Bioethics

= Bioethics = toc

Definition
Bioethics is the application of ethics to the field of medicine, healthcare, biotechnology, and ecology. Bioethics is concerned with the moral implications and controversies of research, procedures, and applications in clinical practice. Bioethicists critically discuss and engage in a variety of medical related issues in order to create standards and raise new questions. Bioethicists can be considered safeguards in medicine, healthcare, biotechnology, and related fields. Bioethics does not provide absolute standards; these standards change or expand with time, culture, and new knowledge. Bioethics guides healthcare professionals’ and researchers’ moral duties and actions in the field.

There are four commonly accepted principles in bioethics: respect for //autonomy//, //non-maleficence//, //beneficence//, and //justice//.


 * //Respect for Autonomy// refers to, “self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice .” Respect for autonomy supports other specific actions such as telling the truth, respecting the privacy of others, protection of confidential information, obtaining informed consent, and helping others making important decisions.


 * //Non-maleficence// is the duty to refrain from causing harm. Non-maleficence underlies the medical maxim found in the Hippocratic Oath, “above all (or first) do no harm .” The principle of Non-maleficence includes do not kill, cause pain or suffering, incapacitate, cause offense, and deprive others of the goods of life.


 * //Beneficence// “asserts the duty to help others further their important and legitimate interests .” Simply, beneficence is to bring or create benefit. Under beneficence, one ought to prevent evil or harm, remove evil or harm, and do or promote good. The principle of beneficence also includes protecting and defending the rights of others, preventing harm from occurring to others, and removing conditions that will cause harm to others.


 * //Justice// underlies concerns about how social benefits and burdens should be distributed. In bioethics, justice is divided into three theories—utilitarian, egalitarian, and libertarian . A just distribution of benefits and burdens would be one that produces the most overall happiness; whatever does the greatest overall good will be considered just. Egalitarian theory of justice states persons should receive an equal distribution of certain goods. John Rawl’s “veil of ignorance” describes principles of justice as chosen by persons who “would not know their own race, sex, degree of wealth, or natural abilities. ” Hence, all persons are owed an equal opportunity. Libertarian conceptions of justice emphasize justice of any particular distribution of a good among a population depends not upon how much of the good each person has, but upon how the distribution came about . Distributive justice for libertarians is based on fair rules and regulations for how a person distributes benefits and burdens.

History
In 1927, Fritz Jahr, pastor, philosopher, and professor used the term bioethics in a published article called “Bio-Ethics: A Review of the Ethical Relationship of Humans to Animals and Plants”. He proposed a bioethical imperative regarding the moral obligations to humans and nonhuman forms of life. Additionally, he outlined the concept of bioethics as an academic discipline.

Bioethics gained academic and social prominence post-World War II with the discovery of Nazi human experiments. Technological medical advancements in organ transplantation, end-of-life care, and respirators then raised questions about life, death, and the role of medicine.In 1970, biochemist and professor of oncology, Van Rensselaer Potter broaden Jahr's original concept of bioethics to include moral philosophy that integrates biology, ecology, and medicine to express the social implications of science. Academic bioethics programs and centers started to emerge with philosophers developing ethical theories and applications for “real world” medical problems. The Hastings Center, a non-profit bioethics research institute, was founded in 1969. In 1971, the Kennedy Institute of Ethics was established by Georgetown University. The Kennedy Institute of Ethics is the most comprehensive bioethics library and is a renowned resource, publishing the Kennedy Institute of Ethics Journal, for the bioethics community.

In 1985 philosophers James Childress and Tom Beauchamp published the first American bioethics textbook, //Principles of Biomedical Ethics//. //Principles of Biomedical Ethics// established a dominant principlism approach in the field due to the four-principles approach. The four principles are respect for autonomy, non-maleficence, beneficence, and justice. The approach is also known as the Georgetown Mantra. Most bioethical dilemmas are analyzed using this principlism framework.

Over the past three decades, the field of bioethics has addressed and debated a diverse collection of human-related problems. The problems range from abortion, euthanasia, surrogacy, allocation of scare resources, to refusal of medical care for religious or cultural reasons, children’s medical rights, parenthood, gene sequencing, clinical trials, embryonic stem cells, reproductive rights, cloning, animal rights, climate change, and environmental obligations.

