Global bioethics

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Summerschool Health law and ethics Erasmus
University Rotterdam, July 2009
Global bioethics

• Two contexts of bioethics diachronic and
  synchronic
• History of bioethics development in time
• Social and cultural context of bioethics
  development in place
• The implicit context of bioethics
• specific history
• specific agenda
• specific methods

3. Need for a different history, a new agenda
and new methods 4. Basic reflection on what is
ethics? Ethics is per definition a global
perspective
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The contexts of bioethics
Bioethics always has a historical context
Bioethics
Philosophy of medicine
Medical ethics
Conceptual development
epistemological phase
anthropological phase
ethical phase
Broadening of perspective
External morality Professionalization Applied
ethics
Internal morality Deontology
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Development of bioethics

• Deontology INTERNAL MORALITY
• Emphasis on EXTERNAL MORALITY
• - religious traditions
• - secular humanism
• Professionalisation of bioethics
• Specific conception and practice of ethics
• applied ethics
• principlism

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• Ethics in the tradition of medicine European
  context
• Component of philosophy of medicine
• Hippocrates as founder of medicine
• Related to development of modern medicine (19th
  century) question what is medicine?
• - science epistemology
• - life science anthropology
• - science of human beings bioethics

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Philosophy of medicine Epistemological
tradition

• Medicine as natural science
• Problem medical synthesis
• Response
• rigorous methodology
• medicine as an art

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• Epistemological tradition
• (second part 19th century first decades of 20th
  century)
• Lvov University school of Twardowski
  (1866-1938)
• Polish medical philosophers
• Tytus Chalubinski (1820-1889)
• Edmund Biernacki (1866-1908)
• Wladyslaw Bieganski (1857-1917)
• Zygmunt Kramsztyk (1848-1920)
• German physician-philosophers
• Richard Koch
• Georg Honigmann (1863-1930)

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Bieganski General practitioner in
Czestochowa 113 publications Medizinische Logik.
Kritik der artzlichen Erkenntnis (Wurzburg, 1909)
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• Internal characteristics of medicine
• Knowledge
• Methods models
• Epistemological subject

Halle (1926) Bernard (1865) Szumowski (1933)
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• Model of medicine are the sciences
  (physics,chemistry,biology)
• medicine is growing rapidly (pathology,
  fysiology, bacteriology)
• enormous quantity of knowledge
• specialization
• fragmentation and incoherence
• Problem unity and synthesis of medical knowledge

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• Problem of medical synthesis
• Solution 1 rigorous method of observation and
  experiment objectivity and preciseness
• Biernacki (The essence and limits of medical
  knowledge, 1898)
• Radical separation of theory and practice of
  medicine
• science of disease vs art of healing
• diagnosis treatment
• Usual view
• priority given to accurate diagnosis in reality
  disease units
• treatment is only rational if the diagnosis is
  clear

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Problem of medical synthesis Solution 2
questioning the status of the epistemological
subject recognize its subjectivity medicine as
an art Koch Medicine is Heilkunst Honigmann
Being a physician mean being a whole human
being Medicine is concerned more with acting
than knowing
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Philosophy of medicine Anthropological tradition

• Medicine as life science
• Problem subject of the patient
• Response
• introduce the subject into medicine
• doctor-patient relationship is crucial

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• Anthropological tradition
• (from 1920s to 1960s)
• German physician-philosophers
• Richard Siebeck (1883-1965)
• Viktor von Weizsacker (1886-1957)
• Viktor von Gebsattel (1883-1976)
• Ludwig Binswanger (1881-1966)
• Erwin W. Strauss
• Dutch medical scientists
• F.J.J. Buytendijk (1887-1974)

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V. von Weizsacker 1926-1951 professor at
Heidelberg University Gestaltkreis theory 1941
Klinische Vorstellungen 1947 Falle und
Probleme 1951 Der kranke Mensch
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Internal and external characteristics of
medicine physician and patient as
anthropological subject
Buytendijk 1965 Von Weizsacker 1947 Christian 1952
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• The anthropological tradition
• rejection of Cartesian dualism
• any demarcation of body and mind is artificial
• no distinction between an objective, real world
  and an isolated, individual subject
• medicine as science of the human person
• if medicine is not objective, it is impossible
  if medicine is only an objective science, it is
  inhuman
• comprehensive understanding of disease
• disease has meaning it expresses that existence
  is threatened being ill is a way of being a
  human person it is not blind fate but it is
  important what we make of it

