An Overview of American Bioethics of Medical Code and Its Founders
In order to completely comprehend the expansive topic of bioethics, its root word, “ethics,” must be adequately defined. Ethics has been characterized by author and professor Albert R. Jonsen as “the rules, customs, and beliefs of a society: it also names the scholarly effort to articulate and analyze those rules, customs, and beliefs” (Jonsen 6). Jonsen continues to state that ethical study has developed into three general topics of investigation: “character, duty, and social responsibility” (6). Essentially, ethics attempts to determine the differences between right and wrong; good and bad, relative to and derived from the accepted values of a society.
Bioethics is an American word, probably coined by Van Rensselar Potter, a cancer researcher, in a book titled Bioethics: Bridge to the Future. The idea of bioethics; that is, creating an ethical code in relation to biological and medical practices, came into being during the 1960s (Basterra 26). Since ethics is a way to distinguish between good and bad actions, bioethics, at its core, is a way to distinguish between acceptable and unacceptable medical practices in relation to the commonly accepted standards of American society.
To think of bioethics as simply a code for a doctor-patient relationship is to not fully understand its depth and breadth. Bioethics deals with all components of medicine, including mental health, public health, research, and occasionally, even non-human subjects such as plants and animals (Basterra 28). It can be understood as the ethical scale of health care, against which all forms of medicine have to weigh their procedures. Some believe that bioethics goes so far as to attempt to define the ideal of the good life (Smith 5).
Medical ethics was not always a socially important topic. Prior to the turn of the twentieth century, doctors were not held in high esteem by the public. Many saw doctors as dangerous or selfish and even somewhat predatory on the ill. In fact, it was only during the Middle Ages in Europe that medical practices even became formalized. Before that, doctors did not have a specific niche in the world. The Middle Ages marked the first time that public authority began to realize the importance of specifically trained physicians. This, in turn, marked the establishment of universities to formally educate medical students (Jonsen 7).
The original code of ethics followed by most physicians is the well-known Hippocratic Oath. It was created prior to the birth of Christ in ancient Greece and remains today as a guideline to help doctors choose moral actions (Jonsen 6). It demands that doctors feed their patients and aid in their excretory processes if necessary, protect their patients from injury or further sickness, and refuse to administer death-inducing or injurious drugs, even if prompted by the patient (Smith 19). The Hippocratic Oath is no longer the only ethical code in medicine. It was during the 1900s that ethical regulations became more prevalent among American medical practitioners, and ethics as a school of thought really began to prosper (Jonsen 4-5).
After World War I, the United States created the US Public Health Service to protect the safety of humans being used in research. This led to the later development of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in the 1970s. Following this, in the 1980s, a President’s Commission for the Study of Ethical Problems in Biomedical Research came into existence (Drane x). James F. Drane offers a list of the considerations taken by these early commissions: “compensating for research injuries; deciding to forgo life sustaining treatment; defining death; implementing human research regulations; making health care decisions; protecting human subjects; screening and counseling for genetic conditions; securing access to health care; splicing life; whistle blowing in biomedical research” (Drane xi). Drane feels that this list displays the direction of American bioethics at its inception.
While the attention of this study is on American bioethics, ethical issues of this sort are far from solely domestic. The United States and Canada were the first to develop ethical commissions to work out solutions to bioethical problems. Shortly thereafter, Europe followed suit. More recently, Asian scholars have been studying the American, Canadian, and European traditions as a way to develop systems in their own home countries. Each of these countries has taken the originally American-driven field of bioethics and left their own cultural imprints on it, allowing bioethics to evolve into a global undertaking (Drane ix).
Bioethics is a reflection of American society in the late twentieth and early twenty-first centuries. “Medicine and the life sciences are to our period in history what religion and salvation were in medieval times” (Drane ix). Americans today know this to be true. People are constantly searching for the newest breakthroughs in medical technology. Bioethics has the responsibility of balancing between science’s ability to perform an action and the culture’s perception of whether or not that action is right. Americans face these types of questions daily. Scientists can physically perform fetal stem cell research, late-term and post-birth abortions, physician-assisted suicide, and cloning, but the American people and Legislation must wrestle with the morality of these actions.
