Unethical bioethics

Bioethics: how did we get so confused?

Ten years ago, Diana Irving published her article "Bioethical Confusion" on the Human Life Matters blog. In a new article on the same topic, her doubts about the ethics of bioethics sound even more acute.

Please note: the opinion of the editorial board may not coincide with the opinion of the author of the article, especially if the author is a fanatical Catholic who has retrained from a biochemist to a bioethicist.

The term "bioethics" is associated with traditional medical ethics, which are trying to apply to new medical technologies. This consists in extending traditional philosophical or theological principles to moral dilemmas generated, for example, by cloning or experimenting with new HIV drugs/AIDS, isn't it?

Not quite. Just like the term "bioethics" itself, which appeared only in the early 70s of the last century, so the philosophical justification of bioethics has nothing to do with what underlies traditional medical ethics.

The key point of the latter is the duty of the doctor to the patient, whose life and well-being are almost sacred.

Bioethics is based on utilitarianism and, like all utilitarian disciplines, its action is aimed at maximizing human well-being on a global scale.

Factors such as the feelings or preferences of other people – the parents of a child with severe birth defects, a husband whose wife is in a hopeless coma, or even a doctor who considered that the best choice for a patient with Alzheimer's disease would be death, as well as the possible costs of society for treatment may eventually outweigh the needs of a sick person. Goodbye, Hippocrates; hello, Peter Singer! Farewell also to the Catholic understanding of the sanctity of the life of every human being.

Peter Singer (b. 1946) is an Australian philosopher, author of the acclaimed book Animal Liberation (1975) and many other treatises on the need for equality between humans and other animals.

The concept of "bioethics" appeared after the mass exposure of the use of large groups of people who were not given the right to choose as "guinea pigs" during state-funded medical experiments in the late 60s and early 70s of the last century: orphans in appropriate institutions, blacks from impoverished American villages, recruited Tuskegee Institute, prisoners, psychiatric patients, residents of "black" ghettos. Abortive embryos quickly began to turn into valuable material for medical research, which raised serious moral questions.

In addition, new methods of prolonging life have led to ethical dilemmas. There have been publications about patients passing away in agony and spending their last days, and in some cases even weeks or months, surrounded by many tubes and impartial life-supporting devices. It seemed that nursing homes and hospitals were overflowing with terminally ill patients consuming a huge amount of precious medical resources.

In the late 60s and early 70s of the last century, Senator Edward Kennedy (Edward Kennedy), and, after him, Senator Walter Mondale (Walter Mondale), later, under President Jimmy Carter (Jimmy Carter), who became vice president, held hearings on a variety of similar abuses. As a result, an article of federal legislation appeared, called the National Research Act of 1974. He demanded that the U.S. Department of Health, Education and Welfare (now the Department of Health and Human Services) appoint a commission to "determine the fundamental ethical principles" that should be used by the federal government to solve such extraordinary dilemmas. These "ethical principles" should have been implemented as the basis of federal regulations concerning the use of people as research objects.

In 1974, Casper Weinberger, Secretary of President Gerald Ford for Health, Education and Welfare, appointed a commission of 11 experts, which in 1978 issued a document called the Belmont Report, which listed and explained three ethical principles: respect for the individual, justice and mercy. Until now, these principles are known as the "Belmont Principles".

The Belmont principles formed the basis of the guidelines that the Department for Human Protection as a Research Subject (OHRP, Office for Human Research Protections) applies to assess the ethics of using people as research objects. In addition, they are taken as the basis for a number of other federal regulations and guidelines for medical research, and are also used in the work of non-governmental organizations. Universities and clinics usually apply (or try to apply) these principles when approving research projects, deciding which patients are suitable for certain medical interventions, who continues to live, who dies, and even who makes these decisions.

Thus, bioethics is a completely new ethical theory – a new method of determining right and wrong. How did we come to this? How is it that our government and its unelected experts, not religious leaders or even traditional philosophers, have been given the power to decide what is the norm of ethics for all Americans facing complex medical or scientific issues?

A Brief History of Medical EthicsThe roots of the subject of medical ethics go back to ancient times to the Greek physician Hippocrates (approximately 460-380 BC), who was concerned about the qualities of a "good doctor", as well as etiquette and manners that a doctor should observe when communicating with a patient.

From the point of view of Hippocrates, a good doctor should be a "virtuoso" whose duties include helping, not harming patients, ensuring patient confidentiality, as well as refraining from abusing them financially or sexually. The Hippocratic Code of Conduct strictly prohibited abortion and euthanasia. The model of this code of conduct was described in the Hippocratic Oath, which graduates of most medical educational institutions had to take until relatively recently.