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History is not over
Anthropological tradition
Epistemological tradition
Psycho-social interventions
Evidence-based medicine
1988
1976
2000
1997
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Philosophy of medicine Ethical tradition

• Medicine as normative science of life
• Problem preserve human values
• Response
• social significance of health care
• from internal to external morality

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• Recent evolution of medical ethics
• internal morality deontology
• norms and values intrinsic to medical
  practice
• - specific goals
• - specific means
• - context of subject-subject relationship
• external morality bioethics
• norms and values in society and culture

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• Recent evolution terminology
• medical ethics doctor-patient relationship
• healthcare ethics healthcare system
• bioethics life in general

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The contexts of bioethics
Bioethics always has a socio-cultural context
culture
Developed within a specific culture
bioethics
society
Applied within specific societies
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New interest in ethics and healthcare
1. Technological and scientific development -
resuscitation - medical research - scandals
(Tusgekee) 2. Demography ageing chronic
illness 3. Economic restraints - dialysis (1967
Seattle) 4. Culture individual autonomy 5. Moral
uncertainty decline of grand narratives
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The contexts of bioethics
diachronical context
bioethics
synchronical context
But in the development and application of
bioethics context usually ignored or regarded
as background or of secondary importance
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The implicit context of bioethics

• The implicit context of bioethics
• Specific history
• Specific agenda
• Specific method

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The implicit context of bioethics
The implicit context of bioethics Specific
history
Albert Jonsen The Birth of Bioethics, 1998
Bioethics has grown both as a discipline and as
a public discourseboth draw their vigor from the
surrounding ethos of American culture
(p.372). International bioethics began more than
a decade after the birth of bioethics in the
United States (p.378).
Book with 12 chapters and 415 pages only the
last chapters deals with bioethics outside the
USA and only 6 of the 26 pages in this chapter
deal with non- American issues
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The implicit context of bioethics
The implicit context of bioethics Specific
history
Crucial events 1969 Establishment of the
Institute of Society, Ethics and the Life
Sciences (Hastings Center) 1970 Society for
Health and Human Values 1971 Creation of the
Joseph and Rose Kennedy Center for the Study of
Human Reproduction and Bioethics at Georgetown
University 1975 National Commission for the
Protection of Human Subjects of Biomedical and
Behavioral Research 1978 Encyclopedia of Bioethics
Bioethics the systematic study of the moral
dimensions including moral vision, decisions,
conduct and policies of the life sciences and
health care, employing a variety of ethical
methodologies in an interdisciplinary setting
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The implicit context of bioethics
The implicit context of bioethics Specific agenda

• focus on advanced technologies
• emphasis on individual decision-making
• focus on problems of the rich
• commercialisation and commodification of
  science and technology

Northern agenda
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The implicit context of bioethics
The implicit context of bioethics Specific method
Applied ethics Set of principles to solve
special category of problems Particular image of
man Autonomous subject in control of bodily
mechanisms and rationally deciding what to do
Body
Bioethics
Autonomous subject
Provides principles to decide

• Informed consent
• Beneficence
• Non-maleficence

control ownership
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Global bioethics

• What is bioethics?
• North-America and Europe
• related to medicine, health care, medical
  technology
• Latin America
• related to human dignity, human rights, social
  justice
• Asia
• related to nature, cosmos, harmony

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Global bioethics
A different history
Potter (1911-2001) cancer researcher in Wisconsin
first use of the term bioethics in 1970 We
need a new discipline, a science of survival, to
deal with the priority problems jeopardizing the
survival of humankind population, peace,
pollution, poverty, politics and progress
Van Rensselaer Potter Bioethics. Bridge to the
Future, 1971.
Bioethics combining the science of living
systems, biological knowledge (bio) and knowledge
of human value systems, philosophy (ethics).
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Global bioethics
A different history
William James concepts do not represent anything
but they lead to something they are like
bridges, bringing us from one experience to
another.
Potter (1911-2001)

• Bioethics is like a bridge
• Bridge between present and future
• Bridge between science and values
• Bridge between nature and culture
• Bridge between man and nature

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Global bioethics
A different history
1. Bridge between present and future

