Bioethics

2004
Vincent Guss, Ethics Consultant and Director of Pastoral Care, Inova Alexandria Hospital

 Moral perplexity is evident in the practice of medicine with the awesome advance of biomedical and genetic research as attended by the resultant development of biomedical technology. There is renewed interest in promoting the rights and articulating the moral duties of health care professionals, researchers, and patients. Health care is delivered in the context of a multi-cultural and pluralistic society. These factors are largely responsible for the contemporary prominence of bioethics as a sub-discipline within the more general discipline of the study of morality known as "descriptive ethics." The goal of descriptive ethics is to attain empirical knowledge about morality. The practitioner of descriptive ethics is dedicated to describing existing moral views, and subsequently, explaining such views by advancing an account of their causal origin. Bioethics provides an approach for reflection, consultation, and articulation of the moral dilemmas that arise in the practice of medicine in an increasingly complicated institutional setting of hospitals and other healthcare delivery systems.

There is a myriad of moral questions that arise in the context of health care delivery that present dilemmas that bioethics reflection address. For example, is a physician always morally obligated to tell a terminally ill patient that he or she is dying? Can a breach of medical confidentiality ever be morally defensible? Can euthanasia ever be morally justified? What ethical considerations must be addressed in surrogate motherhood and in vitro fertilization? Should research into cloning technology and genetic manipulation be promoted? When does aggressive medical care become futile treatment? Bioethics is a type of applied ethics that includes deliberation by all parties significantly affected by health care professionals, involving the perspectives and participation of all professionals representing pertinent disciplines, including medicine, nursing, pastoral care, social work, law, and other allied health professions.

In the past, the practice of medicine was largely confined within the bounds of the physician-patient relationship. However, now hospitals and other healthcare institutions are intimately intertwined with physicians and allied healthcare personnel in the delivery of medical care. There as been an extension of the consumer rights movement within the health-care arena, a heightened emphasis on the legal requirements of informed consent, and an accompanying escalation of concern within the healthcare community about legal liability. As a result, health-care professionals and institutions find it necessary to pay closer attention to the interplay among medical, legal, spiritual, social, and cultural ethical considerations. Moreover, as a society, there has come an increasing consciousness of issues of social justice. There is much consideration of "rights" to health care and the confrontation of the numerous problems of allocation of health care resources.

One prominent approach to addressing bioethical problems has been articulated by Tom L Beauchuamp and James F. Childress in Principles of Biomedical Ethics, originally published in 1979. The basic idea is that problems can be appropriately identified, analyzed, and resolved by reference to a set of four principles tailored specifically to be relevant to the field of bioethics: autonomy, nonmaleficence, beneficence, and justice. The principle of autonomy requires that health-care professionals respect and promote the effective exercise of patient choice, assuming informed consent. When patient choice is not possible, then consideration of the patient's values must be weighed heavily through "advanced directives" (if they exists) and the input of surrogate decision makers and/or significant others in the patient's life presumably reflecting those values, desires and "best-interest" of the patient. The principle of nonmaleficence requires that health-care professionals not act in ways that entail harm or injury to the patient. The principle of beneficence requires that the health-care professional act in ways to promote the patient welfare. The principle of justice requires that social benefits and social burdens be distributed in accordance with the demands of fairness and effective utility of those resources.

Whether one utilizes a "principle-based" approach to bioethics, or takes other competing approaches, it is important to be able to define the parameters, meaning, and substance of those principles by identifying the values of the patient, family members, health care staff, the institution, and the community itself. These values are influenced by philosophy, culture, religion, and historical backgrounds of all significant persons and institutions involved. The task of bioethical reflection is to resolve ethical problems associated with medicine and biomedical research in the context of dialogue with those of differing and possibly conflicting ethical values and perspectives.

How does that "ethical resolution" occur? Is a particular medical practice right or wrong? Is it morally justifiable? In applied bioethics, the concern is not so much to establish the "correct" ethical or moral view. The mission is not even necessarily aimed at achieving "consensus" or "agreement" to the proper way to proceed with medical treatment. The goal is to provide a process, a forum, a way of describing a range of ethical options for health care that is reflective of the values and moral perspectives articulated by those significantly affected (primarily the patient and/or research subject and/or the community).

The enterprise of bioethics reflection often occurs in the context of a hospital's interdisciplinary bioethics committee or institutional review boards. It can be provided through the employment of clinically trained bioethics consultants. It can be evident through public forums, the media, and the bioethics literature. Representative from all the relevant health care disciplines and medical specialties, from faith communities and specific cultural groups, from government, social service agencies and the law, and from lay-people in the community itself must be involved to give a holistic and balanced character to the quality of the reflection and consultation. Bioethics has at it's heart the underlying premise of respect for human dignity, and as such, respect for the varying points of view, values, and philosophic, spiritual, and cultural perspectives of every one affected by the health-care decisions that are made to contribute to the well-being of the patient and of the whole community. When this form of "applied ethics" is operative when health-care decisions are being made, medical outcomes are generally improved and those affected by those outcomes are more satisfied because their input into making such decisions has been enhanced and valued