"'Bioethics' -- What It Really Means for Prolife Nurses"

Dianne N. Irving
National Association of Pro-life Nurses Annual Meeting
Hyatt Regency in Crystal City
Washington, D.C.
Copyright July 2, 2004
Reproduced with Permission

[Based on Irving, "What is 'bioethics?'", UFL Proceedings of the Conference 2000, in Joseph W. Koterski (ed.), Life and Learning X: Proceedings of the Tenth University Faculty For Life Conference (Washington, D.C.: University Faculty For Life, 2002), pp. 1-84, at several websites, including: lifeissues.net and uffl.org

I. Introduction

I'd first like to thank the National Association of Pro-life Nurses very much for inviting me to be here with you this evening. It is an honor to have been invited, and to be able to share with you some thoughts that concern me about the difficult struggle you find yourself in as vital members of the "healing professions".

To begin, let me share with you something recently said to me by a very special prolife nurse - we'll just call her, "Jennifer":

"Nurses are by their very nature, compassionate people. But it is difficult to keep that in focus with ethical issues when we see suffering up close and personal, sometimes on a daily basis."

Quite a very perceptive statement this good nurse made, and it probably reflects to some extent the sentiments of each of you good nurses here this evening. Her reference point was the direct killing of human patients under the guise of what is known as "mis-placed compassion". But what I see in her concern and confusion really goes much deeper -- a deep-seated tension between her personal and her professional lived-experiences on the one hand, and "ethics" on the other. And herein is the exact problem I want to talk with you about this evening. When you find yourself in a situation where you and your deepest gut instincts are so pitted against some "theory" - any "theory" - then perhaps it is time to stop and to question this "theory"? The specific "theory" in question here is not really "ethics", but, I would suggest -- "bioethics".

What is bioethics? How did it come about? How sound is this "theory"? What impact has it had on the practice of medicine and medical research, especially its influence on medical professionals - at the bedside, up-front and personal? How has bioethics attacked the fundamental concept of "personhood", especially as formulated in bioethics as "preference" utilitarianism? How has it so profoundly affected our understanding of who is a person to the extent that we don't even know one when we're staring one in the face - at the bedside?

II. Different Ethics, Different Conclusions

First, just what IS "bioethics"? Most people would say that it IS "ethics" -- just the application of traditional philosophical and theological principles to current technological issues in medicine and medical research, right?

Not really. There is no such thing as "ethics per se". In the real world there are dozens of different ethical theories, using very different ethical norms and principles, thus arriving at fundamentally and even contradictory ethical conclusions - and thus different "medical ethics" and "research ethics" conclusions. Consider that the traditional Hippocratic medical ethics focuses on the physician's duty to the individual patient, whose life and welfare are always primary. The focus of bioethics is fundamentally utilitarian, centered on "maximizing total human happiness", or, as we shall see, maximizing total "preferences" and "interests" for society is primary.

To put my endeavor into sharp focus, consider for a moment the strikingly different conclusions reached by secular bioethics and those of a traditional medical ethics on an array of issues. Secular bioethics generally considers the following as "ethical": abortion, contraception, the use of abortifacients, prenatal diagnosis with the intent to abort defective and disabled babies; destructive human embryo and human fetal research; human cloning; the formation of human chimeras (cross-breeding with other species); human embryonic and fetal stem cell research; "brain birth"; purely experimental high risk research with the mentally ill; euthanasia; physician-assisted suicide; and living wills documenting absolute "autonomous" consent to just about anything. In contrast, traditional medical ethics considered all of these unethical.

Therefore, there is no such thing as a "neutral" ethics -- including bioethics. All ethical theories are normative -- i.e., they take a stand on what is right or wrong. Wouldn't it make common sense, therefore, to wonder why any "ethical theory" should be forced on any members of a pluralistic, multicultural, democratic society as the basis for public policy making?

III. The Transition From Traditional Medical Ethics to Bioethics

Given the startling differences between traditional Hippocratic medical ethics and current bioethics, how did we get here - historically? Well, just after World War II, new medical research and technologies began to complicate patient care, thanks to massive federal funding of the health sciences. The crucial bonds of the physician-patient relationship were beginning to fray. Traditional Hippocratic medicine was breaking down rapidly, seemingly impotent in the face of pressing new questions brought on especially by advances in science and technology.

The Conferences

The "hot" questions we debate today in bioethics are not that new. Starting in the 1960's there were a series of conferences around the country on pop control, thought control, sterilization, cloning, artificial insemination, and sperm banks. One of the first, the "Great Issues of Conscience in Modern Medicine Conference" at Dartmouth College in 1960, hosted an array of scientific and medical savants, including the microbiologist Rene Dubos of the Rockefeller Institute, the physician Sir George Pickering of Oxford University, and Brock Chrisholm, a leading medical light of the World Health Organization, together with such famous humanists as C. P. Snow and Aldous Huxley.

