The term bioethics was coined in the early 1970s by biologists who brought to the public’s attention two pressing issues; the need to maintain the plant’s ecology and the implication of advances in the life sciences toward manipulating human nature. Van Rensselaer Potter has focused on the growing human ability to change the nature, including human nature and the implication of this for our global future [ CITATION Van71 \l 1033 ]. While bioethics has been interdisciplinary since its inception, theology played a fundamental role in its creation. It continues to have a profound influence today also.
At its inception, the central issues in bioethics were researched with human subjects, genetics, organ transplantation, death and dying, and reproduction. These issues still continues to be the important ones. Increasingly, the area referred as reproduction or reproductive technology is attracting bioethical concern. This includes birth control, abortion, and a number of relatively new developments, such as in vitro fertilization, surrogate parenthood, the use of human fetuses in research, and the possible introduction in Australia of RU 486, the post-coital contraceptive or abortion pill as a form of birth control. The issues surrounding birth control and abortion are capable of generating intense ethical and political debate. The killing of several doctors in United States doing abortion operations demonstrates the intensity of this issue (Neill, Conway, Wyndham). The other side of coin to contraception, in vitro fertilization attracts a similar ethical response from its opponents. Apart from its being unnatural, arguments against in vitro fertilization are based on the claim that satisfying the desires of the older women to have children raises long-term problems concerning the welfare of the children produced. Surrogate parenthood, or the act of women bearing a child for other women who will later become its mother, raises a number of bioethical questions. These questions are elated to the variations of surrogacy. It is possible, for instance, a women to bear a child following implantation of a fertilized ovum using the genetic parents gametes, that is, both sperm and ovum. On the other hand, implantation can involve only one parent’s gamete, the sperm or ovum coming from a donor who could be the woman who bears the child. In the latter instance, fertilization could precede implantation. These variations poses various questions like will the child be comfortable with the fact that it has as much as five parents involved in its birth process and who remains the true biological parents of the child. From where the child derives its biological connection? Will the child ever be able to forgo its tendency to relate back to its parents biologically? All these unanswered questions raise a concern related to bioethics.
Organ donation and transplantation is also one are which is facing opposition from bioethics field. We may take for granted the existence of some forms of human tissue donation and transplantation like bone marrow, cornea, kidney transplants and blood transfusions; still it raises numerous bioethical questions. The ethical treatment of organ donation and transplantation can be discussed at two levels, at individual level, for the individual who are actually the donor of the organs; the cultural sensitivity regarding this process is taken into consideration or not is a big question. For instance, Japanese are resistant to heart transplants because of their cultural assumptions about the heart, families of deceased individuals may, for religious and other cultural reasons, not want organs to be removed at death even though the donor has given its consent for this [ CITATION JLT99 \l 1033 ]. Moreover, there is a question of equal treatment of recipient and donor.
All these questions posed regarding abortion and organ donation and transplantation would be discussed in detail in relation to the principles of bioethics in subsequent chapters.
Bioethics was expected to generate a single normative theory; however in reality it reflects a wide range of theatrical approaches in normative ethics, including utilitarianism, deontology, natural law, contractarianism, virtue ethics, communitarianism, pragmatism, and feminist ethics (Steinbock et al 2003). An approach that is known as principlism, advocated by Beauchamp and Childress in their classic text “Principles of Bioethics” (1979 - 2001), attempts to derive answers to bioethical dilemmas from the basic principles: autonomy, non-maleficence, beneficence, and justice. These principles are thematic in the writing of scholars adopting the principles orientation.
Autonomy is the most prominent within the principles orientation. In philosophical terms, its necessary condition includes an individual being able to legislate the norms of conduct and voluntarily to fix a course of action (Beauchamp and Childress, 61). At the macro level, autonomy is the supreme value. Bioethics researchers have captured the significance of the social context in which individual autonomy has emerged by “unparalleled endorsement to individualism and individual rights and a concern for civil rights protection of vulnerable groups, including the subjects of medical research and the recipients of medical care” (McNeill, 63).
Autonomy is the central concept in bioethics because it ranks logically in front of, and is invoked to defend the appeal to other ethical principles, such as justice, confidentiality and truth telling. Autonomy is “supreme, and central, justice is closed linked with autonomy since it is concerned with treating people with equal respect precisely because they are autonomous moral agents or persons” (Charlesworth, 115).
