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Worldwide bioethics

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  1. 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

  2. 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

  3. 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

  4. 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

  5. Philosophy of medicine * Epistemological tradition • Medicine as natural science • Problem: medical synthesis • Response: • rigorous methodology • medicine as an art

  6. 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)

  7. Bieganski General practitioner in Czestochowa 113 publications Medizinische Logik. Kritik der artzlichen Erkenntnis (Wurzburg, 1909)

  8. Internal characteristics of medicine • Knowledge • Methods; models • Epistemological subject Halle (1926) Bernard (1865) Szumowski (1933)

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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)

  14. V. von Weizsacker 1926-1951 professor at Heidelberg University Gestaltkreis theory 1941 Klinische Vorstellungen 1947 Falle und Probleme 1951 Der kranke Mensch

  15. Internal and external characteristics of medicine: physician and patient as anthropological subject Buytendijk 1965 Von Weizsacker 1947 Christian 1952

  16. 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

  17. History is not over Anthropological tradition Epistemological tradition Psycho-social interventions Evidence-based medicine 1988 1976 2000 1997

  18. 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

  19. 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

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

  21. The contexts of bioethics Bioethics always has a socio-cultural context culture Developed within a specific culture bioethics society Applied within specific societies

  22. 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

  23. 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

  24. The implicit context of bioethics • The implicit context of bioethics: • Specific history • Specific agenda • Specific method

  25. 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

  26. 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

  27. 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”

  28. 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

  29. 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

  30. 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).

  31. 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

  32. 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

  33. 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…”

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. Globalisationof bioethics

  42. 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

  43. 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