Introduction
Medical ethics is an area that has aroused enthusiasm and controversy in terms of investigation and finding a position in society. In raising and sustaining interest, medical ethics continue to draw more considerable attention in terms of research and inquiry. On the other hand, controversy has been ignited to a standstill in classifying medical ethics as either a field or a discipline.
Nevertheless, according to definitions that have been provided to discipline and field, together with what methods constitute, Sugarman and Sulmasy opine that medical ethics should be perceived as a field that embraces inquiry and integrates many subjects rather than viewing it as a discipline on its own.1
In the midst of all this, common sense still drive among scholars in this field due to their uniform consensus that medical ethics as a body of knowledge cannot function on its own instead it functions appropriately depending on other areas.
The position taken by the authors point out to one thing, medical ethicists share ordinary subject matter but the diverse disciplinary mode of investigation of the subject. Therefore, to medical ethicists, the shared common theme is the normative aspect of health care and the way they approach this is through the integration of wide varieties of disciplines2.
Consequently, the various disciplines in their nature employ a wide variety of methods, whereby some of the ways are shared by different disciplines while others are unique to a particular subject. 3
Notably, medical ethics has been explained as a field that embraces different disciplines and methods hence the rise of diverse sub-areas of interests and specialization. For instance, there are medical ethicists with backgrounds in philosophy, theology, healthcare, history, and to mention but a few.
Consequently, the majority of medical ethics have specialized in critical areas of education, consulting, policy analysis and writing, and expert witness. Further, just like any other field, medical ethicists are not experts all-round, and specialization characterizes medical ethicists.
Indeed, today it is conventional to find specialists in research ethics, ethical issues in genetics, public health ethics, ethical issues at the end of life, and many more depending on academic, training, and professional background.4
Understanding bioethics and its contribution to a broader body of knowledge of medicine require an adequate account of the field history since its inception to its current position. It is in this respect that this research paper aims at providing the historical development of healthcare ethics methods with the aim to understand how normative practices in healthcare ethics have developed over time.
Bioethics in the early stages
Traditional period
The development of bioethics is perceived to be heavily implicated by multiple factors and occurrences in the history of humanity and progress in medicine and biology. Before the period of 1945, development in medicine was appreciated and encouraged as solutions to humankind problems became inevitable. However, it is also during this period that laxity in moral probity was pronounced.5
What majority of practitioners thought was necessary was the recitation of the Hippocratic Oath upon graduating as medical practitioners6. As a result, the period before 1945 was primarily characterized by little consideration of medical ethics, and many of practitioners were probably guided by informal and self-convictions of moral beliefs and character.
Many people viewed the practitioners to be, “jealous, quarrelsome, and delighted in annoying and ridiculing each other”.7 In general, medical practitioners had established mistrust among the people, and the overall actions of the practitioners were viewed to be aimed at killing and not saving lives. All was not lost, as this was the period when it could be said the birth of medical ethics was inevitable, and expectations were high.
This was the period when patterns of medical ethics became a constant novelty in the field of medicine. The work of Richard Cabot (1869-1939) became the driving force in initiating medical ethics during this period.
Cabot noted that medical practitioners need some forms of medical ethics to carry out their duties more effectively. All together, Cabot observed that medical practitioners required a thorough understanding of aspects of diseases including: causes, signs, symptoms, courses, prognoses, treatments, as it pertains to individual patients.8
From the above expression, Cabot observed that the new roles and duties of doctors were to be premised within lenses of moral and ethical performance of a task. This led the author to propose numerous measures that practitioners were to abide to establish and seek extensive cooperation between physicians and all subsequent professionals that have an interest in the care management of the patient.
Further, the need for accurate records of patient care which was to be effectively kept and analyzed. Next, the number of patients each doctor was supposed to treat was to be undertaken in a way that does not compromise attention to other patients. Also, practitioners were required to inform their patients about their diagnosis, and their treatment explained to them more appropriately.
Moreover, practitioners were to uphold the utmost respects for their patients and not be used for teaching purposes without their consent. Besides, senior practitioners were required to ensure they respect their juniors and the harmonious relationship established between them. Lastly, disputes among the profession were to be handled by established committees.
Development of medical ethics in the 1950s
1945 to around 1950 acted as a period of transition from the traditional period. During this period, a lot of observation had been made, and some of the practitioners developed a passion for sanctifying the negative perception that had developed and persisted in the field. One such figure that became prominent during this period was known as Ceriani.9
In the company of other practitioners, the doctor embarked on activities and strategies that eventually saw some organization in the field of medicine.
For instances, the combined efforts of the practitioners resulted into improvement in medical education, an organization in the field especially with the adoption of code of ethics, regulation of the licensure in the area, stigmatization of immoral acts in the field and improvement of the overall administration of medicine. Efforts during this period were directed at reclaiming the moral image of medicine as a field.
