When the first edition of The Basics of Bioethics appeared in the final weeks of the twentieth century, no current, brief survey existed that was a suitable introduction to the field. Textbooks, anthologies, casebooks, and single-authored works were available to provide perspective on the issues of bioethics, but there was no introduction to the field of bioethics under several hundred pages in length. The first edition served that purpose. It was intended for health professionals and lay people who wanted an introduction to the issues in a relatively small edition suitable for use in short courses in schools of medicine, nursing, and the other health professions; continuing professional education; undergraduate courses in philosophy, religion, and the social sciences; and in adult education.
Since the publication of the first edition a great deal has happened in the fast-moving field of bioethics. We have cloned the first human being, isolated stem cells with the potential for generating new genetically matched organs for transplant, formulated new patients' bills of rights, and issued a major revision of the international code for human subjects research. We have also seen the first case of killing a patient with genetic experimentation, seen rationing of health care become common, and (in the Netherlands) formally authorized physician killing of patients for mercy without fear of prosecution.
We have also seen some progress in the slower-paced discipline of formal ethical analysis. More agreement exists on the need to move back and forth at different levels of ethical analysis--moving from bedside case discussion up to statements of rules and codes and on up to the more abstract levels of normative ethics dealing with ethical principles and virtues. There is more agreement now that it matters less where one starts roaming through the different levels of ethical discourse and more agreement that all levels should be encountered before an ethical conclusion is firm. There is more interest in alternative approaches--in an ethic of virtue to supplement an ethic focusing on actions; more interest in something called "care theory" and in feminist approaches to bioethics.
In short, there is a need for a new edition, still at the introductory level but updated both with new developments in clinical medicine and in ethical analysis. This second edition adds two completely new chapters. The first chapter is designed for the reader who has not been exposed to formal ethical theory. It provides a "map" of the ethical terrain, a schema outlining four levels of moral discourse or ethical analysis. This scheme is summarized in the new diagram that appears on the inside of the front and back covers of the book. On this diagram virtually every dispute in bioethics can be mapped.
Some disagreements exist at one of the levels. For example, much of bioethics in the late decades of the twentieth century involved controversies over which ethical principles prevailed. This can be seen in the central shaded boxes at the level of "Normative Ethics" in the diagram. Other disputes involve questions of whether to resolve moral controversies by working at this normative level or at some other level (by applying a code of ethics or by focusing on an individual case, for instance). Portions of this central diagram of the "Four Levels of Moral Discourse" is reproduced in various chapters when the ethical controversies of bioethics are presented in greater detail. I hope this diagram will help to clarify, especially to the reader not trained in ethical analysis, exactly what the basis is for moral disagreements in the field of biomedical ethics.
The second completely new chapter is the last one, "The Virtues in Bioethics." Discussion of the virtues of the physician are as old as the profession of medicine itself. The Hippocratic Oath touted the virtues of "purity" and "holiness"; the ancient Confucian medical ethical texts advocated "compassion," "humaneness," and something mysteriously called "filial piety." Perhaps because these virtues sounded so platitudinous, they more or less disappeared from bioethics in the early years of its renaissance in the last decades of the twentieth century. However, stimulated in part by new developments in feminist bioethics and nursing ethics, a new interest in the virtues of the health professional has emerged. And the virtues have become more controversial. It is now of real substantive importance whether a physician or nurse should give primary attention to being "caring" or "benevolent." Older virtues have, at least in some bioethical approaches, become more debatable, sometimes, as in the case of Percival's virtue of "condescension," even offensive. Chapter 11 presents the role of virtue theory in the new bioethics.
In addition to these two new chapters, material from various places in the first edition on how to reconcile conflicts among ethical principles and how to move from the level of ethical principles down to the individual case has been gathered together in Chapter 10 so that a more organized and systematic treatment of these crucial problems in bioethics can be provided. All the other chapters have been updated, revised, and edited to eliminate unneeded material and bring the discussion up to the moment. The result is, I hope, a current but concise introduction to bioethics.
Law has in a sense taken over in the practice of medicine. In a way that is too bad. Law is obviously important, but it's not all there is to medicine. Medicine is a profession, and, traditionally, one of the chief characteristics of a profession is that it has its own ethic. At least until recently self-regulation was the definitive sign that medicine was a profession; it didn't engender much controversy. In this volume, we look at the controversies over selfregulation in medicine and some of the ethical problems that emerge.
I have taught medical ethics in four medical schools and in several undergraduate and graduate schools. Starting in 1970 I developed the first medical ethics program at the College of Physicians and Surgeons of Columbia University while on the staff of the Hastings Center. Since almost that time I have been doing a one-week version of the same material at the seven-year medical student program at Union College and Albany Medical College, and since 1980 I have been teaching at Georgetown University. Finally, for the past fifteen years I have taught a one-week introduction to medical ethics for the St. George's University School of Medicine in Grenada. I have also taught undergraduates and graduate students at Vasser, Brown, Dartmouth, and Georgetown. In those contacts with thousands of students over the years these chapters have taken shape. Often what was needed was a serious, balanced examination of the issues of biomedical ethics in a format that could be covered in a week or two rather than a semester or year. This volume is designed to serve that purpose.
