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Ethics, as a philosophical discipline, was ﬁrst structured and systematized in ancient Greece, most particularly by Aristotle. Its evolution throughout history is marked by some important shifts, among which two stand out: from a heteronomous ethics to an autonomous ethics and from a necessary universalism to a proposed relativism, each one having different impacts on bioethics. The birth of applied ethics, in which bioethics takes the lead, was another important step in ethics’ contemporary development.
This research paper follows the major shifts of ethics’ evolution, stressing their inﬂuence on bioethics. It also focuses on the required accurate deﬁnition of key concepts of ethical reﬂection and bioethical practice – such as principles and norms, values and virtues, rights and duties – and the right perception of the implication of each one and of their respective interactions in the understanding of action’s rationality.
Ethics, as the thought of Man about his action, is as ancient as Man itself.
An evolutionist perspective shows that as Man began to free himself from the deterministic laws of nature, he started to exercise his own will; at the same time, his action was no longer innate and therefore universally identical, dictated by instinct, and absolutely predictable and became a singular option following a particular deliberation process, and sometimes presenting itself as unexpected and always individual. From then on, Man had to face a plurality of ways of action, to establish criteria for the decision-making process, to assume his own liberty to act, and to bear the consequent responsibility for his actions. This thought about action constitutes ethics at its most spontaneous and indeclinable level (a qualitative difference from all animals), an ethica utens that is morality as it is daily lived by all, or, according to the German philosopher Albert of Saxony who ﬁrst used the expression in the 13th century, ethics as a rule of life; ethica utens was then opposed to ethica docens, which is a subject matter for teaching a philosophical reﬂection, analytical and critical, about action. Ethica docens refers to what is nowadays commonly designated by “ethics.”
Ethics is a philosophical discipline that was established as such by Aristotle, in the 3rd century BC. Intense spirituality, centered in human behavior, and lived in more ancient times by peoples in India or in Asia, was not enough to give birth to a new discipline, which needed Greek rationality.
The constitution of a new discipline also requires a new and particular object, an adequate methodology to study it, and a speciﬁc terminology to understand and refer to it.
It was Aristotle who, for the ﬁrst time, in a very systematized and developed way, especially in the Nicomachean Ethics, deﬁned the object of ethics as human action: “praxis” or immanent action, the kind of action in which the product or effect becomes part of the agent, shaping the agent’s character. For example, actions of charity make the person who acts charitable. The philosopher also structured a methodology of study pursuing a semantic of action, analyzing human behavior and its effects in the shaping of the agent’s character. Finally, Aristotle also established a system of well-deﬁned and interrelated concepts to explain the morality of human action, the accomplishment of good, and the perfection of the human being.
From then on, ethics was differently deﬁned throughout history. The object of ethics broadens: from “praxis,” an immanent action that builds the agent’s character, to “techné,” an action that produces an object external to the agent, and from an interpersonal domain, to which it was conﬁned throughout history, to other domains of human action not only toward other persons but, more recently, also regarding animals, plants, ecosystems, planet Earth, and future generations.
The methodology of ethics prevailed: to uncover the rationality of human action establishing the requirements of morality within a universal horizon, the only one that can guarantee the credibility and validity of moral rules.
But the ethical systems changed through time, gaining more and new concepts to think about new human realities in the world and to communicate them. An example would be the constellation of four concepts needed in ancient Greek philosophy to explain moral life – good, end, happiness, and virtue – to which medievalism added the concept of God, modernity the concept of liberty, and contemporaneity the concept of responsibility. Relevance begins to be given not only to the good but also to duty, not only to virtues but also to values, not only to ends or goals of action but also to principles, and, more recently, not only to principles and ends but also to procedures and not only to rights but also to obligations. Ethics originally heteronomous, being given to Man (from a higher entity: Nature or God), becomes autonomous, being made by Man to Man. Sometimes ethics seems to fall into the temptation of becoming relativistic, merely dictated by circumstances (time, space, culture), and rejecting all attempts of universality, which would simply lead ethics to implode itself, giving way to an emptiness of values, to nihilism. Finally, ethics turned out to be applied to many different concrete ﬁelds of human activity – engineering, media, economics, politics, etc. – but none more developed than in biomedical (and environment) ﬁeld through bioethics.
