Medicine and Surgery

BIOETHICS - Lecture notes

Dr. Bernard Caruana

“Science without conscience

devastates the soul.”
Fransua Rable

Bioethics became a logical answer to numerous ethical questions and

problems which have appeared in the last decades in the process of clinical work,
biomedical research and experiments. It is called not only to identify and analyse
conflict situations at the junction of medicine, biology, philosophy and
jurisprudence, but also to determine concrete ways of their solving. The primary
subjects of consideration of bioethics are the newest achievements in biology and
medicine from the point of view of determining the level of their danger for man
and society in the present and future. Bioethics is directed at the development of
moral and legislative measures, which would shield an individual, society and
humanity on the whole from unde sirable and sometimes ruinous consequences
of implementing new medical and biological technologies in practice.

The formation and striking progress of bioethics is related to revolutionary

changes and achievements in the field of medical and biological disciplines. We
speak about the decoding of the human genome, animal cloning, possibility of
cloning of man, artificial change of gender, extracorporeal impregnation, using
trans-genetic plants for food, success of gene therapy, treatment with the use of
embryonic tissues, new methods of family planning, progress of transplantology,
perfection of vaccine prophylaxis, introduction of the newest technologies of
diagnostics, treatment and prophylaxis of different diseases of man. The issues of
medical secret, euthanasia, mother-foetus conflicts, family planning conceptions,
and methodologies of biomedical research need new bioethical evaluation.

The development of bioethics was a direct result of the implementation of

scientific and technical revolution achievements in practice in the situation of a
deep ideological crisis and growth of global ecological problems. Enormous
success of medical and biological sciences have generated a great number of
questions of moral nature. The affairs amount to the situation, in which people
try to spread their control over their own evolution and lay their claim not simply
to supporting their life, but to improving and changing their nature, depending on
their own understanding. In this situation grounded discussions concerning the
ethical basis and moral competence of such actions arise.
Bioethics represents not only the modern stage of development of the medical
ethics and deontology, but also a basis for establishing scientifically grounded
balance between the newest medical and biological Technologies on one hand,
and human rights, principles of humanism and public progres - on the other.
Bioethics is based on the respect of life and dignity of healthy and sick people,
who’s interests should always be estimated higher than the interests of science or
society. The leading postulate of bioethics is the principle of autonomy with
inviolability of human mental and physical status, which is realized according to
the rule of informed consent of the patient and society to the execution of medical
and prophylactic manipulations.

Bioethics unites a vast circle of socio-economic, moral, ethical and legal issues,
which are considered not only by the medical community, but also by the state
authorities, public, and mass media. Bioethical questions are discussed by the
authoritative international organizations — UN, UNICEF, UNESCO, the
European Council, and WHO. Appropriate declarations, conventions,
agreements, recommendations, and resolutions of these organizations provide the
development of national legal and ethical regulations of practical health services,
medical and biological research.

THE OBJECT AND THEORETICAL BASES OF BIOETHICS

The subject of bioethics is the complex of disputable ethical questions,
which can be identified in the process of medical practice, in the course of
biomedical research and experiments or in the combination of both these types of
professional activity. The term “bioethics” means systematic analysis of human
actions in biology and medicine in the light of moral values and principles.
Bioethics is an organic integration of modern achievements in science and
medicine with spirituality. Bioethics includes a vast circle of socioeconomic,
moral, ethical and legal problems, the content and depth of which constantly
change in the course of biology, medical science and practice development.

