactic instruction in the ethical obligations of physicians. There was also some public discussion of abortion, methods of birth control, and confidentiality in relation to patients with venereal disease.
A Labour government with a strong social welfare platform was elected in Australia in 1941. In the late 1940s this government attempted to introduce a national health service, which would have provided universal access to healthcare for the first time in Australia. However, a bitter debate developed with the BMA, the majority of whose members saw the government's plans as a threat to the autonomy of medical practitioners and as the first step toward the nationalization of medicine. After legal challenges, the plans for a national health program were defeated in 1949 (Gillespie). Under the free-market policies of subsequent Liberal governments, access to publicly funded healthcare was available only to recipients of old-age and invalid pensions. This situation persisted until 1975, when the Labour government introduced Medibank, Australia's first national healthcare program, which provided access to government-subsidized healthcare for all. While the incoming Liberal/National coalition government gradually dismantled this program during the late 1970s, it was reinstated as Medicare in 1983 by the newly elected Labour government, and has continued to operate into the twenty-first century.
Ethical issues in reproduction became a major concern in Australasia in the early 1980s, following pioneering research on in vitro fertilization (IVF) carried out by a joint research team led by Carl Wood and Ian Johnston at the Monash University Queen Victoria Medical Centre and the Royal Women's Hospital in Melbourne during the 1970s. In 1983 this research led to the world's first live IVF births from frozen embryos and donated eggs, and the embryo research carried out by Monash University scientists in order to improve IVF and other assisted reproduction techniques sparked worldwide interest. These developments in reproductive technology stimulated much public discussion in Australia, particularly among Roman Catholics, who constitute over a quarter of the population.
Care for the terminally ill became another widely debated issue in Australia in the 1980s. Influenced by the growing public support for voluntary euthanasia, the state governments of South Australia and Victoria passed legislation (in 1983 and 1988, respectively) permitting patients to refuse medical treatment in certain circumstances, even where such treatment might prolong their lives. In 1995 the Northern Territory's single-chamber parliament passed the Rights of the Terminally Ill Act, making it the first jurisdiction in the world to legalize active voluntary euthanasia. This legislation permitted doctors to carry out voluntary euthanasia, under certain specified conditions, for terminally ill patients with unbearable suffering. The lives of several patients were lawfully ended under this act before it was overruled by the Euthanasia Laws Act, passed by the Australian federal parliament in 1997.
Australasia's first research center in bioethics, the Monash University Centre for Human Bioethics, was established by the philosophy professor Peter Singer, together with colleagues in medicine, science, and the law, in 1980. A number of smaller research centers for bioethics were set up in Australasia during the next two decades, including Melbourne's St. Vincent's Bioethics Centre, Adelaide's Southern Cross Bioethics Institute (both of which have a Christian perspective on bioethics), Sydney's John Plunkett Centre for Ethics in Health Care, the Ethics Unit at Melbourne's Murdoch Childrens Research Institute, and the University of Otago Bioethics Research Centre in Dunedin, New Zealand. Bioethics research is also pursued by several of the large groups of philosophers appointed to the Centre for Applied Philosophy and Public Ethics, which was established by Charles Sturt University in both Canberra and Melbourne in 2000. The interdisciplinary Australasian Bioethics Association was formed in 1990, and its inaugural conference was held in Melbourne in 1991.
With Helga Kuhse and others from the Monash Centre, Peter Singer has written extensively on ethical issues arising from the new reproductive technologies and on questions surrounding the care of terminally ill adults and infants. Other noteworthy Australasian writers in bioethics include the philosophers Max Charlesworth, Julian Savulescu, and Robert Young; the feminist academics Renate Klein and Robyn Rowland; the lawyers Michael Kirby and Loane Skene; and the theologian Norman Ford. In 1989 the Monash Centre introduced Australasia's first master's program in bioethics, and this institution also publishes Australia's only peer-reviewed bioethics journal, the Monash Bioethics Review.
