Contributors

Contributors

It is easy to allow ourselves to be lulled into a state of confident ignorance when it comes to the state of bioethics in countries other than our own. We presume to know what issues are important, what patients want, which policies are being debated, and, at the very least, how our international colleagues are viewing the general bioethics landscape. In a field where we say “good ethics begin with good facts,” we are often woefully ill prepared to see and understand the larger picture.

Historians of the future tracking the development of bioethics will note that the debates and arguments that have most engaged bioethicists thus far have been directed toward addressing the dilemmas attending physicians face as they interact with patients in the clinical setting. This is only to be expected, given the circumstances that gave birth to this burgeoning field. The preoccupation with clinical questions has, however, had an unfortunate consequence. Less examined by bioethicists are the significant behind-the-scenes ethical issues generated by, and specific to, the years of undergraduate and postgraduate medical training.

This special section deals with the new professionalism movement. The interest in the term “professionalism” has been growing steadily in medicine, and the word now seems to be everywhere. However, bioethicists have lagged behind our colleagues in medicine and nursing in explicitly contributing to this movement. This special section adds to the effort to catch up.

In Greek mythology, Icarus and his father Daedalus attempted to escape from Crete on artificial wings built of wax and feathers. Against his father's warning, Icarus flew so close to the sun that the wax melted and he fell to his death in the Aegean Sea. There is no question that the advances of biotechnology are creating a new landscape; but the question is whether that landscape more closely resembles a promised land, or as in Auden's poem, a sea in which the legs of Icarus are disappearing.

There is a wind of change about to affect the training of all house officers in the United States. The Accreditation Council of Graduate Medical Education (ACGME) has promulgated a set of general competencies for all U.S.-trained residents, with a major thrust focused on bioethics and professionalism that will likely catch residency directors unaware. The ACGME's General Competencies document globally addresses many relationship-based ethical roles and responsibilities of house officers in healthcare. Of note, this document contains a specific section on professionalism. However, the entire document is woven with a sustained thread of medical ethics throughout its other sections. The intent is to imbue each physician with those skills, rules, and aspects of character that will be a foundation for humane, ethical, professional conduct. Professionalism does indeed go beyond ethical principles, accounting for competency and commitment to excellence and, most of all, implying a virtue ethics account of medical practice. The need to address the central place of virtue ethics in house-staff education is apparent, and we now have the right tool for the job—the ACGME General Competencies.

Ten years ago there was little talk about adding “professionalism” to the medical curriculum. Educators seemed to believe that professionalism was like the studs of a building—the occupants assume them to be present, supporting and defining the space in which they live or work, but no one talks much about them. Similarly, educators assumed that professional values would just “happen,” as trainees spent years working with mentors and role models, as had presumably been the case in the past. To continue the metaphor, when educators did discuss ethics and values, they tended to focus more on external building codes than on the nature of construction materials. Building codes are designed to ensure the public's safety by establishing procedures and standards. Likewise, the “new” bioethics of autonomy and informed consent that entered the medical curriculum in the 1970s and 1980s was oriented primarily toward protecting human rights (e.g., protecting patients from clinicians and clinicians from patients) by codification (e.g., who should decide and under what circumstances). In fact, educators explicitly warned students against acting on their personal or professional values in a misguided way—that is, in the absence of adequate ethical constraints, a type of behavior that came to be labeled, pejoratively, as paternalism.

In 1970, Jacque Monod, a Nobel Laureate and a founding father of molecular biology, wrote a short celebrated book entitled Chance and Necessity.

It goes almost without saying that there are no academic bioethical debates that are unique to the United Kingdom. The debates in which U.K. bioethicists become involved take place in international journals and in books with a worldwide readership. The contributions of those from these shores are frequently made in response to work by academics from the United States, Australia, Scandinavia, and a whole host of other countries.

When I immigrated to Australia from the United States a few years ago, at first I found many similarities between the countries. But underneath the apparent similarities, notably a shared language, lay much deeper differences in history, politics, and culture that have considerable impacts on attitudes and approaches to issues in bioethics and medicine. For instance, debates continue regarding cloning and embryonic stem cell research, particularly given the long history of research in reproductive medicine and reproductive technologies in Australia. Although there are individuals and groups opposed to such research on grounds associated with pro-life or anti-abortion stances, the discussions more often hinge on what should be funded by the government and eventually what should be provided to all within the public system of healthcare. This theme is one common thread that unites many current controversies in bioethics, but perhaps not for the reasons that an outsider might at first expect. Indeed, allocation of limited resources is part of what is considered relevant, but money is rarely presented as the decisive issue in these debates. Instead, considerations such as what is medically necessary (based on a broad definition of what is medical), what contributes to a “good life” (as defined by what are increasingly heterogeneous community standards), and how to respect and enable fulfillment of autonomous decisions by individuals and families in this rapidly changing context are key to many of the disputes. This brief report is necessarily selective, but it is designed to give a flavor of the terms of the debates as they are currently developing.