The characteristic task of bioethics consists in comprehensive analysis of

such problems with the purpose of their clarification and solving. Besides the
term “bioethics”, another word combination, “biomedical ethics” is often used.
Both these terms became common in the modern language and can be used as
synonyms, but there are some distinctions between them. The term “biomedical
ethics” focuses on the problems related to practical medicine. In this context the
term “bioethics” envelops a wider scope of the disputable questions, including
social medicine, legal issues in biology, and the ethics of biomedical
investigations and experiments.
In any case, we should understand “practical medicine” in a wide sense,
including both the doctors’ professional activities, and other specialists’ activities
related to the public health services The professional conduct of medical workers
is the priority object of bioethical studies. Its formation in 1970-s became a
natural result of the medical ethics development. Bioethics formed on the junction

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of different sciences, such as medicine, biology, philosophy, sociology,
psychology, professions and religion studies, pedagogies, management, and
jurisprudence.
The term “bioethics” was introduced by V. R. Potter in his article
“Bioethics, the Science of Survival” (collected articles “The Prospect of Biology
and Medicine”, 1970) and in his book “Bioethics, a Bridge to the Future” (1971).
The conception of bioethics appeared in the atmosphere of ethical accusations of
medicine and science, which arose in late 1960-s. The term “bioethics” was
suggested by V. R. Potter in order to stress the necessity of new ethical approach,
which would resist the challenges of scientific and technological achievements
and provide the survival of humanity in the post-industrial society.
Bioethics is a science concerning the laws, principles and rules which
regulate the medical and research workers’ professional conduct. It provides safe
implementation of new medical technologies and reminds doctors and scientists
about the impermissibility of doing harm to people, their offspring, all the
humanity and biosphere on the whole. Bioethics is a subsection of a more general
science — ethics. Ethics in its nature is a philosophical discipline. As a section of
philosophy, ethics can be defined as the “philosophical study of morals”. As such,
it should be dissociated from the “scientific study of moral”, which is designated
by the
term “descriptive ethics”. The purpose of descriptive ethics consists in receiving
empiric knowledge concerning morals. The specialists in the field of descriptive
ethics describe the existing moral views and try to explain them on the basis of
their psychological or sociological origin. The moral views, as well as other
aspects of human experience, provide the psychologists and sociologists with a
wide range of phenomena, which need explanation. For example, psycho-analysts
can explain some features of sexual morals using Z. Freud’s theory; and
sociologic questioning shows that the position of certain social groups concerning
euthanasia are related to their religious world view.
Further in this book the term “ethics” will be used only in the philosophical
meaning, different from the subject of descriptive ethics. Philosophers usually
subdivide ethics into normative and meta-ethics. Normative ethics aims at
defining, which human actions are correct from the moral point of view, and
which are not. The tasks of meta-ethics consist in establishing the nature of moral
views and determining specific methods, suitable for the confirmation of separate
moral views and theoretical systems rightness. Probably, the discussions in the
field of normative ethics, to a certain degree, concern the meta-ethical reasoning
and can not be separated from them totally. As we see, there are some differences
between normative ethics and meta-ethics, but it is especially important to
understand that there are pronounced logical distinctions between the normative
and descriptive ethics. While descriptive ethics tries to depict and account for
those moral views which are actually already accepted, normative ethics
tries to establish, what moral views are justified and thus must be accepted. The
task of general normative ethics consists in the development and grounded
confirmation of a generalized theory of moral obligations, other wise speaking,
of an ethical theory which would give a general answer to the question: “What is

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right from the moral point of view and what is wrong?” The task of the applied
normative ethics, unlike general normative ethics, consists in making decisions
on specific moral problems, for example, whether abortions have moral
justification, and if they do — on what conditions.