Throughout this process of more than twenty-four centuries, ethics has always been and still is a rationalization of human action (the logic underneath human actions) concerning the principles it is grounded on, the ends it aims toward, and the processes it entails.
From The Need Of Ethical Universalism To The Proposal Of Moral Relativism
A very brief overview of the history of moral thought must unanimously highlight two well-known benchmarks: Aristotle and his heteronomous teleological ethics of good and Kant and his autonomous and deontological moral of duty. These are two different proposals of rational intelligibility of human action both developed within a universal framework.
The fall of the ethical universals should also be seen as a benchmark and an unavoidable reference even if on a brief historical note, especially because it opens the way to moral relativism which threatens the morals itself.
It is important to characterize, although brieﬂy, the system Aristotle developed and that inﬂuenced moral thought throughout history until today and to stress its impact in the ﬁeld of bioethics, speciﬁcally in the theoretical-practical models of bioethics.
The Aristotelian perspective of ethics can be summarized as the itinerary that Man has to take from his current state to the achievement of the Supreme Good and Final End. This is a path that Man gradually conquers by accomplishing a hierarchy of minor goods and intermediate ends, through actions that progressively shape his character or way of being, leading him along a process of perfection and of personal ﬂourishing that will only end with his death. The gradual achievement of perfection corresponds to the gradual reaching of happiness. The level of happiness corresponds to the level of perfection in a rigorous coincidence between Supreme Good, Final End, Perfection and Happiness.
This path is followed through the practice of virtues, ethical and dianoetic virtues. Dianoetic or intellectual virtues depend on the level of knowledge; ethical virtues or virtues of character consist in a mean or intermediate behavior between two extremes, one by excess and the other by default. For example, “courage” is a virtue deﬁned in its content by the equidistance from recklessness, the vice of excess, and from cowardice, the vice of shortage. This intermediate way is not one geometrically established, equal to all Man. On the contrary, it can differ from person to person (“golden mean”): the acts of courage of a child, of a strong man, or of an old woman will be substantially different among them, but they will all be courageous and virtuous actions if they are an intermediate behavior of the particular agent in question.
Aristotle’s system of ethics is ﬁnalist and eudemonistic, because it aims at the Final End which also corresponds to the achievement of Happiness; it is heteronomous as well because Man’s moral law coincides with the Supreme Good and hence is external to him, given to him (everything in nature tends, by nature, to an end or perfection); it is also a consequentialist ethical theory because the consequences, the product or effect of human actions achieving a good, transforming one’s character or personality, are the main goal of ethics.
The perspective of ethics as a search for the Good and its fulﬁllment, in the wake of Aristotle and developed by Christian philosophers, describes the history of moral thought until Kant, prevailing inﬂuential until today and, namely, in the ﬁeld of bioethics.
In bioethics, Aristotelian ethics is particularly present under two different features: the recognition, by some bioethicists, of the importance of good deeds and of the effective achievement of concrete goods, in a consequentialist perspective, and their acknowledgment of the importance of the agent’s good character, shaped by the practice of virtues, to act morally.
On what concerns the ﬁrst point, the nature of two bioethical core principles should be stressed. Indeed, the so-called principles of medical ethics or Hippocratic principles – beneﬁcence and nonmaleﬁcence (the latter absent from the Hippocratic corpus) – go deep into the moral thought of ancient Greece which Aristotle originally systematized: both being good driven and consequentialist. The identiﬁcation of good in bioethics, although changeable through time and according to the different authors, and most especially “the good of the patient,” which started to be a medical good and evolved to the person’s good, remains essential to guide human action and particularly professional action.
On what concerns the importance of the good character and of the virtues that build it, it should be stressed that virtues also remain necessary in bioethics, even in principlist theories, because they add excellence to the fulﬁllment of rules and ensure the good decision in singular situations for which the known principles do not fully apply.
Edmund Pellegrino and David Thomasma are the most prominent representatives of the Aristotelian inﬂuence in bioethics. Their major work, For the Patient’s Good, the Restoration of Beneficence in Health Care, in 1988, clearly states that the theory “originally formulated by Socrates, Plato and Aristotle,” a “theory based on beneﬁcence, that is, on acting for the good of the patient, and on virtue is more appropriate to the special context of the medical encounter today” (1988, p. 3). These authors consider that “the architectonic principle of medicine is the good of the patient as expressed in a particular right and good healing action” (1988, p. 117) and propose a Virtue-Based Normative Ethics for the Health Professions (1995).