In simple terms, autonomy implies that people have a right to and should make their own decisions in life, provided that the consequences do not violate other people’s autonomy. The basic norm of respect for autonomy in biomedical ethics is informed consent (T. L. Beauchamp & J. F. Childress, 65-66). Both the historical roots as well as the justification of informed consent are grounded in the principle of autonomy [ CITATION RRF86 \l 1033 ]. Beauchamp and Childress describe five elements: competence, disclosure, understanding, voluntariness and consent. Consent is considered genuine when it is informed and voluntary (T.L. Beauchamp & J.F. Childress, 288). Voluntary consent is defined as a person’s acting on account of his/her own free will, the condition of not acting under compulsion, or acting intentionally. Autonomy recognizes the human capacity for self-determination, and puts forward a principle that the autonomy of the person is ought to be respected [ CITATION BMi95 \l 1033 ]. In bioethics autonomy, both the Kantian concept of autonomy (the will’s conformity with universal practical reason) and the radical and more liberal concept of autonomy in medical ethics are applicable [ CITATION BMi95 \l 1033 ].
Non-Maleficence assert one’s obligation to not to inflict harm intentionally. This has been closely related to the maxim primum non nocere, that is, above all do no harm in medical ethics. Fir Beauchamp and Childress the principle for non-maleficence contains the following rule: “do not kill, do not cause pain or suffering to others, do not incapacitate others, do not cause offense to others, do not deprive others of the goods of life” (T.L. Beauchamp & J.F. Childress, 117). The principle of non-maleficence is supported by many ethical theories, especially utilitarian and non-utilitarian theories (T.L. Beauchamp & J.F. Childress, 114).
Beneficence is derived from the Latin word bene and facere meaning “the doing of good, active promotion of good, kindness and charity” (T.L. Beauchamp & J.F. Childress, 135). The principle of beneficence refers to a moral obligation to act for the benefit of others. It obliges one to help others for their own legitimate interest. In some ethical theories, especially utilitarianism, beneficence and benevolence have played a central role. The principle of beneficence includes two principles, namely, the principle of positive beneficence and principle of utility. The former principle demands that people should do well for others and the principle of utility demands that “in medical sciences the risk of harm must constantly be weighed against the possible benefits (T.L. Beauchamp & J.F. Childress, 143).
Principle of Justice is about treating people equally in relation to the certain criteria acknowledged to be morally relevant. Beauchamp and Childress explain that different terms such as fairness, deserved, and entitlement are used by various philosophers to express the concept of justice (T.L. Beauchamp & J.F. Childress, 226).
Living Organ Donation and Transplantation
The concept of autonomy in living organ donation and transplantation can be seen from a normative and a radical point of view. A normative understanding of autonomy does not allow living organ donation and at the cost of respect to human person. Autonomy should be considered in context of the vulnerability and the dignity of the persons (Rossell, 217-236), which is applied to living organ donation and transplantation. However, a radical interpretation of autonomy allows any kind of living organ donation and transplantation. In this case, it is the freedom of the donor to sell organs and it is also the freedom of the recipients to buy the organs. In the radical interpretation of autonomy, the donor and recipient have full freedom in transplantation.
On the contrary, all values are seen from the perspective of personal autonomy of the individual ((J. Rendtorff & P. Kemp, 26). Voluntary consent and forced consent are other issues under discussion in living organ donation and transplantation. The voluntary consent of the human subject is essential for living organs donation. The principal of autonomy requires that the patient or the living donor has genuine consent in deciding whether to make a donation or not (A.S. Daar et a, 101). The general principle that surgery cannot be carried out without the consent of the person to be operated upon is equally applicable to organ transplantation as well. A free informed consent, especially when explicitly given is certainly the best way to express our social solidarity (C. Byk, 58).
Sometimes it is very difficult to make an assessment of fully informed consent of the potential donors. For instance, in the case of liver failure patient, the need for the organ is very acute. This situation might force the living liver donors to make an immediate decision. More problematic are decisions made on behalf of minors and incompetents. In such cases, both the principles of respect of autonomy and justice are involved. For instance, let us consider a positive dilemma within a family; a child is suffering from a progressive liver or kidney disease and is in need of a transplant and the only suitable donor is a minor sibling. The parents face moral and legal conflicts of duties. They have a legal responsibility to protect both children. but a parent cannot exercise authority over a child when the proposed course of action is not in favor of the child’s interests, especially when this child may face risks relating to the surgical intervention.
The autonomy of a healthy person to donate his/her organ has both merits and demerits [ CITATION Daa99 \l 1033 ]. The respect for autonomy is the main issue in living organ donation and transplantation. Finally the concept of autonomy with charity is very important in the case of living organ donation and transplantation.