In the light of the described distinctions, bioethics can be identified as a

branch of applied normative ethics. The task of bioethics is to solve ethical
problems related to medical practice, biomedical research or to both these fields.
Ethical problems related to other aspects of life, naturally, belong to other
sections of applied normative ethics. For example, business ethics concerns
ethical problems which arise in the process of different types of business activity.
It is important that all private problems discussed in applied ethics are normative
by their nature. It has to answer questions concerning ethical rightness or
wrongness of a concrete practical action and its moral justification. The applied
ethics does not try to find out, what moral views people have in reality. This is
the task of descriptive ethics. The applied normative ethics, as well as the general
normative ethics, is directed at deciding which moral views are justified. The
characteristic questions bioethics tries to answer are: “Does a doctor have a moral
obligation to inform the patient that his illness is incurable?”, “Can the violation
of a medical secret be morally warranted?”, “Is there a moral justification for
euthanasia?”, “Is substitute maternity moral?”, etc. All these questions belong to
the field of applied normative ethics and are directed at the evaluation of separate
actions and practices. Other bioethical issues concern ethical justification of laws.
For example, are the laws prohibiting or limiting the abortions just from the moral
point of view? Are laws which prohibit active euthanasia needed? Should specific
laws, allowing to hospitalise a person to a psychiatric clinic without his/her
consent exist? Such questions show that bioethics has certain relationships not
only with general normative ethics, but also with socio-political philosophy and
philosophy of legislation. This fact is demonstrative of the inter-disciplinary
nature of the bioethical science within the framework of philosophy. The inter-
disciplinary nature of bioethics can also be confirmed by the fact that the
debatable problems are often examined not only from the point of philosophical
view upon morals (ethics is a science concerning morals), but also from the
perspective of theological estimation of morals. The principle difference consists
in the fact, that philosophical arguments exclude the recognition of any religion
or religious faith, while theological arguments on the whole stay within the limits
of a specific religion. However, the most essential sign of the inter-disciplinary
nature of bioethics consists in its connection with medicine and biology. The
achievements of medicine and biology act a major part in the development of
bioethics, the nature and orientation of philosophical ideas. It is necessary to
acknowledge the exceptional value of the doctors’ and research workers’
participation in the bioethical discussions. It provides the possibility of
philosophical analysis in accordance with the realities of medical practice and
biomedical investigations (T. A. Mappes, D. De Grazia, 2001).

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 The development of bioethics as a science was promoted by theoretical
developments in the field of fundamental principles of this discipline. An
exceptional role in the determination of an original approach to this problem
belongs to T. L. Beauchamp and J. F. Childress. In their original publication “The
Principles of Biomedical Ethics” (1979) they formulated four principles of this
subject:

1. The principle of respect towards autonomy presupposes respect towards

personality and protection of people with limited autonomy (children,
patients with mental disorders, etc.).
2. The principle of non-harming implies, that a medical worker must not act
in a way, that is practically harmful to a patient.
3. The principle of aid and comfort says that a medical worker must operate
intereses on the behalf of a patient’s wellbeing, show mercy and benefaction.
4. The principle of justice is directed at the observance of just distribution of
both social welfare (for example, possibilities of effective health
protection) and social duties (for example, taxes).

Bioethical training should be carried out continuously during all the period of
a specialist’s professional activity. The interdisciplinary nature of bioethics
presupposes sociological understanding of the medical and biological
communities. It also implies psychological understanding of the researchers’,
doctors’, medical workers’, and patients’ needs, as well as the types of impacts
they are exposed to. A historical understanding of the sources of bioethics theory
and practice is important. The mastering of the ethical analysis methods, as they
are understood by philosophers and theologies, should be combined with
understanding of these methods limitations, when they are applied to concrete
practical situations. Every specialist engaged in biomedical ethics needs to have
direct contact with the ethical problems which arise in medicine and biology. It
is very important for biomedical ethics to develop inductively, i.e. proceeding
from the problems realized by doctors and research workers, who count on co-
operation in determining the methodological strategy and decision-making to
solve these problems.