The approach is systematic. Rather than discussing issue by issue every topic in the current bioethics literature, we begin with an introduction to ethical theory and a brief history of biomedical ethics. We ask in the first two chapters why the old Hippocratic Oath is in trouble and what the alternatives are. In Chapter 3 we discuss what may first seem like a disparate collection of topics: abortion, the definition of death, and the welfare of nonhuman animals. We shall see that they all raise the question of who has moral standing and why. Next, in Chapter 4, we discuss the ethics of benefitting patients. That may sound like a platitude. It seems like it is obvious that the health professional's goal must be to benefit his or her patient. However, we shall see that benefitting patients is increasingly controversial morally. There are in fact many situations in which physicians decide not to provide benefit, at least if they follow more contemporary ethical thinking, rather than the traditional Hippocratic Oath.
In Chapter 5 we deal with the major challenge to the Hippocratic perspective, what is often referred to as the ethics of respect for persons or the ethics of liberal political philosophy. This includes an alternative set of ethical principles that is now being used in place of the Hippocratic Oath. We will be talking about rights of patients and rights of physicians, particularly in terms of fidelity, autonomy, and veracity, and why these principles are causing big problems for health professionals.
Chapters 6 and 7 deal with one of the hottest issues in medical ethics, the care of the terminally ill. Traditional medical ethics of the past hundred years was committed to preserving life, sometimes preserving it at all costs. Life, at least human life, was deemed sacred or ultimately valuable. We shall see that this notion is enormously complex. Euthanasia has variously been taken as referring to active killing for mercy, the forgoing of medical treatment even though the result is likely to be death, and sometimes simply any good death. In Chapter 6 we will begin to examine these issues by dealing with competent patients. Then in Chapter 7 we will grapple with what the real complications are today--dealing with incompetent patients who are terminally ill and considering if these patients would be better off if they were not treated so aggressively.
We then turn, in Chapter 8, with the issue of medical ethics for the twenty-first century, the social ethics of health care, including the morality of allocating scarce medical resources as well as other conflicts such as medical research pitting the individual against the interests of society. We, shall examine the role physicians have to play as society's agent, or gatekeeper, allocating a pie that is too small to give everyone all the health care he or she needs.
Next, in Chapter 9, we step back a bit from the principles of normative medical ethics to ask about an underlying basic value commitment that shapes positions taken on just about every issue in medical ethics: whether humans are going too far in attempting to remake their own basic nature. Here we will focus on genetics, stem cell research, and birth technologies--genetic screening and engineering as well as in vitro fertilization and surrogate motherhood--as the area of medicine that poses this question of fundamental value orientation most dramatically.
Chapter 10 provides the opportunity to examine what should happen when these ethical principles and value orientations conflict as well as how we should move up and down the ladder of the levels of moral discourse from principles down to codes of ethics and to the individual case or--if one is more clinically oriented--from case up to the level of principles and other questions of normative ethics. Finally, in Chapter 11, we discuss the virtues portion of a normative ethic for medicine.
These eleven brief chapters will give the reader a general framework by which the full range of ethical issues in health care can be addressed. It is not that every topic in contemporary medical ethics will have been examined explicitly; that would be impossible in a volume of this size. Rather the goal is to understand the basics of how different approaches to ethics come into play in the biomedical world and why the historical framework of the Hippocratic Oath is increasingly seen as outdated and wrong morally. We will end up with a set of principles that are alternatives to that tradition that will address the major themes of health care ethics of today: confidentiality, informed consent, honesty in communication between patient and provider, the care of the terminally ill, and the allocation of scarce resources. We will have some sense of who has moral standing and why that question is crucial not only for the abortion debate and deciding when an individual is dead, but also how animals are treated in research, education, and other spheres of life. We will have some understanding of whether the human's role is that of co-creator of a new genetic and reproductive future or is better seen as one of proceeding more humbly with fear and trembling, afraid we may be playing with Promethean fire when we attempt to play like one of the gods. We will see how various people have resolved conflicts among ethical principles and among different theoretical approaches to bioethics.
A large number of people have played a role in both the first and second editions of this book. I have tried out many of the ideas and chapters on the Scholars of the Kennedy Institute of Ethics and other colleagues in the field of biomedical ethics. I continue to acknowledge the help of many people in the production of the first edition. David Smith and Cynthia Cohen each provided careful and helpful readings of parts of the manuscript. Kathy McMahon, a former Institute staff member, played a major role in typing and editing early versions of these chapters and Julie Eddinger has provided administrative assistance. Kier Olsen, David Singly and Ashley Fernandes have provided very helpful research assistance.