Most theoretical-practical models of bioethics from the 1980s and 1990s, at the beginning more principle oriented, have evolved to integrate and to value virtues. Also, today’s bioethics all over the world appeals regularly to virtues such as solidarity, which is desirably expected from others and viewed as an evidence of moral behavior, but cannot be imposed as an obligation.
Immanuel Kant moves from the Aristotelian model of a metaphysically grounded ethics of good to a rationally determined moral of duty. This shift is seen as a “Copernican revolution” because, like Copernicus, who put the earth where Ptolemy had put the sun, it presents a new paradigm that puts the person at the center and origin of morality, instead of Nature or God as it has always been (the so-called Kant’s “Copernican revolution” is not only pursued within his theory of knowledge but also in the realm of practical reason).
Kant’s morality has been highly inﬂuential throughout history, being differently present and interpreted in many philosophical trends, as well as in several theoretical-practical models of bioethics. A brief summary of the core structure of Kant’s morality will help to understand the way it shaped major perspectives in bioethics.
The fundamental goal of Kant’s reﬂection on morality was to ground moral law exclusively on reason, that is, to exclude all other determinations for action beyond the exercise of pure reason. By doing so, he expected to formulate a moral law that would be totally objective and that, being purely rational and being reasonably universal, would also be universal. This moral law, rational, objective, and universal, would necessarily be presented by man to all men and therefore would establish an autonomous morality.
Thus, Kant’s morality is formalist and rigorist: formalist because the principle of moral action is reason, is the pure expression of the law, and is a priori determined; and rigorist because, beyond all material determination, it is a moral of duty, of acting by pure respect to the law, and of the fulﬁllment of duty for duty’s sake. Only these features guarantee the objective and universal foundation of morality, together with its autonomy, which Kant aims for above all.
The itinerary to achieve it is established along the Groundwork of the Metaphysic of Morals (1785) and the Critique of Pure Reason (1788). Kant starts with the identiﬁcation of what can be totally good, without restrictions, and states that it is an evidence of common judgment that only the good will, a will that is not moved by any interest, can be entirely good. The will is good for its intention, that is, for its own willingness. Therefore, the will’s worth does not reside in the end it aims toward or in the impact it achieves, but in the principle that moves it, regardless of the level of success it reaches or the results it produces. This principle cannot involve any interest, which is always subjective, but must be exclusively determined by duty, that is, by the need to act out of pure respect for the moral law or practical reason.
Brieﬂy, the good will is not only independent from all inclinations but also expresses the existence of a law as its sole determinant. The good will can only be determined by reason – the good will is a rational will – and its law, or rational rule, has to be objectively necessary, without any relation to any end (always subjective).
The moral law expresses itself by saying: “Act only in accordance with that maxim through which you can at the same time will that it become a universal law” (Kant 2002, p. 56). This ﬁrst formulation of the categorical imperative stresses the universality of the law, its validity to all human beings as an end in itself, subordinating all subjective interests (maxim) to the objectivity of the law. Only the rational being is an end in itself, as expressed by the second formulation of the categorical imperative: “Act so that you use humanity, as much in your own person as in the person of every other, always at the same time as end and never merely as means” (Kant 2002, p. 47). This means that the person has an unconditional and absolute value, in what consists in its dignity. Brieﬂy, it is the will itself of a rational being which makes its own law, becoming legislator and obeying to the law. Moral law is the autonomy of the will.
Kant is a very inﬂuential philosopher in bioethics, and his doctrine is differently used by different theorists. Principlism, contractualism, or libertarianism, among other theories, all appeal to Kant, each one developing a different Kantian line of reasoning: the need to ground rules of practice on principles that impose themselves as requirements for morality, regardless of the outcome of their application in concrete situations (Tom Beauchamp and James Childress); the importance of social contract for an autonomous and universal morality (John Rawls); and the imperative to acknowledge the persons’ liberty and to treat them as ends (and not to use them as means), which is a human basic right (Robert Nozick).