Case Study/Example
The case of Terri Schiavo, a Florida woman who was diagnosed in a persistent vegetative state (PVS) after suffering from a heart attack and imbalance of potassium, is an example of a bioethical issue related to end-of-life care, artificial nutrition and hydration, withdrawing treatment, decision making and legal guardians, and advance directives. The Schiavo case lasted fifteen years (1990 to 2005) and was a legal battle between Terri’s husband Michael, her legal guardian, and Terri’s parents, the Schindlers, about the removal of her feeding tube. Terri’s parents were against the removal of her feeding tube because they considered Terri cognitively aware with an ability to recover. Two doctors, Dr. Maxfield and Hammesfahr, believed Terri was in a minimal conscious state, not in PVS. In particular, Dr. Hammesfahr believed he could positively improve Terri with vasodilation therapy which gave Terri’s parents affirmation their daughter recover. Religion also was a factor in regards to the Schindlers keeping her on artificial hydration and nutrition. As Roman Catholics, they believed discontinuing their daughter’s artificial hydration and nutrition was euthanasia which violates the Church’s teachings.

On the other hand, Terri’s husband Michael, petitioned to have Terri’s feeding tube removed due to her end-of-life wishes. Although Terri did not have an advance directive (living will), she made oral statements regarding her health care wishes. Michael claimed she would not want to be kept alive on a machine in her current circumstance. Several other friends of Terri’s claimed she declared she would want to have the feeding tube removed. In Florida, an advance directive can be either a written or oral statement. If an oral statement is made, it must be heard by at least two people to be legally effective. However, Michael’s first petition to have Terri’s feeding tube removed was denied based on his credibility, his inheritance of Terri’s estate upon her death, and due to the conflicting accounts of Terri’s end-of-life wishes.

After the original petition denial in 1998, two years later, a trial was held to determine what Terri wishes would have been regarding life-prolonging procedures. Additionally the trial was to prove Terri was in a persistent vegetative state. The trial included testimony from 18 witnesses regarding her medical condition and her end-of-life wishes. The judge authorized to discontinue Terri’s artificial hydration and nutrition and found she was in a persistent vegetative state. Afterwards, the Schindlers filed an appeal to the removal of Terri’s feeding tube based on Florida’s definition of life-prolonging procedure. Under Florida law, oral feeding is not considered a life-prolonging procedure. However, the judge ruled she was not autonomously capable of orally ingesting nutrition and hydration to sustain life. Terri’s parents, then challenged, her husband’s guardianship due to Michael having another relationship with a woman but being legally married to Terri. The court denied removal of Michael as Terri’s legal guardian.

In 2001, Terri’s feeding tube was removed for the first time. The Schindlers filed a civil suit against Michael stating he lied about Terri’s wishes and physically abused her. Two days later, Terri’s feeding tube was reinserted. Several appeals were made by Terri’s husband for a reversal, but all were denied. During the year, the Schindlers remained active to remove Michael as her guardian and believed new medical treatment could restore her cognitive ability. In 2002, a hearing was held to determine whether new therapy treatments could restore Terri’s cognitive function. Three doctors testified there was no measurable brain activity and Terri was in PVS. Two doctors testified Terri could be treated, but had no scientific evidence and was unsupported by medical literature The courts continued to affirm Michael as Terri’s guardian.

For the second time, Terri’s feeding tube was removed. Within a week of the removal, the Schindlers appealed and Florida Legislature passed “Terri’s Law.” “Terri’s Law” gave Florida’s governor authority to intervene in the case and he ordered the feeding tube to be reinserted. During this time period, the court appointed a guardian at litem to represent the wishes and best interest for Terri. The guardian ad litem reported to keep Michael as her legal guardian. In 2005, “Terri’s Law” was found unconstitutional and for the third and final time Terri’s feeding tube was removed. President Bush tried to intervene, the Schindlers appeal to the U.S. Supreme Court, and several activist groups petitioned for intervention by the Department of Children & Families but all actions were denied. Terri died March 31, 2005. After the autopsy was performed, the coroner stated she had massive brain damage and her brain weighed less than half of a healthy brain; the brain damage was irreversible. Bioethical questions that arose from this case
 * What is personhood?
 * What are the duties of surrogate decision makers?
 * Is PVS a disability or life-threatening pathology?
 * Did Terri suffer during the process of dehydration?
 * Is artificial nutrition and hydration mandatory humane comfort care, or is it a medical intervention that can be refused, withheld, and/or withdrawn?