The hottest topics then too were genetics and eugenics. Dubos declared that the prolongation of the life of aged and ailing persons and the saving of lives of children with genetic defects -- two benefits of post-World War II advances in medicine -- had created "the most difficult problem of medical ethics we are likely to encounter within the next decade." Geneticists worried that the gene pool was becoming polluted because the early deaths of people with serious abnormalities were now preventable. The Nobel Prize-winning geneticist Muller offered his own solution to that problem: a bank of healthy sperm that, together with "new techniques of reproduction," could prevent the otherwise inevitable degeneration of the race that might ensue thanks to medical advances that allowed the defective to reproduce."

At another conference, "Man and His Future," sponsored by the Ciba Foundation in London in 1962, the luminaries included Muller; Lederberg, winner of the Nobel Prize in medicine; the geneticists Haldane and Crick, and the scientific ethicist Bronowski. As at Dartmouth, concerns about human evolution, eugenics, and pop control were primary. The biologist Sir Julian Huxley declared, "Eventually, the prospect of radical eugenic improvement could become one of the mainsprings of man's evolutionary advance." Huxley proposed a genetic utopia that would include strict government controls over physiological and psychological processes, achieved largely by pharmacological and genetic techniques. They would also include cloning and the deliberate provocation of genetic mutations "to suit the human product for special purposes in the world of the future."

Other conferences of the 1960's delved further into the implications of science for medial ethics. One was a series of Nobel meetings in Minnesota in which many Nobel Prize winners participated. At the first of them, in 1965, whose theme was "genetics and the Future of Man," the Nobel physicist Shockley presented his maverick views on eugenics. He suggested that, since human intelligence was largely genetically determined, scientists would embark on serious efforts to raise the human race's "collective brainpower" by various means, including sterilization, cloning, and artificial insemination.

Also evolving during this time were new concepts of scientific and of medical ethics - "secular" ones that would be arrived at by "consensus" for purposes of public policy making - as if "consensus" would be somehow "neutral" and thus useful in our pluralistic, multicultural democratic society. This sort of thinking would become a major characteristic of the new field of bioethics yet to be formalized.

The Think Tanks

As the 1970's approached, the debates and their participants moved from conferences at universities to permanent think thanks. Callahan and Gaylin set up The Hastings Center outside New York City in 1969. There, such pioneers of bioethics as Dubos, Ramsey, Gustafson, Renee Fox, Arthur Caplan, Robert Veatch, even Senator Mondale and New York Times journalist Peter Steinfels brainstormed.

The first "research groups" at The Hastings Center likewise addressed such issues as death and dying, behavior control, genetic engineering, genetic counseling, pop control, and the conjunction of bioethics and public policy. In 1971, the first volume of the Hastings Center Report appeared, a publication that was to become "the Bible" of secular bioethics, just then acquiring its name. As Al Jonsen, a pioneer of bioethics, noted in his 1998 book, The Birth of Bioethics (Oxford), "The index of the Hastings Center Report over the next years defined the range of topics that were becoming bioethics and constituted a roll call of the authors who would become its proponents."

Under the leadership of the Dutch fetal-development researcher Andre Hellegers, the Kennedy Institute of Ethics opened at Georgetown University in 1971 (originally named the Kennedy Center for the Study of Human Reproduction and Development). [[I walked through its doors in 1979, as a member of the First Generationers - the first graduate student class in bioethics.]] Its mission was to study the ethical issues involved in reproductive research in a Catholic context. Such scholars as Richard McCormick, and later, Ed Pellegrino, worked out of the Kennedy Institute at various times. Also in the 1970's, a Protestant counterpart to the Kennedy Institute opened, the Institute on Human Values, sponsored by the United Ministries in Education, a partnership of the Methodist and Presbyterian churches - with Pellegrino serving as its first Director.

Many of the conference participants of the 1960's and the think-tank scholars of the 1970's were among those testifying before the Mondale and Kennedy congressional hearings that led to the passage of the National Research Act of 1974. Many in this army of secular scholars also sat on the committee that later issued the Belmont Report with its three bioethics principles. Those scholars were indeed, as Jonsen puts it, the midwives at the formal "birth of bioethics" that the 1974 congressional act had mandated. They were also the first formally designated "bioethicists."

IV. The Formal Birth of Bioethics

Bioethics as understood and practiced today was actually "created" out of thin air by a Congressional mandate, with the passage of that National Research Act of 1974. The Act mandated that the Secretary of DHEW appoint a National Commission to: [1] "identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects", and [2] to "develop guidelines that should be followed in such research." As Jonsen, a member of that National Commission, later perceptively noted, "No legislation had ever before charged a government body to identify basic ethical principles as did Public Law 93-348."