Nevertheless, there are two speciﬁc issues in which the Kantian inﬂuence plays a more decisive role within bioethics. The ﬁrst one concerns two of the core principles of bioethics: autonomy and justice. These are deontological principles, that is, they stand by themselves as basic requirements for an autonomous and secular morality: if morality is built by persons for persons, their will must be taken into account and respected, to avoid violence from some to others, and all persons have to be recognized as equal and treated fairly to eliminate all kinds of injustice.
Beauchamp and Childress, on their Principles of Biomedical Ethics (1979), have been systematically criticized for presenting four prima facie principles, which are equally binding – beneﬁcence, nonmaleﬁcence, autonomy, and justice – but always ending up giving more weight to the principle of autonomy. In this context, it is essential to understand that beneﬁcence and nonmaleﬁcence are consequentialist principles that are only observed if they produce a good or avoid an evil; autonomy and justice are deontological principles that just need to be obeyed, regardless of the consequences. If, for example, autonomy and beneﬁcence clash in a particular situation, there are no obstacles to follow the principle of autonomy, but sometimes it is not possible to produce anything good: imposing a blood transfusion to a Jehovah Witness against her/his will would violate the principle of autonomy and would not produce a good (only a medical good but not the good of the person), but complying with his/her will fulﬁlls the respect for autonomy. It is due to its nature that the principle of autonomy prevails over the one of beneficence and not due to the author’s choice: deontological principles always prevail when conﬂicting with consequentialist principles.
The second theme decidedly shaped by Kantian philosophy is the central role of persons, as rational beings and always considered as ends in themselves. This corresponds to a secular deﬁnition of “human dignity,” broader than the former Greek (dignity was an attribute reserved only to a few) or the Christian one (based on the creation of Mankind by God). The principle of human dignity is, formally, the most consensual worldwide and points out, in the wake of Kant, to the unconditional and intrinsic value of the person.
It is true that some libertarians, like Tristram Engelhardt, Jr., in The Foundations of Bioethics (1986) adopt a restrictive view of the person, which the interpretation of Kant allows, stressing rationality as the identifying feature. Consequently, those human beings who, for different reasons, do not have the full use of reason and are not moral agents become less of a person: fetuses, children, senile, mental retarded, etc. Nevertheless, it is fair to say that the Kantian perspective on human dignity is the most inclusive and the most inﬂuential in global bioethics.
Ethical Universalism And Cultural Pluralism
Aristotle and Kant, together with many other moral philosophers throughout history, developed their own systems within a horizon of universality. Morals require a universal framework out of which it is not even possible to talk about morals. Indeed, every single rule is only justiﬁable and valid if it is addressed to all members of the community in question (e.g., legal rules: national law or international law) and, in what concerns moral rules, the community in question is humanity itself.
Nevertheless, throughout the twentieth century and especially in the second half, several authors challenged this universal framework due to two key factors. The ﬁrst was the fall of the ethical universals established throughout history: Man stopped considering the law of nature, natural law, as a guide for his actions and started to trust on his educated liberty to lead him; Man also recognized that not all persons have faith in God and that even God can be differently personiﬁed and therefore could no longer be a universal foundation for human action; moreover, Man became aware that he cannot be reduced, in his identity, to reason, without affection, emotions, and subjective interests that play an important role on the decision-making process and actions. The second key trigger of the relativistic interpretation was the development of cultural anthropology and the study of customs and traditions of different peoples widespread in the world, some of them unknown until then. This leads to the perception that also moral values, principles, and norms, in sum morality, differed according to time and space, people, and culture and consequently to the rejection of a universal frame to morals; it leads to the announcement of a moral relativism and to the statement that all morals are worth the same, regardless of their contents and of their orientations, all due to be equally respected (which would, e.g., make female genital mutilation (FGM) practiced in several cultural or the death penalty acceptable).