In 1982 advances in infertility research in Victoria led the government of that state to appoint Louis Waller, a professor of law at Monash University and an Australian law reform commissioner, to chair a committee whose mandate was to consider the social, ethical, and legal issues arising from IVF. The three reports produced by this committee supported the use of IVF under certain regulations, prompting the Victoria Parliament, in 1984, to enact the Infertility (Medical Procedures) Act, the world's first legislation to deal specifically with these new reproductive technologies (see Charlesworth 1989). Among other provisions, this legislation allowed IVF to be carried out at approved hospitals, for married couples who have already sought infertility treatment for at least twelve months prior to attempting IVF.
At the federal level, the National Bioethics Consultative Committee (NBCC) was established in 1988 as an advisory committee on issues such as access to information about their origins for children conceived through IVF; artificial insemination by donor; surrogate motherhood; and embryo experimentation. In 1990 this committee issued a report that supported surrogacy arrangements and proposed draft legislation to regulate such arrangements. In light of the heated public controversy that ensued, however, the Australian government decided against implementing its recommendations nationally. Nevertheless, most Australian states have not outlawed IVF-assisted surrogacy in cases where the surrogate mother receives no fee, and in 1994 the Australian Capital Territory enacted legislation to regulate such surrogacy arrangements. In 1991 the NBCC was subsumed under the existing National Health and Medical Research Council (NH&MRC), which merged the functions of the NBCC and the Medical Research Ethics Committee to form the Australian Health Ethics Committee.
The groundbreaking work of Australian researchers with human embryonic stem cells and biotechnology became the focus of much public discussion at the beginning of the present century. The cloning of human beings was outlawed in 2002, following the recommendations of a federal parliamentary standing committee, but research will be permitted on stem cells that had been extracted from human embryos prior to early 2001.
Australasia's first recorded institutional ethics committee to review human experimentation was set up at the Royal Victorian Eye and Ear Hospital in Melbourne in 1957 (McNeill), and at the instigation of the NH&MRC (which allocates government funding for medical research), Australian universities began, in the 1980s, to form ethics committees to oversee medical and other research carried out at those institutions. Following wide community consultation and a 1996 federal government review of the relatively brief NH&MRC guidelines on human experimentation, the detailed and remarkably broad-ranging National Statement on Ethical Conduct in Research Involving Humans was issued by the NH&MRC in 1999 as a guide for all human research ethics committees in Australia. The basic principles in the National Statement are integrity, respect for persons, beneficence, and justice, which are developed in more detail through their application to a variety of different types of research.
In New Zealand, the Medical Research Council (set up in 1937 by the government to supervise medical research) decided in 1968 that all research must adhere to the World Medical Association's Declaration of Helsinki, which stressed nonmaleficence and the need for informed consent on the part of the experimental subjects. In 1987 unprecedented public outrage followed revelations of an experiment involving clandestine selective nontreatment of women with cervical cancer, which was carried out at the National Women's Hospital in Auckland from 1966 to 1981. The New Zealand government immediately set up an inquiry into the experiment, which resulted in an amendment to the Human Rights Commission Act of 1977, that added a statement of patients' rights to proper standards of care and adequate disclosures to enable genuinely informed consent. This amendment also provided for the appointment of a national health commissioner to encourage awareness of these rights by members of the medical profession (Campbell).
During the 1990s there was considerable discussion in Australia about patients' legal rights to treatment information, prompted by the Australian High Court decision in Rogers v. Whitaker (1992), which gave legal recognition to a patient-centered standard of disclosure of medical information. Following this decision, the NH&MRC issued a booklet containing guidelines on providing information to patients.
Influenced by the increasing recognition of patient's rights, Australasian medical schools have gradually woven the teaching of ethics into their curricula. For example, the University of New South Wales in Sydney and the University of Newcastle began teaching substantive courses in ethics to medical undergraduates in the 1970s, and the University of Adelaide's medical school introduced ethics into the undergraduate syllabus in the early 1980s. Following the recommendations of the National Inquiry into Medical Education—a committee of academics and health professionals set up by the federal minister for health, which heard submissions during 1987 and 1988—many other Australian medical schools have included clinical ethics as part of their undergraduate programs. These developments in bioethics education should help promote lively and informed discussions of medical ethics issues in Australasia as they arise in the future.
justin oakley (1995)
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