There is an interesting opinion that medicine has saved ethics from dying. The
question is that the philosophers’, physicians’, lawyers’ and other professionals’
co-operation had serious and irreversible impact on the methods and content of
philosophical ethics. Bringing the materials of concrete life situations into ethical
discussions compelled the philosophers to return to Aristotle’s positions, which
were not used for such a long time (S. Toulmin, 1982). The forming and
development of bioethics is directly connected with the development and
transformation of classic ethics on the whole and medical ethics or medical
deontology in particular. The new science has raised and is trying to solve
problems related to the preservation of the human nature, protection of the Earth
biosphere, and the humanity survival. A specialist in the field of biomedical ethics
works in three basic directions:

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 1. Finding problems liable to moral estimation (the determination of the
subjects of discussion).
2. Systematic analysis and discussion of human actions in biology and
medicine in the light of moral values and principles (the methodological
strategy).
3. Helping the doctors and biomedical research workers to ground correct
actions on the basis of biomedical ethics principles and theories (the
decision-making process).

V. Potter, the founder of bioethics, has conceptually developed its basic

directions. He considered that bioethics should embrace the whole complex of
knowledge concerning living creatures and study not only the medical problems,
but also issues of ecological ethics. “It is quite clear, — wrote V. Potter, — that
bioethics should be built on a multidisciplinary basis, and I offer two regions, the
interests of which are seemingly different, but which need each other: they are
the medical and ecological ethics. They intersect in the sense, that the medical
ethics is mainly related to the patients’ and doctors’ direct decisions and optional
choice in their aspiration to prolong human life... Ecological ethics has stable
beliefs in relation to what we should do to save the ecological systems in a form
consonant with the protracted existence of the humanity”.

The idea of such global bioethics which offers to achieve the “acceptable
survival” of a stable society in a healthy ecological environment began to be
realized practically since 1990-s. In 1970-s and 1980-s bioethics, in fact,
developed within the limits of medicine and biomedical research. In 1970-s and
1980-s the terms “bioethics” and “biomedical ethics” were practically synonyms
(the nature of insignificant distinctions between them was discussed at the
beginning of this chapter).
In 1980-s a suggestion was formulated: to separate the so-called “clinical
ethics” from the general biomedical ethics. This suggestion did not get much
support, though. It is generally known, that the appearance of bioethics was based
on the newest scientific achievements in the field of biology, genetics, gene
engineering, transplantology and clinical testing. Certainly, all these fields were
clinical and presupposed contacts of doctors and patients. However, the majority
of doctors did not do research work, a relatively small number of them studied
medical genetics, and quite a few were engaged in transplantology. At the same
time, practical doctors regularly encountered the problems of seriously ill and
dying patients and other ethical problems of modern medicine. These routine
everyday ethical problems of practical medicine were attributed to the “clinical
ethics”, whereas biomedical ethics mainly solved the problems of high medical
technologies and social medicine (M. Siegler, 1979).

Bioethics became global in its nature in 1990-s owing to the globalization of

economy, science and culture, characteristic of the modern society. The reasons
of the world globalization are internationalization of economy, development of a
united world communication network, decreasing of the national states role, and

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the activation of trans-national non-state organizations (ethnic diasporas,
religious denominations, ecological associations). The process of globalization in
the modern society is ambiguous, it is estimated in quite different ways, and it
sometimes causes serious ideological contradictions and even collisions.
However, globalization is undoubtedly useful for the bioethics, because it is
directed at providing the survival of humanity on the basis of creating an interlink
(bridge), necessary for the connection of the medical and ecological ethics in a
world scale.

Presently global bioethics develops in the followings directions:

1. Ethics of the medical professions (doctors, nurses, technical employees,
administrators).
2. Ethics of the clinical research and experiments on animals with therapeutic
and non-therapeutic purposes.
3. Social ethics of medicine (social justice, social-ethical obligations,
allocation of health protection resources, bioethical problems of the
medicine of labour, sports, multinational society, and demographic
development).
4. Ethics of the environment protection.
5. Ethical estimation of biological law as the legal regulation of intrusion into
the human organism, human genome and the biosphere, a part of which
people are.
6. Ethical modification of certain population groups behaviour on the basis of
development and introduction of global educational programs with the
purpose of prevention of some diseases, related to improper life-style and
human conduct (for example, HIV infection/AIDS, infectious diseases
which spread through water, food or air, etc.).

