Bioethics, History Of

The history of bioethics relating to death and dying is, like any philosophical endeavor, about questions and answers. The fundamental challenge to developing a cohesive and consistent approach to such a complex history is that the questions are raised in a pluralistic context in which participants enter the discussion with a variety of religious, ideological, philosophical, educational, and vocational backgrounds. These differences can serve to open new perspectives on a problem, and the history of bioethics is, in part, one of grappling with diverse approaches to moral issues that yield equally diverse responses. These differences can lead to significant impasses, as frequently the end point of a discussion is not an agreement to continue the discussion but rather is a concrete action, one that perhaps must be undertaken with some urgency and may be irrevocable—examples of such include withdrawal of a ventilator, stopping hydration or nutrition, enrolling a dying patient in a research trial with a significant burden of involvement with medical institutions, or actively participating in the death of a person. Such a practical conclusion to a discussion with such high stakes—human death is often at the center of the struggle—lends great significance to this history, and a number of attempts have been made to distill principles that are broadly applicable and comprehensive.

Significant Historical Events

Of the historical events shaping this effort, several have been seminal in the development of contemporary understanding of bioethics as it relates to death and dying, as well as to the structure of research involving human subjects facing potentially lethal diseases. In the United States, one of the earliest influences in the history of ethics—affecting the evolution of ethical codes [Page 105]that offer guidance in medical decision making—was Dr. Benjamin Rush from Philadelphia who had great interest in moral issues around the time of the American Revolution, issues he addressed in lectures to medical students at the University of Pennsylvania. His work led to the Second National Medical Convention in the mid-1800s in which a committee was charged with drafting a code of medical ethics. Though the code of ethics of the American Medical Association that resulted from this effort had its critics, it was largely praised by the medical community. As new technologies (such as anesthesia and advances in surgical techniques) carrying both benefit and risk were developed, ethical issues arose centering around both the transformation of medicine into a scientific discipline and the idea of physician competence as the basis for ethical evaluation. During the 20th century, authority over patients shifted from the locus of physician duty to that of patient rights, a fact that affected subsequent work significantly. The American Medical Association Code of Ethics underwent several revisions, changing in concert with the evolution of the medical profession, which had achieved a firm position in society. This code, which has deeply affected debates over such issues as abortion, withdrawal of medical support, and euthanasia, is considered central to the medical establishment's vision of itself.

There have been a number of important challenges to the assumption of ubiquitous professional virtues and the moral reputation of the medical establishment. Some of the most important have occurred in the context of research; others in the context of caring for patients who have lost functions considered basic to meaningful life or patients who are suffering human moral abuses—such as those uncovered in the Nuremberg trials, the Tuskegee Syphilis Study, and the Advisory Committee on Human Radiation Experiments—have led to important questions about this assumption. The practical yield has been the production of highly influential documents such as the Belmont Report, the Declaration of Helsinki in its several versions, guidelines produced for the international arena by the Council for International Organizations of Medical Sciences, and, most recently, the adoption of the Universal Declaration of Bioethics and Human Rights in October 2005 by the United Nations Educational, Scientific and Cultural Organization. Common to these efforts are principles such as respect for persons, beneficence, and justice, which apply in both clinical medicine and medical research.

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