Moral relativism quickly and widely spread, perhaps due for the convenience of many to invoke what would be a subjective moral in order to nestle their own interests, to eliminate all obligation from morals, and also due to the lack of a sound reﬂection on these issues from the general public opinion, which would inevitably lead to the recognition of intrinsic contradictions. Beyond the logical impossibility of morality outside of a universal framework (if not real, then at least aimed for), moral relativism incurs in two major misunderstandings. The ﬁrst one is that the so-called relativism is only real at the empirical level and at the observational level, but it is not sustainable under a deeper reﬂection (e.g., if all statements are relative, the statement of relativism is also relative). Indeed, there are transcultural values, that is, values that are cherished by all generations of different peoples worldwide; notwithstanding, they are particularly and differently expressed at the empirical level, in different societies: all societies advocate the duty to take care of the elderly, but some members of the community will abandon them outside the community to save them from a public degeneration, and others, from a different community, will surround their elderly with specialized care in order to postpone death. At the empirical level, the two behaviors are totally different, but both express the same obligation of caring for the elderly, and this is the second clariﬁcation in need. Cultural pluralism cannot be mistaken with moral relativism.
A universal ethics remains of paramount importance. Due to the impossibility to ground a universal moral in one single tradition or school of thought, and in the absence of ethical universals, the need for a universal framework was satisﬁed by the elaboration of a worldwide consensual moral: the Universal Declaration of Human Rights (1948). Contrary to the former morals that were lived every-day for years before they became a matter of study and reﬂection and were systematized into norms, the morality of human rights was discussed and established before being experienced: the process was not inside-out, as before, but outside-in, conventionally.
It is well-known that the morality of human rights is not yet universally complied with, but it represents a worldwide consensus about the need for a universal morality, and it is also the widest moral consensus of the humanity’s history. Nevertheless, it is important to stress that the wider the consensus is, the narrower the content: a consensual morality is almost always a minimalist morality.
In what concerns bioethics, under the current issue, there are four points that deserve to be underlined. Firstly, bioethics has always tried to oppose any kind of relativism, although respecting cultural diversity, and global bioethics is a testimony of this endeavor. Secondly, the morality of human rights is the backstage of all theoretical practical models of bioethics. Thirdly, many of these theoretical-practical models of bioethics are explicitly grounded on common morality (the principlism of Beauchamp and Childress), and human rights are part of it. And lastly, it is important to underline that the morality of human rights is particularly relevant for libertarians, although they restrict them to individual rights without taking into account social rights, as communitarians do.
Bioethics is so committed to a universal framework and in particular to the morality of human rights that, today, the ones concerning the application of biology and medicine to human beings are considered worldwide to correspond to the fourth generation of human rights.
Ethics And Morals And “Ingredients” Of Moral Life
Conceptual accuracy is of paramount importance in philosophy and also in ethics. Particularly in ethics, there is a speciﬁc terminology that is also very frequently used in daily life, without the rigorous meaning soundly justiﬁed and required by a philosophical discipline. Therefore, a scholar on ethics, as well as a professional in bioethics, has to commit to the full and accurate understanding of the concepts that reﬂect on human action and to their correct use and the different consequences each of them entails, to apprehend how they translate the dynamics of action into rational intelligibility and how they describe the requirements of moral life as well as the right procedure for a moral decision-making. The contemporary French philosopher Maurice Blondel calls them “ingredients” of moral life, which are indeed essential elements to understand and describe moral life, being also of a different nature and able to combine among themselves differently and, hence, to accordingly express different moral realities.
Some of these concepts play a major role in the analysis of action, in a rational discourse on ethics, and they all constitute speciﬁc terminology to reﬂect on human action.
Ethics And Morals
There are some concepts that do gain particular importance, starting by “ethics” and “morals.” These concepts can be used both as synonyms and with distinct meanings. Either option has to be grounded in the etymology and the conceptual history of both.
“Ethics” has a Greek root (ethos), having been used with two different meanings according to its two different spellings in ancient Greece.
It is possible to trace the origin of the word “ethics” to the 8th century BC, to the epic poems of Homer and Hesiod. At that time, “ethics” was written with a long ﬁrst vowel (êthos, Zyoz; with a Z = êta). For Homer, êthos meant “stable,” “lair,” and “hole”; for Hesiod, it meant a “hostel” for Man. Broadly speaking, êthos refers to the place where animals take shelter, and in a later derivation of meaning in its application to Mankind to “the place from where the acts sprout,” that is the human interiority.
But ethos could also be written with a short ﬁrst vowel (éthos, eyoz; with a e = epsilon), meaning “habit” or “custom.” The Greek language had, in fact, two terms for ethos with two different meanings.