Author Wesley J. Smith is a strong opponent of the current direction of American bioethics: “The ethics of health care are devolving into a stark utilitarianism, which has begun to undermine the ‘do no harm’ credo that has, for millennia, been the cornerstone of medicine” (Smith 3). Here, Smith is referencing the previously mentioned Hippocratic Oath, and implying that American ethics do not live up to the standards outlined in that sacred promise. According to his book, becoming a “bioethicist” is not even all that difficult or rigidly structured: “bioethics education may range from postgraduate university courses to seminars that take mere weeks or even days” (Smith x). Smith believes that bioethics has, to use his own terminology, “euthanized” Hippocrates (Smith19).
Traditional ethics were largely based on religious influence, but bioethics tends to stray from a theological base, in keeping with the current tradition of American secularization. Bioethics has been called relativist and some opponents accuse it of being utilitarian. It is advertised as purely rational and is sometimes viewed as rejecting faith (Smith 21-22). “Bioethics now stresses that morality and proper behavior are best determined through ‘rational analysis’ based on secular philosophical precepts” (Smith 22). Some argue that bioethics’ refusal of religion devalues human life (22).
Interestingly enough, however, bioethics as a subject was actually developed by three theologians. They are the Episcopal Minister Joseph Fletcher, the Methodist professor Paul Ramsey, and the Jesuit moral theologian Richard McCormick (Jonsen 40). Additionally, a non-theological follower of Fletcher, a man named Peter Singer, has also changed the face of bioethics. These men had ideas and ideals that stretched from one ethical extreme to the other. Boiled down to their bare minimums, Fletcher and Singer represented extremely liberal beliefs, Ramsey was the conservative, and McCormick rode the fence as a moderate (40).
Joseph Fletcher pioneered the bioethical evolution, which previously “was not a burning issue” (Jonsen 42). While Fletcher was a minister, he was not actually raised with an official religion to his name. Fletcher joined the Episcopal Church not so much out of a desire for God, but rather from a desire for social reform. His religious experiences did not dramatically alter his deep-set beliefs, however, and the writings that marked his later years often did not correlate with theology (42). Fletcher repeatedly disagreed with the Catholic Church, fighting their views on “sterilization, contraception, artificial insemination, and euthanasia” (Jonsen 43). Fletcher was a strong proponent of scientific and technological advancement, stating that medical science “gives us more control over health and life and death, and therefore raises man to a loftier moral level” (Jonsen 43). He also developed a list of criteria, including fifteen quantifiable qualities, which would effectively distinguish between people who possess humanhood, and those individuals who were only seen as subhuman. Within this list of criteria, Fletcher objectively examines minimum intelligence, self control, and memory, among other qualities, as factors influencing how “human” a person really was (Smith 11-12).
Smith has passionate criticisms of Fletcher, calling him a “radical utilitarian” (Smith 11). Smith explains that while Fletcher claimed to be caring towards his patients, since his “stated goal was to maximize human happiness and minimize suffering” (11), his real meaning has more to do with society and far less to do with the individual patient. Essentially, the human happiness to which he refers is the collective happiness of a society, and in order to benefit Fletcher’s greater good, he permits the wronging of a single individual, particularly when that individual is seen as subhuman (11). Fletcher has been known to speak coldly and cruelly of people he believed to be inferior: “Idiots, that is to say, are not human” (Smith 13). This attitude, according to Smith, is a rejection of Christianity’s belief of human equality in the eyes of God.
Fletcher found a follower in Peter Singer. Singer is “one of the world’s most influential contemporary utilitarian bioethicists/moral philosophers” (Smith 14). He takes the foundation created by Fletcher and draws it to its more extreme ends. He strips Fletcher’s fifteen criteria for personhood down to only two: self-awareness and the ability to reason (14). Following this vein, Singer is a proponent of infanticide and euthanizing the cognitively disabled, since neither infants nor the mentally retarded or comatose have the ability to reason and be self-conscious (Smith 15).
Singer has also put a spin on bioethics that would shock most ethicists: he believed that some animals could be considered human while some humans would have to be denied that very title. He was an opponent of discrimination among species, which he defined as the belief that humans and animals are not equal simply because they have different forms. In his work, Applied Ethics, Singer explains that he is “urging that we extend to other species the basic principle of equality that most of us recognize should be extended to all members of our own species” (Singer, Applied 216).