Thus, in 1974, Secretary Weinberger appointed an eleven-member National Commission that in 1978 issued a document called The Belmont Report, which identified and defined these "ethical principles": respect for "persons" (immediately deconstructed to mean absolute "autonomy"), "justice", and "beneficence." To this day, those principles are called "the Belmont principles", the "Georgetown mantra", "principlism", "federal ethics", or simply "bioethics." Obviously, as we have seen, deducing from these different normative ethical principles of autonomy, justice and beneficence - especially as so curiously defined in The Belmont Report -- will lead to quite different conclusions about what is right or wrong in health care, as compared to deducing from other ethical principles.

Also, as Congressionally mandated, in 1981 the Belmont Report immediately became the explicit foundation for the guidelines that the U.S. federal government was to use when assessing the ethics of using human subjects in research. These Belmont principles, as originally, and curiously, defined, also underlie a host of other federal regulations and guidelines for medicine and medical research, and have worked their way into the private and international sectors as well.

V. Evaluation of Bioethics

There are several misconceptions about bioethics I would like to clarify.

1. First, bioethics is not really just the "general moral consensus of the people", but rather it is an idiosyncratic systematic academic theory of ethics alongside many other such academic ethical theories or systems competing for recognition in the universities -- bioethics simply being the one that was recently made up by an 11-member, politically appointed National Commission.

2. Second, bioethics should not be equated with the entire field of "ethics" per se, as often seems to be the implication today, but again, it is only a sub-field of ethics.

3. Third, bioethics is not a "neutral" ethical theory at all, but defines itself as "normative" - i.e., it takes a stand on what is right or wrong. In fact, there is no such thing as a "neutral" ethics - and that includes utilitarianism, consensus ethics, Kantianism, cultural relativism, emotivism, casuistry, communitarianism or any religious-based "ethics" as well.

4. Each of the three principles of the new bioethics was defined by bioethics as prima facie: i.e., no one principle could overrule any of the other two. However, bioethics theory itself does not provide a way to resolve any conflicts that arise among its principles. In dealing with real-life medical and scientific problems, the bioethicist was supposed to reconcile the values of all three principles.

5. Because the Belmont principles were derived from bits and pieces of fundamentally contradictory philosophical systems, the result was theoretical chaos. More problematically, when people tried to apply the new theory to real patients in medical and research settings, it didn't work because, practically speaking, there was no way to resolve the inherent conflicts among the three principles - other than arbitrarily.

6. The very definition of the bioethics principles is problematic. For example, while the Belmont Report gave a nod to the traditional Hippocratic understanding of BENEFICENCE as doing good for the patient, it also included a second definition of beneficence that was essentially utilitarian: doing "good for society at large." The report even declared that citizens have a "strong moral obligation" to take part in experimental research "for the greater good of society". This obviously contradicts the Hippocratic interpretation of beneficence, and it also violates time-honored international research guidelines, such as the Nuremberg Code and the Declaration of Helsinki, which bar physicians from experimenting on their patients unless it is for the patient's direct benefit.

The Belmont principle of JUSTICE was also defined along utilitarian lines, in terms of "fairness": i.e., allocating the benefits and burdens of research fairly across the social spectrum. This Rawls-influenced definition is obviously very different from the classic Aristotelian definition of justice as treating people fairly as individuals.

Even the Belmont principle of respect for persons - or AUTONOMY -- ended up serving utilitarian goals. Supposedly derived from Kant's respect for persons in which respect for the individual is absolute, the Belmont Report blurred that idea with Mill's utilitarian views of personal autonomy. In Mills' view, only "persons" -- that is, fully conscious, rational adults capable of acting autonomously -- are defined as moral agents with moral responsibilities. However, those incapable of acting autonomously -- infants, the comatose, those with Alzheimer's - were to become defined in bioethics theory as non-moral agents -- and thus as "non-persons", with quite different "rights" than "persons. It is only a short step from this kind of reasoning to that underlying Princeton ethicist Peter Singer's "preference" utilitarianism, in which animals have more rights as persons than young human children, and non-person humans can be used as objects for the greatest good of society.

Eventually, discontent began to smolder within the brave new discipline. Even the founders of bioethics have recently admitted that the Belmont principles present grave problems as guidelines for health care workers and researchers. The Hastings Center's Callahan baldly conceded that after 25 years, bioethics simply has not worked. But not to worry, he said, we'll try communitarianism now (yet another utilitarian theory): "The range of questions that a communitarian bioethics would pose could keep the field of bioethics well and richly occupied for at least another 25 years", Callahan cheered! Gilbert Meilaender has noted "how easily the [reality and worth of the individual human] soul can be lost in bioethics." National Commissioner Al Jonsen recently wrote that principlism should now be regarded as "a sick patient in need of a thorough diagnosis and prognosis." And, I would argue that until that is accomplished, our sick culture will remain confusing and contradictory.

