The Nature and Varieties of Bioethics
John D. Arras
The Nature of Bioethics
Is it ethical
to clone a human being? Shall we legalize euthanasia and physician-assisted suicide? Should Terri Schiavo's feeding tube
be removed? Are genetic screening and abortion of "selected" fetuses compatible with respect for the disabled in our
community? How can we use human subjects in biomedical research without dehumanizing them? Is there a right to health
care - or appropriate limits to demands for treatment? How important are human rights in a time of plague? What do we
owe the starving poor in distant lands? Such questions press upon us both as expert professionals and as ordinary
citizens who read the paper, vote, and go to town meetings. They are also the stuff of bioethical inquiry. Bioethics
is both a field of intellectual inquiry and a professional practice that examines moral questions at the intersection
of biology, medicine, law, public health, policy, and ethics - all broadly construed. Unlike the traditional fields that
contribute their respective problems and perspectives to this broadly based inquiry, bioethics is not a unitary
"discipline" with its own distinctive methods and credentialing institutions. It is an interdisciplinary "field"
populated by scholars, teachers, and clinical practitioners from a wide variety of traditional disciplines, such
as philosophy, religious studies, law, medicine, nursing, social work, public health, the medical humanities
(literature and history), and social sciences (politics, sociology, economics, anthropology).
In recent years, much bioethical work has
taken an "empirical turn," featuring social scientific perspectives
on relevant issues and behaviors. Here anthropologists, sociologists,
empirically trained physicians and nurses do studies, for example,
on the actual practice of Do Not Resuscitate Orders in hospitals,
on the concrete meaning of informed consent to research subjects
in poor developing countries, and on the level of comprehension
exhibited by research subjects in the initial clinical trials of
various drugs. There has also been a recent trend to broaden the
traditional bioethics agenda beyond the narrow confines of medical
institutions to encompass a concern for public health, the environment,
and global health. In place of (or in addition to) the traditional
emphasis on an individualistic doctor-patient ethics, this broader
agenda tends to focus on the ethics of dealing with the health of
entire populations. The bioethics program at the University of Virginia
is definitely pushing the boundaries of the field in these new and
exciting directions.
Varieties of Bioethics
It is important to recognize that "bioethics" is not a monolithic entity or activity. There are at least three
different kinds of bioethical work, each of which may well have a different relationship to philosophical or
religious theorizing. First, there is clinical bioethics , which amounts to the
deployment of bioethical concepts, values and methods within the domain of the hospital or clinic. The
paradigmatic activity of clinical bioethics is the ethics consult, in which perplexed or worried physicians,
nurses, social workers, patients or their family members call upon an ethicist (among others) for assistance
in resolving an actual case. These case discussions take place in real time and they are anything but hypothetical.
While those who discuss bioethics in an academic context can afford to reach the end of the hour in a state of
perplexed indeterminacy, the clinical ethicist is acutely aware that the bedside is not a seminar room and that
a decision must be reached (if only a decision to revisit the issue next week to see if the patient's condition
has worsened or if one of the protagonists has changed his or her mind).
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Although a competent clinical ethicist has no doubt read a good deal of moral theory in the course of her academic
training, and although her approach to clinical problem solving might well exhibit some dependency on the skills of
ethical analysis, the vast bulk of her work in clinical consultation might be best described as a kind of medical
ethical dispute mediation. To be sure, the content of these discussions often revolves around philosophically
charged subjects, such as informed consent, competency, the right to refuse life-sustaining treatments, and so on;
but the discussions themselves are rarely explicitly philosophical. It is in this sense that bioethics might best
be described as a practice .
Second, there is policy-oriented bioethics
. In contrast to the clinical ethicist, who is concerned
with the fate of individual patients, the bioethicist cum
policy analyst is called upon to assist in the formulation of policies
that will affect large numbers of people. Such policy discussions
can take place on the level of individual hospitals or health systems,
where administrators, medical and nursing staff, and bioethicists
debate, for example, the merits of competing policies on medical
futility; or they can take place in the more rarified atmosphere
of various state and national commissions charged with formulating
policy on topics such as cloning, access to health care, or assisted
suicide. Although such commissions operate at much higher levels
of generality than the clinical ethicist in the trenches, both of
these kinds of bioethical activity tend to be intensely practical
and result-oriented. The clinical ethicist will usually be wary
of invoking philosophical or religious theory because her interlocutors
usually have neither the time nor the inclination to discuss matters
on this level, while the bioethicist on the national commission
will soon realize the impossibility of forging a consensus with
his peers on the basis of theory alone.
Finally, at the other end of the practice-theory
spectrum, there is bioethics as a theoretical pursuit ,
a variant unhindered by the resolutely practical constraints of
the clinic and commission. The academic is free to think as deeply
or to soar as high into the theoretical empyrean as she wishes.
Unlike the clinical ethicist, she is unhindered by time constraints,
medical custom, law, or the need to reach closure on a decision.
The seminar lasts all semester, and it might serve a good educational
purpose to leave one's students even more confused at the end than
they were at the beginning. And unlike the bioethicist cum
policy analyst, the academic doesn't have to worry about finding
a common language or bending to the necessities imposed by pluralism
or sponsoring agencies of government. It is here within the academic
domain that the relationship between philosophical-religious theory
and bioethics will tend to be most explicit and most welcome, although
even here bioethicists will need to be responsive to some of the
above constraints should they desire eventually to have some influence
on public policy.
Although I've sketched above three different
kinds of activities that can all be lumped under the common rubric
of "bioethics," it should be kept in mind that each of these constituent
elements of bioethics influences the others - e.g., bioethical theory
can influence reasoning in policy settings, and clinical practice
can sometimes prompt the theoretician to reexamine some of his basic
assumptions. It should also go without saying that quite often the
same individuals can and do engage in various areas of bioethical
activity - alternatively, as clinicians, teachers, theoreticians,
and as consultants to industry or government.
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For information on how the different varieties of bioethics, described above,
might lead to different career paths, see Career
Paths in Bioethics.
Sections from the above paragraphs have been adapted from John D. Arras,
"The Owl and the Caduceus: Does Bioethics Need Philosophy?", in F.G. Miller et al., eds. The Nature and
Prospect of Bioethics (Humana Press, 2003), 1-42.
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