• Focus on the future is necessary for survival
• The future is in danger, because of separation
  between two cultures in modern western society
  common culture is lost (1959 Snow The two
  cultures) the sciences and humanities no longer
  communicate
• Systematic study of future of human civilization
  required, overcoming the gap between knowing and
  doing, values and facts
• The future cannot take care for itself human
  beings should assume their responsibility

Bioethics as new interdisciplinary approach with
focus on long-term interests and goals that
safeguard the survival of humanity
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Global bioethics
A different history
2. Bridge between science and values

• The priority problems of humankind are
  multidimensional we need to combine all
  categories of knowledge
• The goal of the new discipline is wisdom wisdom
  is the knowledge of how to use knowledge for
  human survival and for improvement in the human
  condition
• Wisdom is action-oriented, a guide for action
• There is always uncertainty we need continuous
  testing and assessing we can only proceed with
  humility

Bioethics is a new discipline that combines
biological knowledge with a knowledge of human
value systems in an open-ended biocybernetic
system of self-assessment
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Global bioethics
A different history
3. Bridge between nature and culture

• biological and cultural evolution should be
  linked many analogies and similarities between
  the two processes both are directed towards
  survival
• but progress will not take place automatically
  major issue is the direction in which movement is
  made, the goal of evolution
• species survive because they are adapting to
  their environment but the environment is
  continuously changing. Adaptability is the
  essential ingredient for progress
• science can guide and direct these evolutionary
  processes, anticipating changes in the
  environment
• our present actions are influencing and creating
  environments that future generations will face
• our species is the only one that is conscious of
  the process of evolution and that can take steps
  to guarantee survival

Bioethics as responsibility for the future and as
a way to engage science to accomplish cultural
evolution
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Global bioethics
A different history
4. Bridge between man and nature

• The natural environment of humankind is not
  limitless
• Aldo Leopold three stages in the development of
  ethics
• relations between individuals
• relations between individual and society
• relations of human beings with their
  environment
• Potter the elaboration of bioethics will be the
  realization of this third stage of ethics
• Ethics should be enlarged or extended, including
  not only individual and social issues but also
  environmental issues
• This requires that we reflect on the long-term
  consequences of science

Bioethics is a new ethics that takes into account
the new science of ecology and regards human
beings as interrelated with their environment
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Global bioethics
A different agenda

• Reflection on advanced technologies
• What is the development of science long-term
  impact impact on the environment, impact on
  future generations impact on global scale
• Broader approaches to health technology
  assessment
• Addressing gaps
• 90/10 gaps (WHO)
• Focus on basic health care needs
• Focus on problems of world population
• Pandemics
• Preventing misuse and abuse
• Dual use bio-terrorism
• Biosecurity
• Publication ethics
• Ethics and humanitarian assistance
• Corruption integrity professional responsibility

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Global bioethics
A different method
New concepts - common heritage of humankind -
social responsibility New methodologies -
interpretative ethics Importance of bioethical
infrastructure - bioethics committees vs
research ethics committees - legal frameworks -
ethics education - structures of public debate
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The context of bioethics
Basic reflections of what ethics is
Background the human condition is precarious

• differences in health, life expectancy, quality
  of life
• poverty
• violence, war, insecurity
• hate, discrimination, repression, corruption

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How to ameliorate our condition?
medical interventions

• differences in health, life expectancy,
  quality of life
• poverty
• violence, war, insecurity
• hate, discrimination, repression, corruption

economic measures
social policy
political arrangements
ethics
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What is the contribution of ethics?
moral discourse
increase and widen our sympathies
Ethics is essentially global
Specific vocabulary
Justice Equality Peace Dialogue Dignity Respect
with specific goals

• duties
• values
• ideals
• principles

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Globalisationof bioethics
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Globalisationof bioethics
1970s USA/UK/Netherlands
national
1980s France, Argentina
1990s Hungary, Bulgaria, Japan
regional
Council of Europe, European Commission
European Society for Philosophy of Medicine and
Health Care
continental
PanAmerican Health Organisation
Arab League Educational, Cultural and Scientific
Organisation
UN system UNESCO, WHO, FAO, WIPO, UNU, ILO
global
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Globalisation of bioethics
Ethics committees
Ethics laws/ regulations/ guidelines/ codes
Ethics policies
Ethics textbooks/ manuals
Ethics journals
Ethics research
Ethics education
Ethics centers/ units/ departments
Ethics experts