In the Middle Ages, a more Christian and public understanding of medical ethics prevailed, requiring doctors to position themselves in front of the public as "professionals" and demonstrate their worthiness and authority. Medicine has become more than a doctor-patient relationship. Practitioners received the exclusive privilege of training, testing, licensing and punishing other doctors who committed to use their skills both for the benefit of society as a whole and for the benefit of their own patients.

Since the end of the XIX century, against the background of an increase in the number of medical educational institutions and clinics attached to them, the traditional ethics of Hippocrates began to integrate new rules governing the relationship between doctors. Thus, the so-called "ethics of competence" appeared, especially extending to medicine in the conditions of clinics. The focus has shifted to the active collaboration of doctors and other specialists involved in patient care. Careful registration of information in the medical history and a written description of the patient's condition has become the norm. Doctors were supposed to inform patients about their diagnoses and the courses of therapy used and were not supposed to use patients for educational purposes. Doctors holding senior positions should not have exploited subordinates. "Ethical practice" has been defined as "competent practice", including in medical research.

After World War II, the results of medical research and new technologies, which appeared thanks to large-scale federal funding of medical sciences, began to complicate the process of medical care. The important connections that form the interaction between the doctor and the patient began to thin out. The foundations of traditional Hippocratic medicine were rapidly crumbling due to the inability to provide answers to constantly emerging new questions: can one experiment on a dying patient help other patients? How to work in conditions of increasing interpenetration of the spheres of medical practice, government, commerce and technology? How can the benefits of medical research and the costs associated with them, as well as insufficient medical resources, be fairly distributed? Who should make these decisions? Patients? Their families? Doctors? The clergy? Specialists?

ConferencesSince the end of the 60s of the last century, a series of conferences has been held in the United States dedicated to addressing issues such as birth control, restriction of intellectual freedom ("thought control", thought control), sterilization, cloning, artificial insemination and sperm banks.

One of the first conferences "Serious Questions of Morality in Modern Medicine", held by Dartmouth College in 1960, was attended by many luminaries of science and medicine, including microbiologist Rene Dubos from the Rockefeller Institute, physician Sir George Pickering from Oxford University and Brock Chrisholm) – a leading medical specialist of the World Health Organization, as well as such famous humanists as C. P. Snow and Aldous Huxley.

The most important topics under consideration were genetics and eugenics. Dubo stated that "prolonging the lives of aging and sick people," as well as preserving the lives of children with genetic defects – two achievements of post–war medical science - created "the most difficult problem of medical ethics that we will face over the next decade." Geneticists expressed concern that the gene pool of the population began to be polluted due to the possibility of preventing early deaths of people with serious hereditary diseases. Nobel Prize-winning geneticist Hermann Muller has proposed his own solution to this problem: the creation of a sperm bank of healthy men, which, in combination with "new methods of reproduction", is able to prevent, otherwise, the inevitable "degeneration of the race", which may be the result of medical advances that allow people with genetic defects to leave offspring.

During other conferences, great minds continued to immerse themselves in discussions of the possible consequences of scientific achievements for the modern world. A number of proposals were made, including focusing the activities of scientists on developing a strategy to increase the level of human intelligence (which was found to be largely determined by genes) on a global scale using methods such as sterilization, cloning and artificial insemination.

Most of the luminaries of the 60s supported the theory of ethical relativism, which was popular at that time, justifying the expediency of allowing the scientific elite to develop ethical strategies outside the limitations established by traditional ethical principles.

The result of all the debates was the separation of theology and philosophy from medicine in the interests of public policy. Most experts agreed that the official formulation of the new regulatory medical ethics should be the result of a "consensus". This type of thinking subsequently became the main characteristic of the emerging field of bioethics.

Think tanksBy the 70s, the debates and their participants had moved from university conferences to stationary "brain cents".

In 1969, not far from New York, The Hastings Center was organized, in which such pioneers of bioethics as Dubo, Ramsey, Gustafson, Rene Fox, Arthur Kaplan, Robert Veatch and even Catholic journalist Peter Steinfels were engaged in intellectual work.

The center's specialists discussed issues such as death and dying, behavior management, genetic engineering, genetic counseling, birth control and the fusion of ethics and public policy. The first volume of the report on the work of the center, published in 1971, subsequently became the bible of "secular" bioethics.

Belmont's three principles – respect for the individual, justice and mercy – were supposedly borrowed from the works of leading secular philosophers of the XVIII-XX centuries, mainly Kant, John Stuart Mill and John Rawls, a very influential philosopher at Harvard University, whose book "A Theory of Justice" published in 1971 formed the basis of a number of radical official and social egalitarian theories, such as theories of legal protection of interests and redistribution of material goods.

