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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

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slide1

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

slide2

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

slide3

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
slide4

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
slide5

Philosophy of medicine

* Epistemological tradition

  • Medicine as natural science
  • Problem: medical synthesis
  • Response:
  • rigorous methodology
  • medicine as an art
slide6

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)
slide7

Bieganski

General practitioner in Czestochowa

113 publications

Medizinische Logik. Kritik der artzlichen Erkenntnis (Wurzburg, 1909)

slide8

Internal characteristics of medicine

  • Knowledge
  • Methods; models
  • Epistemological subject

Halle (1926)

Bernard (1865)

Szumowski (1933)

slide9

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
slide10

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
slide11

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 actingthanknowing

slide12

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
slide13

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)
slide14

V. von Weizsacker

1926-1951 professor at Heidelberg University

Gestaltkreis theory

1941 Klinische Vorstellungen

1947 Falle und Probleme

1951 Der kranke Mensch

slide15

Internal and external characteristics of medicine:

physician and patient as anthropological subject

Buytendijk 1965

Von Weizsacker 1947

Christian 1952

slide16

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
slide17

History is not over

Anthropological tradition

Epistemological

tradition

Psycho-social interventions

Evidence-based medicine

1988

1976

2000

1997

slide18

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
slide19

Recent evolution of ‘medical ethics’

  • internal moralitydeontology
  • norms and values intrinsic to medical practice
  • - specific goals
  • - specific means
  • - context of subject-subject relationship
  • external moralitybioethics
  • norms and values in society and culture
slide20

Recent evolution – terminology

  • medical ethics doctor-patient relationship
  • healthcare ethics healthcare system
  • bioethics life in general
slide21

The contexts of bioethics

Bioethics always has a socio-cultural context

culture

Developed within a specific culture

bioethics

society

Applied within specific societies

slide22

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

slide23

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

slide24

The implicit context of bioethics

  • The implicit context of bioethics:
  • Specific history
  • Specific agenda
  • Specific method
slide25

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 discourse…both 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

slide26

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

slide27

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”

slide28

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

Bioethics

Body

Autonomous

subject

Provides principles to decide

  • Informed consent
  • Beneficence
  • Non-maleficence

control ownership

slide29

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
slide30

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).

slide31

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
slide32

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

slide33

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…”

slide34

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

slide35

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

slide36

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
slide37

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

slide38

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
slide39

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

slide40

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
slide42

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

slide43

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

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