1

What Is Bioethics?
A Historical Introduction

HELGA KUHSE AND PETER SINGER

Since the 1960s ethical problems in health care and the biomedical sciences have gripped the public consciousness in unprecedented ways. In part, this is the result of new and sometimes revolutionary developments in the biomedical sciences and in clinical medicine. Dialysis machines, artificial ventilators, and organ transplants offer the possibility of keeping alive patients who otherwise would have died. In vitro fertilization and related reproduction techniques allow a range of new relationships between parents and children, including the birth of children who are not genetically related to the women who bear them. The development of modern contraceptives, prenatal testing, and the availability of safe abortions have given women and couples increased choices about the number and kinds of children they are going to have. Groundbreaking developments in genetics and the possibility of genetic enhancement add a further dimension to these choices. Technological breakthroughs, however, have not been the only factor in the increasing interest in ethical problems in this area. Another factor has been a growing concern about the power exercised by doctors and scientists, which shows itself in issues about “patients’ rights” and the rights of the community as a whole to be involved in decisions that affect them. This has meant greater public awareness of the value-laden nature of medical decision-making, and a critical questioning of the basis on which such decisions are made. It has become patently obvious during the past three or four decades that, to give just one example, someone has to decide whether to continue life-support for patients who will never regain consciousness. This is not a technical decision that only doctors are capable of making, but an ethical decision, on which patients and others may have views no less defensible than those of doctors.

It was in the climate of such new ethical issues and choices that the field of inquiry now known as “bioethics” was born. The word was not originally used in this sense. Van Rensselaer Potter first proposed the term for a “science of survival” in the ecological sense – that is, an interdisciplinary study aimed at ensuring the preservation of the biosphere (Potter 1970). This terminology never became widely established, however, and instead “bioethics” came to refer to the growing interest in the ethical issues arising from health care and the biomedical sciences. It is to bioethics in this latter sense that the present volume forms a Companion.

Although the term itself is new, and the prominence of bioethics owes much to recent developments in the biomedical sciences, bioethics can also be seen as a modern version of a much older field of thought, namely medical ethics. Undoubtedly, bioethics claims medical ethics as part of its province, but in many ways it takes a distinctly different approach. Traditionally, medical ethics has focused primarily on the doctor–patient relationship and on the virtues possessed by the good doctor. It has also been very much concerned with relations between colleagues within the profession, to the extent that it has sometimes seemed to exemplify George Bernard Shaw’s remark that “all professions are conspiracies against the laity.” Bioethics, on the other hand, is a more overtly critical and reflective enterprise. Not limited to questioning the ethical dimensions of doctor–patient and doctor–doctor relationships, it goes well beyond the scope of traditional medical ethics in several ways. First, its goal is not the development of, or adherence to, a code or set of precepts, but a better understanding of the issues. Second, it is prepared to ask deep philosophical questions about the nature of ethics, the value of life, what it is to be a person, the significance of being human. Third, it embraces issues of public policy and the direction and control of science. In all these senses, bioethics is a novel and distinct field of inquiry. Nevertheless, its history must begin with the history of medical ethics.

Medical Ethics

Medical ethics has a long and varied history (Reich 1995: 1439–646). While it is often thought that it had its beginning in the days of Hippocrates, in ancient Greece, it is in fact much older. Even tribal societies, without a written language, already had more or less well-articulated values that directed the provision of health care by shamans, exorcists, witches, sorcerers, and priests, as well as by midwives, bonesetters, and herbalists. One of the earliest written provisions relating to the practice of medicine is from the Code of Hammurabi, written in Babylon in about 1750 BC. It stipulates that if a doctor uses a bronze lancet to perform a major operation on a member of the nobility that results in death or leads to the loss of an eye, the doctor’s hand will be cut off (Pritchard 1969). Other early provisions of medical ethics were embedded in a religious tradition. A monument in the sanctuary of Asclepius, for example, tells doctors to be “like God: savior equally of slaves, of paupers, of rich men, of princes, and to all a brother, such help he would give” (Etziony 1973); and the Daily Prayer of a Physician, often attributed to the twelfth-century Jewish doctor Moses Maimonides (but now thought to date from the eighteenth century), condemns not only “thirst for profit” but also “ambition for renown and admiration” (Veatch 1989: 14).

The ancient ethical codes were often expressed in the form of oaths. The best-known medical oath in the Western tradition is the Oath of Hippocrates, commonly assumed to be from the fifth century BC, and often regarded as the very foundation of Western medical ethics. Despite the oath’s continuing appeal, its origins are clouded in mystery. Around 500 BC many different schools of medical practice coexisted, each of them reflecting somewhat different medical, philosophical, and religious beliefs. One of these medical schools, on the island of Cos, was headed by the physician Hippocrates. The Hippocratic School produced a large body of writings on medicine, science, and ethics. The date of the oath, however, is unknown, with estimates ranging from the sixth century BC to the beginning of the Christian era (Edelstein 1967). The oath’s significance in the history of Western medical ethics is twofold. In affirming that “I will use dietetic measures to the use and profit of the sick according to my capacity and understanding. If any danger and hurt threatens, I will endeavor to avert it,” the oath establishes the principles of beneficence and nonmaleficence, that is, that doctors must act so as to benefit their patients and seek to prevent harm. In addition, the oath’s prohibition on giving a potion to produce an abortion, or giving any poison to end the life of a patient, is consonant with the view of the sanctity of human life that has dominated medical ethics under Christendom. Other aspects of the oath – like the injunction to honor one’s teacher like a parent, “to share his fate and if occasion arise supply him with the necessaries of life” – are less frequently referred to in modern discussions of medical ethics.

While some scholars hold that the increasing importance of the Hippocratic Oath is linked to the rise of Christianity, this is disputed by others who believe that there are significant differences and tensions in the ethical precepts on which Hippocratic and Christian medicine were built. One obvious difference lies in the two traditions’ religious commitment. At different times, various modifications were thus introduced to make the Hippocratic Oath acceptable to Christians. One of the earliest of these dates from the tenth or eleventh century. It is entitled “From the Oath According to Hippocrates Insofar as a Christian May Swear it.” This oath no longer required Christian doctors to swear to Greek gods and goddesses; rather, those taking the oath addressed themselves to “God the Father of our Lord Jesus Christ” (Jones 1924: 23).

Perhaps one of the most significant moral influences of Christianity relates to its emphasis on love for one’s neighbor and compassion for the ill. Religious institutions, such as monasteries, began to set up “hospitals” for the ill and destitute, and Christian teaching emphasized that doctors must cultivate the virtues of compassion and charity. A treatise, probably dating from the early twelfth century, exhorts doctors not to heal “for the sake of gain, nor to give more consideration to the wealthy than to the poor, or to the noble than the ignoble” (MacKinney 1952: 27), and in the thirteenth century Thomas Aquinas considered it a sin if a doctor demanded an excessive fee, or if he refused to give gratuitous treatment to a patient who would die for want of it.

If greed and lack of charity were regarded as sins, so were other practices as well. Navarrus, a leading sixteenth-century canonist, provided a clear statement that condemned euthanasia as sinful, even if motivated by pity. In this, he followed St Augustine’s earlier pronouncement, in The City of God, that Christians must not choose suicide to escape illness; and Thomas Aquinas’ condemnation of the practice on the grounds that it was unnatural and a usurpation of God’s prerogative to give and take life.

When it came to another topic still central to contemporary bioethical debate – that of abortion – the historical position of...