The thematic of non-malificence can also be applied to organ donation and transplantation. The fundamental ethical and legal starting point is the common law or principal that one should not be killed or seriously injured. This is why the donation of the living heart is excluded. From a legal standpoint, this is not a matter to be settled with the reference to an individual’s consent. Since it is a matter of public interest one cannot consent to certain forms of harm. Even with the consent of the person concerned, the principle of non-maleficence forbids mutilation (Lamb, 43 – 52). Thus, in living organ donation, the living organ donation is not a matter of choice and there involves various risks. For instance, in the case of a liver transplant, the estimation of the risks is not clear for the donor [ CITATION Daa99 \l 1033 ]. This discourages certain types of living order donation and transplantation.
However, in certain circumstances harm can be avoided or limited solely by inflicting injury. Sometimes injury is acceptable in order to avoid greater harm [ CITATION Daa99 \l 1033 ] which is the justification for modern medical treatment. Furthermore, Beauchamp and Childress observe that sometimes we have to do harm to the body in order to prevent harm (149). In relation to this, Irwin Kleinman and Frederick H. Lowy say “Ethical dilemmas by their very nature necessitate compromise. Living organ donation compromises the principle of non-maleficence, since healthy donors are allowed to assume risks” [ CITATION Low92 \l 1033 ].
Moreover, in case of blood donation, one does not see any harm or risk to the donor. Hence, it is acceptable according to non-maleficence. In the case of living organ donation, it is not the same. For instance, in cornea donation, when the donation decreases the sight of donors, it results in harm to the donor (Finnis & Fisher, 39). But in the case of kidney donation, the donation is morally right. The reason is that even if the donor faces some risk, there is no functional decrease of the organs (Finnis & Fisher, 39). In this case, one justifies non-maleficence with regard to living organ donation.
Abortion
Justice and non-maleficence prohibits every abortion; that is, every procedure or technical process carried out with the intention of killing an unborn child or terminating its development. Every attempt to harm an innocent harmless person violates the non-maleficence and justice. Every procedure adopted with the intention of killing an unborn child, or of terminating its development, is an attempt to harm, even if it is adopted only as a means to some beneficent end and even if it is carried out with great reluctance and regret. Such procedures are often called direct abortions which mean that it is willed as such directly.
Every living human individual is equal to every other human person in respect of the right to life. Since universal propositions are true equally of every instance which falls under them, equality in right to life is entailed by the truth of two universal propositions, that is, every living human individual must be regarded and treated as a person, and every innocent human person has the right never to be directly killed. Since respect for individual freedom can be curtailed only to prevent harm to another person, there is a need to establish whether the fertilized egg, the embryo, or the fetus fully qualifies as a person an therefore merits the same respect as the pregnant women. The progressive development process from one cell, the zygote, to a newborn baby has a parallel in philosophical reflections and legislation from antiquity to today.
WHO has set the limit for viability at twenty two completed weeks of gestation and beyond this, the termination of the pregnancy is considered as the abortion. The termination of the pregnancy violates the right of the two persons who are equally eligible for respect for persons under the concept of autonomy. The women and the unborn child both possess the same rights. However, the question on prioritizing the life of one is always under discussion, specifically in the cases wherein the pregnancy poses a threat to the women. The choice between the fetus and the women always remains a decision involving many aspects. In the situations, where there is a threat to health or life of women, even the Catholic Church allows indirect abortion and specifies two specific circumstances; ectopic pregnancy and cancer of the genital organs coexisting with pregnancy.
Conversely, the assumption that a woman can be pressured or forced to interrupt her pregnancy is an equal transgression against the ethical principle of respect of persons. Moreover the presence of emotional attachment of the women with the growing fetus is also discussed by psychologists (Brazelton & Cramer). The first feeling of the pregnancy starts between fourteen and twenty weeks and women establish connection with the embryo during this period. Clearly, to have an abortion after fetal movements are perceived exponentially increases the psychological dilemma of pregnancy termination and for many women makes the decision more difficult (Brazelton & Cramer). Thus, applying the principle of non-maleficence, there may be a point in time after which the psychological and physical consequences of pregnancy termination may be more detrimental to a women’s well being than the birth of an unwanted child.
There are several questions in bioethics which remain unanswered. The foremost question which requires further research and understanding is when the situation of the person changes, does the change in opinion with the situation regarding bioethics is acceptable and normal. When the family of a person with failed liver is procuring the liver from the donor, the views regarding bioethics are different and when the same family has some donor in between them, either living or dead, the cultural influences and the feelings become a major driver of the situation. the complete case of donation of organs by living or dead organ is a subjective situation which changes with the need of the person. Further research and analysis of case study would be required to analyze the behavior of the concerned individuals in this area.
Moreover, living world comprises of unique situations and always poses different questions in front of bioethics researchers. The flexibility of the four principles of the bioethics is a matter of examination and how does the principles accommodate the new unique cases of humans as subject of research requires further research.
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