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Biomedical Ethics: Contexts, Challenges Problems, and Issues*,

NATIVIDAD DOMINIQUE MANAUAT. MA

OBJECTIVES

After reading this chapter, students are expected to

1. Describe Bioethics, its scope and relevance to the fields of Philosophy and Life Science,

2. Explain how context is vital in identifying fundamental bioethical issues and problems,
especially in the Philippine setting, and

3. Identify the key issues, as well as ethical and moral decision-making strategies, and dominant
ethical principles in bioethical inquiry.

“What ought I do?” This is one of the questions that Immanuel Kant posed as fundamental
in the field of philosophy. In pursuit of wisdom, the ethical and moral self seeks not only to “know”
things in the abstract but also to be able to apply this knowledge in the concrete level ,i.e., her
everyday life, particularly when moral decision-making is involved. Values, good or bad, and what
is morally right or wrong, falls in the purview of normative ethics, as it seriously seeks to establish
which moral views are justifiable, and thus ought to be accepted.

“Biomedical ethics,” also commonly referred to as “bioethics” are two terms that are often
used interchangeably. The latter suggests a wider scope transcending the practice of medicine to
encompass not only the professional activities of medical practitioners. (i.e., doctors, nurses, and
other health professionals), but rather in the context of the innumerable and myriad activities
involved in the health care profession, including research and development (Mappes 2001).

Bioethics is a neologism coined by the first “original bioethicist,” Van Rensselear Potter1
who saw it as a necessity in establishing “an ethic that can incorporate our obligations, not just to
other humans, but to the biosphere as a whole” (Potter, kuhse and singer 2006). His original
concept of the new discipline as an “integration of biology and values was designed to guide human
survival” where this primarily involves “the incorporation of ecological concepts and values in
medicine and health..."2 While medical ethics makes up a huge and central part of bioethics, it
transcends the spheres of medicine and health care to encompass fields including environmental
ethics, ethical issues of sexuality and reproduction, and “genethics” or ethics of genetic choice and
manipulation (Harris 2001). Moreover, it is also concerned with the ethics involved in scientific
research and experimentation, as well as the ways by which science is conducted, regulated and
controlled.
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Etymologically, it also means “the ethics of life” (Shannon 1997; Timbreza 1993). As an
applied ethics 3 however, bioethical concerns impact not only the health professional but more
importantly, the laypersons as well, because although not everyone finds herself practicing this
profession, we are all at one time or another, patients, requiring the service of the health
professional. The health and well-being of each one, as we seek our purpose as beings-in-this
world, requires awareness of being a vital part of the ecology. As an applied normative (Mappes
and Degrazias 2001), bioethics is thus tasked as professional ethics to seek resolution to ethical
problems associated with the practice of medicine, the pursuit of medical research, and related
areas of concern.

As applied, bioethics is interdisciplinary in the sense that it approaches issues and concerns
with consideration of different fields such as medicine, law, public policy, sociology and
occasionally, even religion. However, despite this overlapping discipline, it remains under the
rubric of philosophical ethics, where decision-making is grounded on philosophical precepts, as
ethical theory and moral philosophy are both referring to what Beauchamp and Childress call,
“philosophical reflection on morality’s nature and function...(where) the purpose of theory is to
enhance clarity, systematic order, and precision of argument in our thinking about morality.”

REASONING THROUGH MORAL DILEMMAS

The questions of Immanuel Kant and how to live well had been earlier formulated by
Aristotle as he asked: “what kind of life is to be thought of as fine, fortunate, or even enviable?”on
the abstract, this query opens wide into the general question of how to pursue happiness, but on
the concrete level, moral dilemmas compel us to face certain situations by carefully and rationally
choosing our actions.

An earlier chapter in this book (see Timbreza’s “Ethics”) discusses in great detail the many
different ethical theories. Placed in the bioethical context these theories have different approaches
to the question of what is right, good, virtuous, or just. Ethical principles are important for making
sound ethical decisions in as much as they convey our most deepley-held convictions as they also
carry within them a moral force, where part of the solutions we seek involved upholding these said
principles.

