Bioethics as a field is relatively new, emerging only in the late 1960s, though many of the questions it addresses are as old as medicine itself. When Hippocrates wrote his now famous dictum Primumnon nocere(First, do no harm), he was grappling with one of the core issues still facing human medicine, namely, the role and duty of the physician. With the advent of late twentieth-century science, an academic field emerged to reflect not only on the important and age-old issues raised by the practice of medicine, but also on the ethical problems generated by rapid progress in technology and science. Forty years after the emergence of this field, bioethics now reflects the profound changes in medicine and the life sciences.
Against the backdrop of advances in the life sciences, the field of bioethics has a threefold mission: (1) to raise important questions about the general practice of medicine and the institutions of health care and other economically advanced nations, (2) to wrestle with the novel bioethical dilemmas constantly being generated by new biomedical technologies, and (3) to challenge the presumptions of international and population-based efforts in public health and the delivery of health care in economically underdeveloped parts of the globe. While attention to the ethical dilemmas accompanying the appearance of new technologies such as stem cell research or nanotechnology can command much of the popular attention devoted to the field, the other missions are of equal importance.
At the core of bioethics are questions about medical professionalism, such as: What are the obligations of physicians to their patients? And what are the virtues of the “good doctor”? Bioethics explores critical issues in clinical and research medicine, including truth telling, informed consent, confidentiality, end-of-life care, conflict of interest, non abandonment, euthanasia, substituted judgment, rationing of and access to health care, and the withdrawal and withholding of care. Only minimally affected by advances in technology and science, these core bioethical concerns remain the so-called bread and butter issues of the field.
The second mission of bioethics is to enable ethical reflection to keep pace with scientific and medical breakthroughs. With each new technology or medical breakthrough, the public finds itself in uncharted ethical terrain it does not know how to navigate. In the twenty-first century—what is very likely to be the “century of biology”—there will be a constant stream of moral quandaries as scientific reach exceeds ethical grasp. As a response to these monumental strides in science and technology, the scope of bioethics has expanded to include the ethical questions raised by the Human Genome Project, stem cell research, artificial reproductive technologies, the genetic engineering of plants and animals, the synthesis of new life-forms, the possibility of successful reproductive cloning, pre implantation genetic diagnosis, nanotechnology, and xeno transplantation—to name only some of the key advances.
Bioethics has also begun to engage with the challenges posed by delivering care in underdeveloped nations. Whose moral standards should govern the conduct of research to find therapies or preventive vaccines useful against malaria, HIV, or Ebola—local standards or Western principles? And to what extent is manipulation or even coercion justified in pursuing such goals as the reduction of risks to health care in children or the advancement of national security? This population based focus raises new sorts of ethical challenges both for health care providers who seek to improve overall health indicators in populations and for researchers who are trying to conduct research against fatal diseases that are at epidemic levels in some parts of the world. As no realm of academic or public life remains untouched by pressing bioethical issues, the field of bioethics has broadened to include representation from scholars in disciplines as diverse as philosophy, religion, medicine, law, social science, public policy, disability studies, nursing, and literature.
The bioethical issues being addressed by the field are too numerous to count, but the flavor of bioethics in the early twenty- first century can be conveyed by an exploration of the bioethical implications of genetic research, health care access reform, and stem cell research, arguably the most pressing issue in the field to date. Advances in the science of genetics, including the Human Genome Project and the ability to find genetic markers for particular diseases, have raised difficult ethical dilemmas. Two of the most pressing issues are pre implantation genetic diagnosis and the genetic testing of adults. With the technology to identify inherited diseases in the early embryo comes questions about which embryos ought to be implanted, which diseases constitute a legitimate moral reason to discard an embryo or become the criterion for embryo selection, which traits ought parents be allowed to select or test for, and who ought to have access to this technology and on what grounds. As the twenty-first century unfolds, new and expanding areas of research will require increasing attention to their related ethical aspects.
New knowledge of the brain will soon have an enormous impact on the legal and penal systems. How to integrate knowledge of the brain into the practice of forensics, the prosecution of persons accused of crime, and the screening of those seeking parole are all issues likely to become pressing in the not-too-distant future. Equally controversial will be the use of new knowledge about the brain in the detection and prevention of the onset of undesirable behavior in adolescents and children and in trying to improve or enhance their capabilities and skills.
While there has been much attention in bioethics to the mapping of the human genome and to the nuclear transfer techniques used to clone Dolly the sheep and other animals, the most provocative genetics-related issue facing society during the first half of the twenty-first century is likely to be to what extent ought humans design their children. Rudimentary steps toward making eugenics a reality are all around us. Another fascinating emerging ethical issue is whether humanity should seek to control the time of death. It is one thing to agree that individuals who are dying have the right to withdraw or not initiate medical treatments. It is quite a different matter to say that someone who is not terminally ill but is suffering from a terribly disabling chronic condition, a severely diminished quality of life, or the prospect of decades of life in a state of dementia or extreme frailty should have the right to medical or technological assistance in dying. The focus of these debates, however, has been almost exclusively the terminally ill. As the population of the world ages over the course of the twenty-first century, more and more persons may begin to ask or demand the right to control the timing of their death, whether they are deemed terminally ill or not.