Subsequently, there was the establishment of the Code of Ethics by the American Medical Association. The code became essential and beneficial to the field, especially in informing medical practitioners about their primary duty to the patients. According to expressions in the system, the practitioners were to refrain from unorthodox, uneducated and unethical practices that could harm their patients.10
Growth of medical ethics in the 1960s
Momentum in medical ethics was evidenced in the early 1960s, especially after the revision that was done on the Code of Ethics in 1966. Upon this ratification in 1966, medical ethics were reduced from an earlier number of ten to seven, and the expression of these principles was in clear terms.
On overall, the established principles required physicians to uphold utmost respect for the rights of the patients they were attending, to improve on their professional skills, to operate with the disciplinary limits of the profession willingly, to ensure thorough consultation where necessary, to keep confidences and to always work as good citizens.11
Together, the principles outlined limitations on the extent physicians could restrict or allow independent medical judgment or on how to obtain professional income other than the outlined remuneration for services. Consequently, it became clear that ethics performed the role that ensured professional cohesion and respectability.
Contribution of religion to the growth of bioethics
Ethics within the understanding of religion
The position of theologists is that theology is composed of specific norms that can be applied comprehensively to any new or complicated situation in the environment.12 As such, theology promotes understanding that the presence of beliefs about creation, responsibility, sin, and salvation are adopted to ensure that individuals act within the specified moral limits and a clear direction of progress is established.13
Thus, a religious position can be interpreted to postulate that there are a universal human nature and an acceptable unified ideal of the good society. To reinforce this, medical ethicists in the Catholic community observe that people have a common environment and an acceptable allied model of good society.14
As a result of having shared experiences and common fundamental values, a common ground always emerges of what to permit, prohibit, or limit about science, innovation, and genetic engineering. In their overall applications, it is expressed that the ethical methods of theology cannot be perceived to be either separated or insulated from one another or even detached from the realities and dilemmas of particular historical contexts.
Theologists’ contribution to the development of bioethics
During the early 1960s, the majority of theologists commanded significant influence in outlining the basic ethics in the medical field. For instance, theologists, in this period, became pivotal in defining questions that guided the emerging field. It is anticipated and almost accepted the conclusion that the desire of theologists together with that of philosophers was largely ignited by the emergence of new biomedical technologies.15
Bioethics exhibit great appreciative work from critical protestant theologians such as Joseph Fletcher, Paul Ramsey, and James Gustafson, who is contributing to the emerging field, incorporated ideas of self-sacrificial love, covenant, creation and image of God16. The understanding was that incorporation of these aspects in the field of medicine was paramount in ensuring the moral ability of area.17
Another group was that of Catholic theologians’ who included Richard McCormick, Charles Curran, and Germain Grisez who brought immense benefit to the emerging field by introducing the traditions of authoritative teaching and moral law18.
Subsequently, theologians such as Ramsey, Gustafson, McCormick, and Lebacqz who served in essential policy bodies in 1970, 1975, 1981 and 1983 respectively19 took a more active role in designing policy framework for bioethics while at the same time working to enrich the field.
Examples of the vital bodies the theologians served under include National Commission on the Protection of Human Subjects of Biomedical and Behavioral Research (1974); and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical Behavioral Research in 197920.
By being part of these bodies, the theologians became key pillars in providing resourceful help in the creation of bioethics institutes. For instance, the early publication and edition of the Encyclopedia of Bioethics were immensely designed and enriched by theologians.
The success of theologians in their various capacities in these initial stages of bioethics development can be associated to the presence of long-standing traditions of reflection on life, death, and suffering which had provided a fertile ground for the establishment of moral conduct norms and moral philosophy at the moment of development.21
Development of bioethics in institutions
Role of conferences
Before institutions and centers became the major fortified avenues in which bioethics methods were cemented and developed, meetings played significant roles. The discussions became critical in the 1960s when considerable changes in terms of innovations and development were being realized in medicine. This was a turmoil period in medicine as social and ethical problems emerged from the increasing medical and scientific progress.22
In the majority of these conferences held in major cities of the USA, medical scientists gathered to discuss the significant issues that were affecting the medical field as science and technology became inevitable. Themes of the conferences leaned significantly to the morality of medicine and the area as large where the idea was to explore how well drug could perform in larger society even as social and ethical problems became a setback.
According to S. Marsh, one of the conferences key personalities, medicine in the growing science and technological world was becoming remote and indifferent to human values.23 As a result, there was a need for the field of medicine to remind itself of the fact that it is a human factor that should override everything else in medicine administration.
Due to this, Tenney, observed that the primary aim of the conferences during the time was to, “examine the issues of conscience in medical and scientific progress, not simply the question of the survival or the extinction of man, but what kind of survival and a future of what nature?”24
This led to a cornucopia of time during the conferences being dedicated to discussing genetics and brain sciences and mainly to discuss and debate ethical considerations that could guide the identified issues.
Institutions and centers where bioethics developed
The end of the 1960s and start of a new decade of 1970s witnessed the shift of debates and discussions of medical ethics from the conferences to development and enrichment of medical ethics in interpretive centers.