When one is faced with a moral dilemma, she is in a quandary and is unlikely to recall
which philosopher said what but it is imperative to give justification for what we deem as the right,
good, virtuous, or right thing to do. Each situation is unique, and while there are certain factors
that simply could not be ignored about each case, philosophical reflection is valuable in aiding us
to come up with an answer to those classic questions involving what “ought” to be done. While
an author came up with lengthy and very detailed strategy 4 for ethical decision making (Pfeiffer
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and Forsberg 1992) involving a thorough and step-by-step process of careful deliberation, one
could reduce the process to just two simple yet important steps.

Consider the following judgment as it applies to the case of gaining access to

contraceptives 5 . In the city of manila, former Mayor Lito Atienza signed Executive Order 003
(February 2000) which proclaims that his office “upholds natural family planning not just as a
method but as a way of self-awareness in promoting the culture of life (italics mine) while
discouraging the use of artificial method of contraception.” Because of this order, which is still
being implemented by his successor, the people of Manila are deprived of their right to valuable
information and access to options that they could otherwise choose.

Value 1. it is wrong to discourage your constituency by denying them access to a wide

range of reproductive health care services.

While legislation always carries within it an agenda to promote the general welfare and
well being of the people (principle of beneficence), freedom of choice is also a given. In bioethics,
freedom of choice is the same as “informed consent” where patients are free to choose from among
many possible options with full knowledge and information.

Now, in order to determine the likely truth or falsehood of such a judgment, one mus
scrutinize the evidence both for, and against it. To cite and evaluate such substantiation is to ensue
within the discipline of applied ethics.

Principle 1. A person in power ought not impose his/her own personal beliefs (religious or
otherwise) in legislating and enforcing rules that affect his or her constituency.

In this case then, the person in authority is denying his constituents the freedom to make
that choice by “discouraging” and keenly withholding information that runs counter to his own
beliefs (viz. where use of “the culture of life” is vague and ambiguous), and there by actively
denying his constituents access to health resources.

Hence, Principle 1 is anethical principle as it makes an ethical value judgment about range
of cases that apply not only to this particular case, but may also apply to other situations. These
ethical principles are essential because we use them as reasons to think that a given decision is a
good one.

Logic and reasoning can help us clarify our moral dilemmas particularly in understanding
what is at stake. The Executive Order in the given case above uses the word “discourages” but in
actual practice, it “denies” citizens of Manila the access to these services. But logic could only
take us thus far. Ethical decision-making involves our active participation in the deliberative
process, and ultimately, in consciously making those choices.
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ETHICAL PRINCIPLES
As Jean Paul Sartre and the existentialists put it, our every action define our being. In our
quest for authenticity we must have a stake in making not only rational decisions but ethical one
as well. However, making good moral decisions is not always easy as we are burdened with having
to make ethical decisions in our everyday lives. In the context of bioethics, all stakeholders,
doctors, nurses, hospital administrators, scientist and researchers and patients must all make these
decisions in one way or another.

In the light of the case illustrated above, one handy approach is to employ moral principles
that have already been derived from and justified by a moral theory, which can provide as a direct
guide to decision making and direct action.

First Do No Harm; Primum Non Nocere

The Oath of Hippocrates, the earliest known statement written as an ethical code for
physicians, opens with this admonition, Primum Non Nocere in Latin or, “First do no Harm.” As
physicians are entrusted with the care of the patient, oftentimes it becomes a matter of life and
death, hence his duties should be taken most seriously. The Principles of Beneficdence and Non-
Maleficence are two sides of the same coin where the former is formulated. as, “We should act in
ways that promote the welfare of the people” (Munson 2000). This simply means that the
physician is duty-bound in acting only in ways that actively promote good whereas the latter, non-
maleficence, actively seeks to avoid harm. Munson formulated this principle thus, “We ought to
act in ways that do not cause needless harm or injury to others.” These are duties we expect of
physicians where failure to meet the standards are left open to the charge of moral or legal
maleficence (i.e., medical malpractice).

