Varieties of Bioethics

As the field has developed, it has become clear that because of the range of diversity of bioethics issues, more than one methodology is needed; by the same token, no single discipline can claim a commanding role. At least four general areas of inquiry can be distinguished, even though in practice they often overlap and cannot clearly be separated.

THEORETICAL BIOETHICS. Theoretical bioethics deals with the intellectual foundations of the field. What are its moral roots and what ethical warrant can be found for the moral judgments made in the name of bioethics? Part of the debate turns on whether its foundations should be looked for within the practices and traditions of the life sciences, or whether they have philosophical or theological starting points. Philosophers and theologians have a central place in this enterprise, but draw strongly upon the history and practices of the life sciences to grasp the aims and developments of these fields.

CLINICAL ETHICS. Clinical ethics refers to the day-to-day moral decision making of those caring for patients. Because of that context, it typically focuses on the individual case, seeking to determine what is to be done here and now with a patient. Should a respirator be turned off? Is this patient competent to make a decision? Should the full truth be disclosed to a fearful cancer patient? Individual cases often give rise to great medical and moral uncertainty, and they evoke powerful emotions among those with a role in the decisions. Decision-making procedures, as well as the melding of theory and practice—what Aristotle called "practical reason"—come sharply into play. It is the concreteness of the judgment that is central here: What is to be done for this patient at this time? The experience of practicing physicians, other healthcare workers, and patients themselves takes a prominent place, yet on occasion can require a collaborative interplay with those trained more specifically in ethics.

REGULATORY AND POLICY BIOETHICS. The aim of regulatory and policy bioethics is to fashion legal or clinical rules and procedures designed to apply to types of cases or general practices; this area of bioethics does not focus on individual cases. The effort in the early 1970s to fashion a new legal definition of clinical death (from a heart-lung to a brain-death definition), the development of guidelines for the use of human subjects in medical research, and hospital rules for do-not-resuscitate (DNR) orders are examples of regulatory ethics. It can also encompass policies designed to allocate scarce healthcare resources or to protect the environment. Regulatory ethics ordinarily seeks laws, rules, policies, and regulations that will command a wide consensus, and its aim is practical rather than theoretical. The law and the policy sciences are highly important in this kind of bioethics work; but it also requires a rich, ongoing dialogue among those concerned with theoretical bioethics, on the one hand, and clinical ethics and political realities, on the other. Regulatory bioethics seeks legal and policy solutions to pressing societal problems that are ethically defensible and clinically sensible and feasible.

CULTURAL BIOETHICS. Cultural bioethics refers to the effort systematically to relate bioethics to the historical, ideological, cultural, and social context in which it is expressed. How do the trends within bioethics reflect the larger culture of which they are a part? What ideological leanings do the moral theories undergirding bioethics openly or implicitly manifest? A heavy emphasis on the moral principle of autonomy or self-determination can, for example, be said to display the political and ideological bias of culturally individualistic societies, notably the United States. Other nations—those in central and eastern Europe, for instance—give societal rather than individual concerns a more pronounced priority (Fox). Solidarity rather than autonomy would be their highest value.

The social sciences, as well as history and the humanities, have a central place in this interpretive effort (Marshall). If done well, the insights and analysis they provide can help everyone to a better understanding of the larger cultural and social dynamic that underlies the ethical problems. Those problems will usually have a social history that reflects the influence of the culture of which they are a part. Even the definition of what constitutes an ethical "problem" will show the force of cultural differences. Countries with strong paternalistic traditions may not consider it necessary to consult with patients about some kinds of decisions; they will not see the issue of patient choice or informed consent as a moral issue at all—yet they may have a far livelier dedication to equality of access to healthcare.

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