The observation that was made for this was that there was a paramount need to move from conferences and its procedures to a more disciplined, careful, long-range way of operation in which concrete solutions to emerging ethical problems could be found.25
Institutions were preferred as the best avenues given their relative possession of critical resources that could be used in establishing concrete bioethics methods. The foundation of the centers was largely ingrained in tremendous work of conferences where materials from meetings became tools of developing framework of research, which now had to be carried out in permanent centers.
As a result, three key centers which became avenues for the development and growth of bioethics discourse were created. These centers included the Institute of Society, Ethics and the Life Sciences (The Hastings Center); the Kennedy Institute of Ethics at Georgetown University; and the Society for Health and Human Values26.
The Hastings Center became operational in the mid-1960s, pioneered by Dan Callahan and William Gaylin. The need to do intensive research on abortion is what drove Dan Callahan into developing the desire to initiate the center.
Observation made by Dan was that the list of controversial moral questions that were appearing in the biomedical world was becoming more abundant and given that conferences and media had become prominent, the issue was that there was the absence of provision for concentrated interdisciplinary study.27
Therefore, the effect of abortion and its related aspects could not be explored adequately outside an established center of a distinguished body of literature and concrete frameworks.
After the initial processes of equipping the center with adequate human resource and infrastructure, four areas emerged in which the center became prominent in terms of research: death and dying, behavior control, genetic engineering and counseling, and population control.
Activities of the center became famous mainly through the organizing of symposium and conferences. As a result, the center is credited for inviting and having one of the largest pools of scientists and non-scientists who came together for topical discussions and debates which propelled bioethics into the intellectual map.28
The Kennedy Institute’s pioneer was Andre E. Hallegers, a research scientist in the area of fetal physiology. As a research scientist, Andre became prominent in organizing conferences on abortion, especially in 1967, which he did in collaboration with Kennedy Foundation.
After the conference, the scientist developed an urge that occasional meetings could not address the emerging issues in reproductive sciences and what was needed was a center that could turn to be a scholarly unit for these issues.
As the center developed into a full academic organization, it was clear that it became an avenue where bioethics studies became more pronounced and an avenue where organization and assembling of scientists and moral ethicists shared platform and knowledge that became critical and resourceful in development of bioethics.
More so, the center is credited with fostering professorships, fellowships, and courses by creating the tools for research specifically in the Bibliography of Bioethics and the Encyclopedia of Bioethics.29
Another center was the Society for Health and Human Values, which was appreciated for its role in the development of the field of bioethics. The center was a matured idea following discussion between United Ministries in Education and Methodist and Presbyterian Churches.
Primary aims for the establishment of the center rose from the identified concern to do with ‘depersonalization of medical students and the tendency to teach mechanistic medicine30.
As a way of providing the necessary contribution in the medical field, the society became critical in identifying the related problems, forming groups that could develop methods to clarify and assist in solving the issues and subsequently developing a change in professional attitude and public awareness.
Following this, the society became deep-seated in identifying and solving ethical issues in health care and advocating for medical humanities. This way, the community did participate significantly in the creation and development of bioethics methods.
Conclusion
In this short account on the development of healthcare ethics, it has become clear that the field of bioethics possesses multiple origins in interdependent areas. Nevertheless, the majority of early contributors and field development were drawn from theology institutions, and their overall role to the ground is enormous.
However, it has to be remembered that as time has elapsed, the field of bioethics has continued to grow and expand, especially as dynamism engulfs the entire field of medicine and society. Development of science and technology has guaranteed the continued growth of the field of bioethics, which is likely to continue.
Although the field in concerted efforts to establish its unique methods, it should not be forgotten that much will still come from other areas, a situation that will see bioethics continue to depend on other disciplines.
Endnotes
1 Jeremy Sugarman and Daniel P. Sulmasy, Methods in Medical Ethics (WA: Georgetown University Press, 2010) p.5.
2 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.79
3 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.6.
4 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.7.
5 Albert R. Jonsen, The Birth of Bioethics (NY: Oxford University Press, 1998) p.4.
6 Albert R. Jonsen, ibid, p.100
7 Albert R. Jonsen, ibid, p.5.
8 Albert R. Jonsen, ibid, p.6.
9 Albert R. Jonsen, ibid, p.7.
10 Albert R. Jonsen, ibid, p.8.
11 Albert R. Jonsen, ibid, p.9.
12 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.34.
13 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.73.
14 Albert R. Jonsen, ibid, p.79.
15 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.75.
16 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.41
17 Albert R. Jonsen, ibid, p.73.
18 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.76.
19 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.35.
20 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.36.
21 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.77.
22 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.13.
23 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.14.
24 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.15.
25 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.18.
26 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.20.
27 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.21.
28 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.22.
29 Jeremy Sugarman and Daniel P. Sulmasy, ibid, p.23.
30 Jeremy Sugarman and Daniel P. Sulmasy , ibid, p.24
Bibliography
Jonsen, Albert. R. The Birth of Bioethics. NY: Oxford University Press, 1998.
Sugarman Jeremy and Sulmasy, Daniel. Methods in Medical Ethics. WA: Georgetown University Press, 2010.