The Principle of Autonomy

Our subjectivity is denied when other people make decisions for us. Unless we are
otherwise incapacitated, we human beings enjoy a fundamental right to choose and determine what
is the best for us. This is evident not only in our constitution and the UN Bill of Rights but the
active promotion of one’s freedom is manifested in many realms, moral or legal. We act as
autonomous beings when we decide for ourselves what ought to be done. A tacit recognition of
our autonomy is premised on our capacity to make rational and sound decisions for ourselves. To
put it simply, rational individual ought to be self-determining. A failure to recognize one’s
autonomy is a denial of one’s worth as a person. Hence it is premised on human freedom i.e., that
we are free to choose our path, and that it is “our life” as we make it. In the medical setting, patients
are autonomous persons who determine what sort of treatment they ultimately decide on, after
being informed of their options (viz., informed choice, informed consent).
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The Principle of Justice

To be given what is due to us or what we merited is an expectation that we have of people
and institutions that we deal with in our everyday lives. However, there are two features of justice;
one is non-comparative justice, or when people get what they are entitled to and their basic rights
are secured; while the other is comparative justice, or when people are concerned with applying
pre-existing guides, rules and laws vis-a-vis the distribution of costs and benefits. In the medical
contexts this concern is distributive justice, where each one’s interest or need is weighed carefully
against other competing interests. The question of who is entitled to get what and why is actively
sought. In the case of EO 003 (see case above), the Mayor of Manila decided to withhold services
in consideration of what is in his view, a larger, and more processing need.

The above principles, although inspired by ethical theories, could stand on their own.
However, certain ethical theories are worth citing for their influence in the way that bioethics is
being shaped today. According to the advocates of these ethical theories, they cannot be reduced
to mere abstract principles and ought to be taken in their wholeness.

Virtue Ethics

Since the opening question of this article is framed on what ought to be done (What to do?),
there is a shift in virtue ethics from “do” to “be” (How to be?). Virtue is based on character and
does not necessarily require principles or rules to guide one’s actions. Needless to say, only the
right character with the essential set of virtues can bring out the right set of actions. For example,
moral virtues, as written in the works of Chinese philosopher Mencius such as ren, li, yi and zhi,
or benevolence, compassion, propriety and wisdom, lead to the right actions and support his view
that human nature is good. In the medical context the ideal health professional or researcher should
be in good possession of these virtues, including honesty in disclosing to her patients, and integrity
in doing research.

Care Ethics
Not unlike feminist ethics, with which Care Ethics is closely identified, they reject
traditional and male-dominated models of doing value theory. With this, they also reject abstract
moral principles and put great emphasis on contexts. Care ethics maintains that it is inappropriate
to think in terms of rigid rules and principles when certain kinds of relationships are concerned.
So in the medical context, relationships between all stakeholders, the patients, their family, the
health professionals, requires a deep understanding of the way that each one is bound in a complex
situation where abstract principles cannot possibly capture everything relevant in coming up with
sound and caring moral decisions. Feminist ethicists argue that highlighting care, empathy and
values traditionally associated with women as equally important in making ethical decisions would
contribute greatly to the old means of undervaluing these by traditional ethicists, all in the name
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of justice and autonomy. Care ethics is telling us that despite having no involvement of abstract
principles, this approach is morally legitimate.

CURRENT ISSUES IN BIOETHICS

Age-old moral dilemmas or perennial problems in bioethics such as the physician-patient
relationship, abortion and euthanasia, had already been cited by Hippocrates in his oath. Particular
cases involving these issues are continuously challenging bioethicists the world over. However,
science and technology are making a huge impact as well. New breakthroughs in health and
medicine have increased human expectation to live longer and enjoy a better quality of life, and
some would say, even the quality of our death.

Issues in Bioethics range from relationships between the stakeholders, or how the health
professionals ought to relate with their patients in the context of a complex system with
consideration for public policy and government legislation, the interests of hospital administration,
Health Maintenance Organizations (HMO), and health care systems (Jackson 2006); medical
research (involving human subjects, the ethical use of animals, and other organisms including
GMOs), medical practice and malpractice; pre-birth concerns (sexual and reproductive health,
surrogacy, abortion) and birth technologies (IVF, reprogenetics and genetic engineering);
technologically-driven research and practice (stem cell research, xenotransplantation,
nanomedicine, organ supply and transplantation, brain-computer interface); and end-of-life
concerns (life support treatments, euthanasia, cryogenics, transhumanism).

Inasmuch as there is a variety of issues in bioethics and the context may vary per region,
the same concern is given about the value of the person, the other (human or otherwise), and the
world at large. Technology, resources and efficiency in managing them might be playing a huge
part in the way that these issues get priority in certain areas but needless to say the emphasis on
relationships between interested parties, the meaning of health, the quality of life, and the
inevitability of death would always be recurring themes.