As expected, the new ethics were exceptionally systematic. The Commission selectively selected fragments from various contradictory theories and put them together. Moreover, each of the three principles of the new bioethics was formulated according to the principle of prima facie (in the absence of evidence to the contrary): none of the principles could refute any of the other two. When dealing with real medical and scientific problems, bioethicists had to coordinate the significance of all three principles.

Inevitably, theoretical cracks began to form in the very basis of the new theory of bioethics. In fact, due to the fact that Belmont's principles were derived from fragments of fundamentally contradictory philosophical systems, attempts to apply them led to theoretical chaos. The most problematic thing was that when people tried to apply the new theory to real patients in a medical or research facility, it did not work because of the impossibility of resolving the conflict between the three principles.

Moreover, while Belmont's report gave the go-ahead to the traditional, formulated by Hippocampus, understanding of mercy as good for the patient, it contained another purely utilitarian definition of this concept: work for the "good of society as a whole." The report even stated that citizens have a "serious moral obligation" to take part in experimental research for the benefit of society. Obviously, this contradicts Hippocrates' interpretation of mercy, and also tramples on the "time-honored" Nuremberg Code and the Helsinki Declaration, prohibiting doctors from experimenting on their patients, except in cases when it is done for the benefit of the patient. Belmont's second principle – fairness – was also defined according to the utilitarian approach as "impartiality": the equal distribution of the benefits of research and the associated burden on all segments of the population. This interpretation is very different from the classical definition of Aristotle, describing the fair treatment of people as individuals.

Even Belmont's third principle–respect for the individual–has been modified to suit utilitarian purposes. From the point of view of the traditional Kantian concept, respect for the individual is absolute. According to the new interpretation, the principles of morality apply only to people who are fully conscious, rationally thinking adults capable of independent actions. Based on this, people who are incapable of independent action – infants, patients in a coma or suffering from Alzheimer's disease – within the framework of the theory of bioethics were recognized as "non-persons" who do not have rights. From this it remains very close to the utilitarianism of "preference", formulated by an ethicist from Princeton University Peter Singer (Peter Singer), according to which animals have more rights than small children.

In the end, even the founders of the theory of bioethics have recently recognized that the Belmont principles pose very serious problems for doctors and researchers trying to follow the relevant recommendations.

Another reason for the formation of theoretical and practical chaos surrounding bioethics at the present time is that almost anyone can become an expert in this field. A few experts who are members of bioethics committees have academic degrees in this discipline, but most of the professors who teach them do not know the historical and philosophical roots of the subject they teach. The content of bioethics courses varies greatly and there are neither real professional standards nor an ethical code for bioethics specialists.

Against the background of all this criticism, bioethicists currently prefer to say that their field is more a form of "public lectures" than an academic discipline, a kind of "consensus ethics" born in the course of democratic discussion, and not as a result of the application of formal principles. However, if bioethics is only a "course of lectures", why are its practitioners considered "ethics experts"? And, as a rule, only they themselves come to a consensus, and not patients, their families and society as a whole.

Moreover, the three principles of bioethics – respect for the individual, justice and mercy – still appear in documents issued by many official bodies that make medical, social and political decisions. The list of government regulations based on the three principles of bioethics is truly endless.

Moreover, the principles of bioethics sometimes take completely unexpected forms. Peter Singer explains to Princeton University students that killing even a healthy human baby can be "ethical." The bioethicist from Baylor Medical College Tristram Engelhardt (Tristram Engelhardt) argues that "in the strict sense, individuals are moral objects that have self-awareness, act rationally, are capable of free choice and benefit. These include not only normal adults, but also, possibly, aliens with similar qualities." Bioethicist Dan Wikler from WHO states that "the state of the population's gene pool should be regulated by government policy, not the whim of individuals."

Bioethics, which is replacing traditional ethics before our eyes, has nothing in common with the traditional ethics of Hippocrates, which for almost two and a half thousand years required doctors to treat every human being as worthy of respect, regardless of the severity of his condition and age. It also has nothing to do with Catholic medical ethics, which continued the Hippocratic tradition in the light of the moral laws taught by the church. And it practically does not provide doctors and researchers with specific guidance according to which they could carry out their activities.

Perhaps in the near future, society will finally sort out the moral and practical confusion created by bioethics and find a worthy replacement for it.

Evgeniya Ryabtseva
Portal "Eternal youth" http://vechnayamolodost.ru based on the materials of Human Life Matters:
Bioethics: how did we get into this mess?16.04.2012