“Character counts at Central High” is the message frequently exhibited on the curbside marquee outside our local secondary school. Its meaning, however, is left to interpretation by those who happen to drive by the electronic display. More than likely, the deceptively simple declaration implies that Central's curriculum and associated activities are value laden, that they somehow address the collective and somewhat ambiguous set of traits we label “character.” It is a hopeful message to those who consider forming the character of the country's future workforce and citizenry to be an important goal of schooling.

Robert Coles' sentiment characterizes well the moral tenor of medical education today. Indeed, medical educators are frequently “seized by spasms of genuine moral awareness,” as they try to cope with the massive social and economic problems that face medical schools and teaching hospitals. The perception among educators that we currently fail to adequately teach several core aspects of doctoring, including professional values and behavior, constitutes one such spasm. In this case, the proposed remedy has generated considerable enthusiasm, but whether the “core competencies” curriculum will make a difference, or simply “accommodate to the prevailing rhythms of the world we inhabit,” remains to be seen.

It is a commonplace in the scientific and corporate discourse advocating biotechnology that the public is largely uneducated or scientifically illiterate when it comes to understanding the research methods and goals of biotechnology. Public dissent from biotechnology is, in this understanding, based exclusively in irrational fears. The way to dispel these public fears is for scientists in the research community and among corporate culture to engage in education of the public. At one level, it is argued that public educational forums will provide the information the public needs to make an informed choice about the scientific, ethical, and social implications of biotechnology or will provide guidance on such practical questions as whether to consume genetically modified food. However, the educational agenda is not quite that innocent of normative intent: rather, the assumption is that information the public is provided about biotechnology will persuade them of its benefits, its minimal risks, and its ultimate prospects for reshaping our world for the good of all. Objections to biotechnology will then largely dissipate, perhaps voiced occasionally by extremists who will represent the inevitable Luddite resistance to all things technological.

Medicine is in a very self-reflective mood. There is a revival of interest not only in medical ethics (a.k.a. bioethics) but also in medical history, the Hippocratic corpus, and various kinds of literature that indicate physicians are reexamining the foundations of medicine and what it is that gives meaning to medicine. That is, they are reexamining the physician's vocation, in the true sense of vocation as a calling. This interest has coincided with the concern of third parties such as accreditation agencies about the professionalism of physicians.

Sex is not the answer to everything, though young men think it is, but it may be the answer to the intractable debate over the ethics of human embryonic stem cell research. In this paper, I advance one ethical principle that, as yet, has not received the attention its platitudinous character would seem to merit. If found acceptable, this principle would permit the beneficial use of any embryonic or fetal tissue that would, by default, be lost or destroyed. More important, I make two appeals to consistency, or to parity of reasoning, that I believe show that no one who either has used or intends to use sexual reproduction as their means of procreation, nor indeed anyone who has unprotected heterosexual intercourse, nor anyone who finds in vitro fertilization (IVF) acceptable, nor anyone who believes that abortion is ever permissible can consistently object on principle to human embryo research nor to the use of embryonic stem cells for research or therapy.

Over the past 15 years, medical schools have paid some attention to the importance of developing students' communication skills as part of their medical education. Over the past decade, medical ethics has been added to the curriculum of most U.S. medical schools, at least on paper. More recently, there has been growing discussion of the importance of professionalism in medical education. Yet, the nature and content of these fields and their relationship to one another remains confused and vague, and that lack of clarity, in turn, impairs the effectiveness of medical education. This ambiguity invites serious contention over who should design and teach the curriculum as well as when, where, and how it should be taught.

Unlike most Western nations, Israel does not recognize full separation of church and state but seeks instead a gentle fusion of Jewish and democratic values. Inasmuch as important religious norms such as sanctity of life may clash with dignity, privacy, and self-determination, conflicts frequently arise as Israeli lawmakers, ethicists, and healthcare professionals attempt to give substance to the idea of a Jewish-democratic state. Emerging issues in Israeli bioethics—end-of-life treatment, fertility, genetic research, and medical ethics during armed conflict—highlight this conflict vividly.