When Aristotle distinguishes dianoetic (dianoétikès) from ethical (éthikè) virtues, he links the adjective éthikè, correlated to êthos, to the noun éthos. This connection contributes to the perception of the ethos, root of the word “ethics,” only as éthos (and not anymore as êthos).
This interpretation was reinforced when Greek literature was translated into Latin. The Latin language had only one term – mos (genitive: moris) – meaning “habit,” “custom,” “character,” and “rule,” to translate either the ancient êthos or the more recent éthos. Therefore, both Greek spellings were translated indifferently by mos, the Latin root of “morals.” Melting the two different meanings of the Greek ethos in just one Latin word, mos, the most ancient Greek meaning, the one that refers to human interiority, was lost in the history of ethics or morals, both justiﬁably considered synonyms.
The speciﬁc meaning of the ancient êthos would only be recovered in the twentieth century, by the philosopher and scholar of Greek preclassic thought Martin Heidegger in his Letter on Humanism, in 1947. Heidegger unveils that “ethics,” in its original and therefore true meaning, refers to human interiority, to the depths of each one, where human acts are born. Aristotle, and the other authors that followed him throughout history, forgot this original signiﬁcance of ethics and used this concept to designate human action oriented by a view of the good.
On the wake of Heidegger, many philosophers, as the distinguished Paul Ricoeur, tend to consider that ethics refers to the foundational level of human action, answering to the question “why do people act the way they do?” Moral refers to the normative level of human action, answering to the question “how should people act?”
Brieﬂy, from the philosophical and historical perspectives, it is justiﬁable to use the words “ethics” and “morals” either as synonyms, which is quite common in the current literature, or as distinct concepts, an option that has been growing among scholars. Those who value the historical perspective will tend to use “ethics” and “morals” indifferently, as happened throughout centuries, arguing that the two words have a different origin but share the same meaning. Those who value the etymological perspective will tend to use “ethics” and “morals” differently arguing that “ethics” corresponds to the most ancient meaning of êthos, as the origin of human action, “the place from where the acts sprout,” and therefore to the foundation of action, and “morals” corresponds to the more recent meaning of éthos, the same one that “morals” also expresses, as a “rule” of practice, and therefore to the orientation of action. Both perspectives about the relation between “ethics” and “morals” are, then, justiﬁable.
One can argue further that, having already two different terms, with two different possible meanings to reﬂect on action, to analyze and describe it, the use of both, distinctly, is very convenient to widen and deepen the understanding of human action. The more linguistic resources are available and used the more faithfully will thought coincide with reality. A distinction between “ethics” and “morals” allows separate consideration of the level of the foundation of human action (ethics) and the normative level (morals), the “why” or reason to act in a speciﬁc way, and the “how” or the rule to follow in action. This distinction is not common in Anglo-Saxon bioethics that inﬂuences most bioethics worldwide, and it has been used mainly in continental European bioethics. Nevertheless, it is very helpful for a more accurate and detailed or ﬁner ethical analysis of human action.
Principles And Norms
“Principles” and “norms” are also concepts sometimes used synonymously. Indeed, both are general statements, expressing an obligation, but their level of speciﬁcation or content establishes their distinction: principles are more abstract and, therefore, easier to gather consensus; they unfold in norms or rules of practice that specify their content and the way they should be applied to concrete situations, to the ever singular cases. Principles are formulated at the foundational level of action (ethics), and norms are established at the normative level (morals); a principle-based theory develops itself at the grounding level, and a norm-based theory develops itself at the justiﬁcation level. However, after the crisis of metaphysics and the dissolution of the absolute required as philosophical ground, most moral theories develop at the justiﬁcation level, as logic of human action.
Anglo-American bioethics does not usually follow the distinction between “principles” and “norms.” For example, the core principles of bioethics, proposed by Tom Beauchamp and James Childress in Principles of Biomedical Ethics, 1979 (which holds until the 7th and so far the last edition, in 2013), are referred as “mid-level principles” which corresponds to “norms” within the distinction between principles and norms.
Bioethics requires a three-level analysis: metaethics, in order to understand the presupposition of moral thought, including the identiﬁcation of the foundational ethical principles; normative, to formulate the rules that derive from the principles and that can be directly applied to speciﬁc cases, assisting decision-making; and casuistic, to take into account the particularities of each case and to evaluate the outcome of the application of the norms and principles previously established. This is a top-down scheme, traditionally characteristic of principlist theories; casuistry would typically follow a bottom-up scheme.