7. Another reason for the theoretical and practical chaos surrounding bioethics these days is that almost anyone can be a bioethicist - slightly irritating to we bioethics graduate students who had to pass at least 60 graduate credits with an "A" average, pass three 8-hour written comprehensives, and write a doctoral dissertation defended university-wide! Few "professional" bioethics experts -- the doctors, researchers, and lawyers who sit on hospital and government bioethics committees -- have academic graduate degrees in the discipline, and even for those very few who do there is no uniform or standardized curriculum to which their degrees conform. Most professors of bioethics have only taken a community seminar or two, don't know the historical or philosophical roots of the subject they teach; the courses vary wildly from institution to institution; there are no local, state, or national boards of examination for bioethicists; and there are no real professional standards. There is not even a professional code of ethics for bioethicists.

Because of these criticisms, many nervous bioethicists now prefer to say that their field is more a form of "public discourse" than an academic discipline, a kind of "consensus ethics" arrived at by democratic discussion rather than by formal principles. The problem with this line of reasoning is that (1) there is no "level playing field" out there, and (2) the ethical principles used in the "discourse" are still exactly the same bioethics principles with the same curious definitions, and those who typically reach the "consensus" are the bioethicists themselves, not the patients, their families, or society at large, so the process is not exactly neutral or democratic. And if bioethics is just a "discourse," then why are its practitioners regarded as "ethics experts" - even in the court rooms?

VI. Erroneous Science Used By Early Bioethics

8. The use of false science propagated in bioethics pervades many medical ethics and medical research issues as well, and surely precludes health care workers from accurately forming their consciences about abortion, the use of abortifacients, genetic pre-selection, euthanasia, and a host of other related issues. Right from the start bioethics has propagated its own "science" and "medicine" in order to advance its own agenda. If the facts don't fit the agenda, just change the facts. Indeed, it is the erroneous "science" used so successfully in the issues at the beginning of life that grounded their erroneous concept of "person" - which concept was then simply transferred without fanfare to issues involving adults at the end of life. In order to prevent public scrutiny of this "conceptual transfer", bioethics relied brilliantly on the political strategy of making any and all public or academic discussions and debates on the "abortion" issue politically incorrect - off-base. No debates, no scrutiny, no problems. But the disturbing issues concerning the end of life simply cannot be thoroughly addressed without at least taking a look at this "conceptual transfer".

Of note, for example, the National Commission used several "odd" scientific definitions in its individual reports, e.g., in its Report on Fetal Research (1975) Even the Commission acknowledged this: "For the purposes of this report, the Commission has used the following definitions which, in some instances, differ from medical, legal or common usage. These definitions have been adopted in the interest of clarity and to conform to the language used in the legislative mandate" [referring to the National Research Act of 1974!]. Among such "unique" scientific definitions used by the Commission was that of the "fetus" as beginning at implantation (i.e., 5-7 days post-fertilization). Before that there was only a "pre-embryo". The terms "human being" and "human embryo" were never defined. Similarly, the OPRR federal research regulations, based explicitly on the Commission's Belmont principles, contain two "unique" scientific definitions. "fetus" and "pregnancy" are both defined as beginning at implantation! Again, no definitions of either "human being" or of "human embryo".

Of course, such "definitions" are rather bizarre, as the single dissenting report by National Commissioner Louisell pointed out. Science has known since the 1880's, with the publication of Wilhelm His' three-volume tome, Human Embryology, that fertilization was the beginning of the existence of the human being, the human embryo, using sexual methods of reproduction. Normal pregnancy also begins at fertilization in the woman's fallopian tube. And the "fetal period" doesn't even begin until the 9th week post-fertilization.

Clearly, such "odd" scientific definitions -- or re-definitions -- in the National Commission's Report and in the OPRR federal research regulations would simply serve the purpose of allowing the removal of "flushed" human embryos, and artificially produced human embryos (through 8-weeks-post fertilization), from any sort of governmental protection or oversight in the future -- especially given the growing interests in viable human embryos as biological materials for use in IVF "research" and "therapy". They would be especially prized for used in human cloning, human chimera, and all human genetic engineering research. But such "odd" scientific definitions would also be used as the basis for bioethics' "conceptual transfer" of "personhood" at the beginning of life to issues at the end of life - and all stages in-between. If, by using such false science, a human embryo or fetus - even a young child - is not a "person", then neither are adult disabled human beings, or those at the end of life.

Next Page: VII. Erroneous 'Personhood' Theories Used By Bioethics
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