The ideas of post-modernism appeared and spread widely by the end of the
XX century. The post-modernism tendencies of the contemporary postindustrial
consumer society can be characterised with the lack of canonised rules and
systems, with the disappointment in ideals and values of the Renaissance and
Enlightening. The main ideas of humanity — the faith in progres and
emancipation of personality, the focus on scientific knowledge, the belief in the
boundlessness of human possibilities and the triumph of reason — were lost. The
post-modernism ideology had influenced not only the ethics, but also the people’s
world outlook, life style, science, art and religion.
Today the theories of modernism and post-modernism are replaced by the idea
of globalization, which, unfortunately, also can not help in finding answers to the
problems, related to the unevenness of different regions of the planet
development, the “westernisation”, and the decrease of national self-
identification. The development of global bioethics as a special world outlook of
the end of the XX-th century was conditioned by people’s awareness of the
possible de-humanisation of science, oblivion of authentic humaneness, and the
isolation of people from the veritable life, which they perceive only indirectly in

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the process of cognition. The events which have occurred by the end of the last
century promoted the beginning of the
public discussion of the moral responsibility for the wide application of the
newest technologies.
The global bioethics, to a certain extent, is a result of interpenetration and
crosscoupling of different cultures and different ethical systems. Its origin, along
with other cultural phenomena, became the starting point in the development of
a new human self-consciousness characterised by democratic views, de-
ideologisation, tolerance, pluralism of tastes and ideals, and multiplicity of ethical
paradigms. As a multidisciplinary school, global bioethics aims at overcoming
narrow-mindedness of the former scientific knowledge philosophical and
theoretical bases. It criticizes one-dimensional traditional philosophical axioms,
and aspires to create qualitatively new fusion of different ethical points of view.
In the field of global bioethics scientific analysis there is a vast set of ethical,
utilitarian, deontological, communicative, and
theological governing rules and principles, which sometimes conflict with each
other.

The modern society professes increasing interest to the methods of ethical

control of the physicians’ and researchers’ activities, carried out on the basis of
normative documents developed and approved by different international
organizations. The most important of these documents is the Convention On
Human Rights and Biomedicine. It was approved by the European Council and
concerns the protection of human rights and dignity in connection with the
practical application of accomplishments in the field of biology and medicine.
Legal registration of the biological law as a mechanism of regulation of
research in the field of medicine, biology and ecology become an objective reality
in the life of the modern society. The transition from ethical values to legal norms
grounds the necessity of a methodologically correct determination of relations
between the bioethics and law (fields of responsibility, autonomy, and
coexistence of these disciplines). Their task consists in creating an effective,
socially just mechanism of control and regulation of the medical and biological
intervention into the human organism and its environment. Once J. H. Poincaré
(1910) considered that the idea of states parliaments making competent decisions
concerning the issues of scientific research was ridiculous. To his opinion, it was
“necessary to follow one’s
own conscience; any legal interference would be inappropriate and somewhat
ridiculous”.
Things have changed cardinally: our modern society discusses the need in
a scientific tribunal, which would settle the disputable questions and prepare a
statute-book, regulating issues of research. Scientific journals have a right to
withhold from publishing the results of research which did not undergo ethical
examination.
One of the characteristic features of global bioethics is its deep connection
and closeness to the Christian attitude. It presupposes the necessity of careful

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attitude of people towards every display of life as a higher value and the
“veneration for life” (A. Schweizer).
The multidisciplinary and “multi-style” nature of global bioethics
determines the possibility of moral orientation in the modern multinational
society and finding non-standard decisions of individual ethical problems. The
social orientation of global bioethics, its orientation at the observance of
principles of justice, veracity, autonomy of personality, non-harming, and
informed consent determine the possibility of creating an organic and steady
connection between the scientific knowledge and moral values with the purpose
of the humanity survival and the preservation of its environment. The role and
importance of global bioethics in the modern world are especially clear from the
historical perspective.