This distinction is not as hard anymore though. The application of Rawls’ method of reﬂective equilibrium to bioethics requires what has also been called an integrated method top-down-bottom-up: working, back and forth, the application of principles and norms to cases, and considering the outcomes which might recommend the revision of the norms and principles for a further application to new cases achieving a more satisfactory outcome. Bioethics, as all applied ethics, requires efﬁcacy in the resolution of the different problems it handles, and the success and satisfaction of practice is as important as the soundness of theory. The main goal of the integrated method is to guarantee coherence among principles, norms, and outcomes and among different cases.
Values And Virtues
“Values” and “virtues” are both concepts that go back to ancient Greek philosophy, but if virtues have always played an important role in morality throughout history, values have become relevant mainly in contemporaneity and more speciﬁcally after David Hume’s distinction between facts (descriptive: what is) and values (prescriptive: what ought to be), leading to the development of a general theory of value which includes different kinds of values – moral, religious, esthetics, economic, environmental, etc. – and values of different natures, namely, subjective and objective values.
In what concerns moral values, the main point for axiology is to classify which things are good and how good they are (good, better, best, bad, worse, worst); in what concerns the different nature of values, it is only contemporary general theories of values that build not only from objective values but also from subjective ones, centering the debate on whether values are dictated by subjective psychological states or correspond to objective states of the world. Indeed, both can coexist, and in a hierarchy of values, those attributed by the person according to his/her own interests (what is wished: instrumental value) will occupy the lower level, and the permanent values independent from the agent and intrinsic to objects or actions (what is wishable or desirable: constitutive value) are placed at the top level.
Subjective and objective values both play an important role in bioethics and must therefore be acknowledged and respected. Subjective values can present themselves as religious beliefs or personal convictions, and unless they result in personal or collective harm, they should be accepted. Examples would be the use of placebo or alternative therapies. Objective values are intrinsic to some realities, such as health or life, valued in themselves, and they take precedence over subjective values. Nevertheless, these values are no longer considered absolutes within bioethics, and they have been subordinated to quantiﬁcation: balancing the level of health achievable and the amount of pain and suffering endured and balancing the level of development and quality of a life and the consequences of maintaining it. This potential inversion of values, where subjective values take over objective values, is a consequence of the weight given to consensus in detriment of a theory of values or principles. “Virtue” is one of the oldest concepts in Greek ancient thought: ﬁrstly referring to physical outstanding capacities and later including also traits of character. In both cases, virtues always designate excellence in action, achieved by the repetition of the same kind of actions, contributing to the perfection of the person in question.
A principle-based bioethics without virtues could be very efﬁcient and efﬁcacious but would also be empty of affections or emotions; it would be distant and cold, far from the warmth and closeness of true human relationships that only virtues can develop. Virtues do not address themselves as obligations (like principles, norms, or even values) but as an appeal to each one’s will. A healthcare professional can comply with the highest professional and ethical standards, but he/she will never be a good professional without compassion, ﬁdelity to trust, integrity, self-effacement (Pellegrino and Thomasma 1993), kindness, commitment, thoughtfulness, caring, etc.
Rights And Duties
The idea of rights as entitlements (privileges or powers) belonging or attributed to some persons always existed. What becomes a novelty in contemporary times, in the wake of the philosophy of rights of the Enlightenment, is the statement that all human beings have rights and that there are natural rights, inalienable and indefeasible. Further developments, and different theories, lead to a diverse classiﬁcation of rights. These have been said not only natural, universal, and intrinsic to the human condition but also recognized as formulated by society as a collective commitment toward each and all citizens. The four generations of human rights (civil and political rights, socioeconomical and cultural rights, solidarity rights, and rights related to genetic engineering or broadly referred as rights of future generations) fall in this category. In both cases, rights are upheld by law.
Rights have also been deﬁned in terms of duties which ground the common perception that rights “correlate” with duties. Nevertheless, the language of duties or obligations comes later than the language of rights and entitlements in common morality, and the recognition of responsibilities is still substantially weaker than the claim for liberties. One example of what has been said is surely the Declaration of Lisbon on Rights of the Patient, issued in 1981, by the World Medical Association. It was only later, by the initiative of different institutions, that a roll of duties was proposed, although its diffusion and general public knowledge is still limited.