CONTEXTS: BIOETHICS IN THE PHILIPPINES

Most resources available on bioethics to be found in university libraries and online are
almost situated in first-world countries. Inevitably, the kind of media coverage this sub-branch of
ethics generates involves huge advances in technology (e.g., the ethics involved in stem cell
research or human cloning, euthanasia). Incidentally this is a field where our country lags behind.
It is excruciating to talk about euthanasia in contexts where patients die before they are brought in
to hospitals because of hospital bed shortages, inadequate professional care, or financial
deficiencies. To die honorably is a luxury that many impoverished Third World people do not
experience in the hands of health professionals.

Context is vital especially as we consider who has access to advanced scientific knowledge
and technological resources. In Shannon’s book, his discussion on technology impacts the way we
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view nature, as this includes the belief that the rise of science and technological improvements, as
well as the ordinary person’s access to them, affect the way that we live and consequently, the way
that we die (Shannon 1997). This ought to explain why despite the discovery of successful
intervention, viz., a cure, tuberculosis has long been banished from the West while it remains to
be the 6th top deadly disease in the Philippines.

Because context is crucial in ethical decision-making, Susan Sherwin notes the problem
involved in globalizing aspects that many bioethicists have, viz. that feeling that they need to
control the geographical and political scope of their positions where local conditions and realities
vary greatly (in Tong, et al.). And although bioethicists around the world have a common
vocabulary, the field of bioethics takes a myriad of forms outside of the First World (Wertz, in De
Vries 1998).

Feminist bioethicists, as well as others who are concerned about local contexts, bring to
light the way that traditional moral theories tend to obscure power relations that are within the
configuration of health care practices. Hence, there is a re-shifting in the way that issues in
bioethics get highlighted, depending on the local level. In the Philippines, for example, local
discourses in bioethics could not care less about the Human Genome Project but rather, the concern
is shifted to the mass exodus of Filipino doctors and nurses, of doctors getting retrained for nursing,
negligence, abuses of health practitioners, and sexual and reproductive health6 , to cite some
examples.

CONCLUDING REMARKS

It is difficult to miss the relevance of Bioethics especially as we come to realize and value
health concerns and increasing the quality of life. As an applied ethics, this sub-field presents
issues that have universal significance as well as personal impact when one ponders on the quality
of life. If health and physical well being are among the conditions for the pursuit of happiness then
it becomes an important task to reflect on these matters. However, this field also opens a myriad
of questions directly linked to what ought to be done. Moral decision making always happens in
particular contexts. Whether about the case of contraception, as cited above or the morality of
cloning humans, the reflective individual is urged to carefully and rationally think things through,
make a stand, and defend it when the time arises.

ENDNOTES

1 Considered as the “first and foremost bioethicist,” Van Rensselaer Potter, a biochemist,
was born 27 August 1911 and died 6 September 2001. See Van Rensselaer Potter: The
Original Bioethicist. Journal article by Peter Whitehouse; The Hastings Center Report,
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Vol. 31, 2001. Online article accessed March 2, 2008. URL

http://www.questia.com/googleScholar.qst?docId=5002434589
2 The author of this journal article makes an argument that Potter’s initial vision for bioethics
has yet to be realized. See: The Rebirth of Bioethics: Extending the Original Formulations
of Van Rensselaer Potter by Peter J. Whitehouse 2003. The American Journal of Bioethics
3(4):W26-W31. Online article accessed March 2, 2008. URL:
http://www.bioethics.net/journal/j_articles.php?aid=71
3 See Chapter 18, Timbreza, EPT for a general overview of Ethics as a main branch of
philosophy.
4 Dubbed as The RESOLVEDD Strategy of Ethical Decision Making by Raymond S.
Pfeiffer and Ralph P. Forsberg. This strategy involves the RESOLVEDD strategy as
acronym for: Review, Estimate, Solutions listed, Outcome statement, Likely impact,
Values, Evaluate, Decide and Defend.
5 This case is inspired by a report “Filipino Women and Men Sue Manila Mayor For Ban on
Contraception”, see URL http://www.reproductiverights.org/pr_08_0130
FilipinoSueManila.html dated January 30, 2008. Web site accessed March 2, 2008.
6 The pending piece of legislation, House Bill 4110: The Reproductive Healthcare Act, 12 th
Philippine Congress; filed on Dec. 19, 2001 is being lobbied by feminist groups, medical
practitioners, NGOs and urban poor women.