Since some people do not fulfill the criteria required for personhood (that is, reason and self-awareness), and some animals, particularly mammals, would fill these criteria, then those cannot logically be denied the title of personhood (Smith 14-15). In another work, In Defense of Animals, Singer has been quoted saying this: “If it is wrong to take the life of a severely brain-damaged, abandoned human infant, it must be equally wrong to the take the life of a dog or a pig at a comparable mental level” (Singer, Defense 8). This view is extremely radical, but strangely enough, Singer is not considered a radical. The situation is quite the opposite, actually, as he is very mainstream, teaching as a bioethics professor at the acclaimed Princeton University. Perhaps even more incredibly, he authored the essay on ethics for an edition of the Encyclopedia Britannica (Smith 14-15).
The second theologian mentioned by Jonsen is Paul Ramsey, a religion professor at Princeton University. Unlike Fletcher, Ramsey “did not hesitate to write as a Christian ethicist” (Jonsen 48). No one could accuse Ramsey of utilitarianism, for he “makes clear that, for him as a Christian ethicist, the good of the individual ought never be dominated by the good of society” (Jonsen 50). This claim is starkly different from Fletcher’s. Ramsey’s ethical work was based on his deeply religious Methodist background, and an underlying belief that all human life is sacred. Ramsey disagreed with Fletcher’s criteria for humanhood, because he felt that God alone judged value and worth, and no human could deem another unfit (Smith 14).
It has been thought that Ramsey’s most significant addition to bioethical development was his viewpoint on the care of a terminal patient. While it was common thought that the doctor must toil endlessly trying to cure the patient’s terminal disease, Ramsey contradictorily felt that there came a point when the doctor must step back and allow God to take His own course. At a certain point in the patient’s disease, Ramsey felt that the most important thing a doctor could do was simply facilitate the process of death and make that patient’s end of life comfortable and peaceful (Jonsen 51).
The third theologian that Jonsen credits with the creation of bioethics is Father Richard A. McCormick, a Roman Catholic theologian and a Jesuit. Since McCormick came from a strong Catholic background, he embraced the natural law thesis supported by his Church. This thesis claims that religious belief is justifiable by reason, and that all people have an inherent value (Jonsen 52). However, McCormick tempered his religious conviction by saying that “religious premises need not be brought explicitly into the discussion if this would hinder public discourse” (52). McCormick attempted to bridge the often daunting gap that existed between Catholic dogma and secular practices by tackling such heated topics as abortion rights and contraception through an attempt to “formulate an orthodox position that was liberal” (53). His main goal was to make religious doctrine seem reasonable and sensible to non-religious, reason-driven people (55).
McCormick found a friend and, more importantly, an excellent debate partner in Paul Ramsey. The two respected one another’s views, but were not afraid to verbally spar as a way to further define their individual beliefs. One topic of disagreement among these two existed within McCormick’s theory for the care of dying persons. McCormick believed that the quality of a human life can be defined by the person’s ability to maintain relationships with those around them, and when those fundamental relationships can no longer exist, the quality of that person’s life has declined to the point of making passive euthanasia, or the denial of treatment, permissible (Jonsen 53). Ramsey found this claim highly offensive because it rejects a solid belief in an inherent human value (53).
The four men mentioned above have made lasting imprints on American bioethics. While there are many others who have helped to mold the tradition, these men have blazed paths through it. It is clear, just from this brief overview, that bioethics is not a black-and-white topic. The followers of bioethics are exceptionally diverse in their beliefs, creating a large “gray” area in ethical study. Adding to this “gray” is the fact that bioethics covers a broad spectrum of topics and actions. Strong degrees of variation exist even within the field and those that practice and teach it. Some believe that religion should rule ethics while others take a more secular stance, claiming that only reason can dominate. All that can be solidly concluded is that bioethics is a topic worth evaluating, studying, and attempting to define, no matter how difficult that task may be. It seems that no matter which way the tide of bioethics turns, all involved can agree on one thing: it is truly a crucial aspect of American medicine in the twenty-first century.