Medical anthropology questions that arose from this case
 * Is a patient diagnosed in a persistent vegetative state meaningfully alive ?
 * How does our health care system portray and manage death?
 * What does it mean to be human—locally and globally—and at what point do people cease to have identities?
 * What is the social and history account of people who are connected to life-support machinery?

Bioethicists used the case of Terri Schiavo to demonstrate the principle of autonomy with the importance of advance directives and end-of-life wishes. Bioethicists with public health officials urged people to create clear advance directives and assign a surrogate decision maker. Less focus was placed on the complex dimension of Terri’s personhood. Medical anthropologist used the Schiavo case to reflect a distinction between biologically “being alive”, legal “right to die”, and social personhood. Using ethnographic studies and critical perspectives, medical anthropologists helped reveal assumptions and miscommunications behind bioethical practices and policy recommendations. Medical anthropologists also drew connections between end-of-life medical technology practices and issues of health equity; compared to bioethicists which focus on the individual dilemma between prolonging the dying process or foregoing medical technologies.

Rather than bioethicists solely using the four-principles approach to analyze ethical dilemmas, an adaptation of medical anthropologist A. Kleinman’s explanatory model can help bioethicists explain end-of-life situations and treatments to surrogate decision makers, family members, and other interested parties. Integrating Kleinman’s explanatory model and four-principles approach in the Schiavo situation may have enabled Michael and Terri’s parents to make better informed decisions about her treatment in the end-of-life medical system.

Related videos
 * Terri Schiavo Case http://youtu.be/XxUuV-q2vy0
 * Medical View of Schiavo http://www.cbsnews.com/video/watch/?id=682090n
 * Sides of Schiavo Debate http://www.cbsnews.com/video/watch/?id=683351n

Related Terms/Pages
Biomedical ethics, medical ethics, health care ethics, medical law, philosophy of medicine, medical humanities, biomedicine, Arthur Kleinman

Online Resources

 * The Kennedy Institute of Ethics http://kennedyinstitute.georgetown.edu/
 * The Hastings Center http://www.thehastingscenter.org/
 * Markkula Center for Applied Ethics http://www.scu.edu/ethics/practicing/focusareas/medical/
 * National Institutes of Health: Bioethics Resources on the Web http://bioethics.od.nih.gov/
 * Presidential Commission for the Study of Biomedical Issues http://www.bioethics.gov/
 * American Society for Bioethics and Humanities http://www.asbh.org/

Dr. Ezekiel Emanuel, a bioethicist and fellow at The Hastings Center, on Bioethics media type="youtube" key="oF-lsp2drFo?version=3" height="300" width="400"

Further Readings
Davis, L. (2006). Life, death, and biocultural literacy. //The chronicle of higher education//, 52(18), B9.

Paola, F.A., Walker R., & Nixon, L. (2009). //Medical ethics and humanities//. Sudbury, MA: Jones & Bartlett Publishers.

Pence, G. (2010). //Medical ethics: Accounts of ground-breaking cases// (6th ed.). New York, NY: McGraw-Hill.

Kuhse, H., &, Singer, P. (2006). //Bioethics: An anthology// (2nd ed.). Oxford, UK: Blackwell Publishing.

Fadiman, A. (1998). //The spirit catches you and you fall down: A hmong child, her american doctors, and the collision of two cultures//. New York, NY: Farrar, Straus and Giroux.

Sargent, C., & Smith-Morris, C. (2006). Questioning our principles: Anthropological contributions to ethical dilemmas in clinical practice. //Anthropology Research// 1(1), 123-134.

Skloot, R. (2011). //The immortal life of henrietta lacks//. New York, NY: Crown Publishing Group.