Today, at the theoretical level, rights and duties come together more often; in daily life, however, the focus on rights is still overwhelming relative to duties, even on the healthcare setting, as became obvious on the discussion, in 2014, on rights and duties of healthcare professionals under the danger of Ebola (very much like the discussion over HIV in the 1980s, when patients were abandoned due to the fear of infection).
It is worthwhile to stress the pertinence of the German philosopher Hans Jonas’ reﬂection on this issue, establishing an inverse proportionality between rights and duties: those who are less powerful (newborns, sick or old people, handicap, etc.) have far stronger claim of rights than the responsibilities they can perform; in contrast, those who are more powerful (politicians, healthcare professionals, media, etc.) have weaker claim of rights than the responsibilities they should answer for. Both perspectives are important in bioethics, being the one from Jonas also applied to environmental issues and in a more demanding way.
Applied Ethics: Bioethics
Applied ethics arose in the 1960s due to a convergence of quite different factors: the demoralization process following the advocacy of moral relativism, which leads to the lack of sound orientation for human action; the urgency to regain the guidance provided by ethics in order to contribute to more respectful, kind, and fair personal relationships; and the democratization of ethics with the rejection of a superior authority dictating the moral rules and the willingness of the citizens in general to participate in the formulation of morals (sometimes referred to as a “ethiocracy” or assumption that all and each one can be the author of morals). Applied ethics is a restricted ﬁeld of ethics speciﬁcally concerned with a concrete social domain of activity, whose success extended to evermore domains (healthcare, environment, engineering, media, business, international relations, etc.), and equally involving all stakeholders. This feature is important to distinguish applied ethics from professional ethics, both being closely related and sometimes mistaken for each other.
Applied ethics is a branch of ethics speciﬁc toa concrete social domain of activity, grounded on common morality and addressed to all people possibly involved in that activity (bioethics addresses healthcare professionals, as well as patients and their families, and also all who might need healthcare or those who want to be involved in societal matters); but professional ethics is a branch of ethics speciﬁc to a professional group, established by those professionals for themselves (in a closed circuit: medical ethics addresses only medical doctors). Applied ethics formulates moral rules aiming to promote personal ﬂourishing and good human relations according to a shared perception of good or duty, within a speciﬁc social domain of activity; professional ethics formulates administrative, legal, and ethical rules aiming to promote good practices and the prestige of the profession. Therefore, applied ethics is broad and pluralist, and professional ethics is restricted and unisonous voiced.
All applied ethics are of a theoretical-practical nature, having a double requirement: on the one hand, a sound theory to guarantee the objectivity of its justiﬁcations and the coherence of its orientations and, on the other hand, efﬁcient and efﬁcacious interventions in concrete situations to assure the real and satisfactory resolution of problems.
The ﬁrst and most prominent applied ethics is bioethics, introduced in December 1970 by Van Rensselaer Potter, in his work “Bioethics, Science of Survival,” a chapter of the book Bioethics: Bridge to the Future, published a month later. “Bioethics” was then regarded to have an ecological dimension, as a new science gathering the knowledge of life sciences and of the systems of values in order to assure the survival of Man in a threatened environment. Months later, on 1 July 1971, André Hellegers also introduced the word “bioethics,” without knowing Potter’s work, at the foundation of “The Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics.” “Bioethics” was then understood as a biomedical ethics, a reﬂection and practice upon the impact of the new biotechnology on Man, a meaning that has prevailed.
Applied ethics have been answering, in a broad and consensual way, to the many concrete questions that are raised by the wide diversity of domains of human activity to which citizens of democratic societies are today called to participate in. Taking into account that rules of practice are not predetermined and can be revised throughout time, citizens are challenged to collaborate and to get involved in what concerns them too. Today, applied ethics are indispensable to democratic coexistence and to active citizenship.
Ethics has evolved along the centuries, mostly in contemporaneity, but has always preserved its identity as a rationalization of human action, in which it grounds its objectivity and coherence and its validity and credibility, within a universal framework. These requirements prevail either in a heteronomous or in an autonomous ethics, either in a maximalist or in a minimalist ethics, and should also be observed in applied ethics, such as bioethics.
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