Summary
1 Origin and identity of bioethics
2 Latin American Bioethics
3 Bioethics and Theology
4 Bioethics of the borderline situations of human life
5 Clinical Bioethics
6 Sanitary Bioethics
7 Environmental Bioethics
8 Bibliographical References
Bioethics is one of the areas of moral knowledge with the greatest impact on contemporary society, due to the ethical challenges of life management, increasingly present in biotechnologies and their political and economic dynamics. The Church has included bioethics in its discourse with a concern for respect for nascent human life (artificial reproduction techniques, contraception, abortion, cryogenesis, status of the human embryo) and terminal life (euthanasia, palliative care). This interest raises the epistemological challenge of the interfaces between theology and bioethics. It is not a matter of formulating a theological bioethics, but of discussing the role of theology in the interdisciplinary and secular forum of bioethics.
1 Origin and identity of bioethics
The word bioethics was born from an ecological perspective in Fritz Jahr (1927) and Van Renseleer Potter (1971), concerned with the survival of life on planet earth due to the repercussions of technological development on the environment (ecoethics). At the same time (1974), André Hellegers was concerned with medical ethics in facing the challenges of applying medical technologies in the borderline situations of human life. Therefore, he proposed an expansion of Hippocratic ethics, which he called bioethics. Thus, from the beginning, bioethics had two origins: one ecological and the other more clinical. The latter was more successful because it was of interest to hospitals and biotechnology companies.
Ecological bioethics (ecoethics), although it was forgotten in its beginnings, today is increasingly important. Another central fact for the emergence of bioethics was the reaction to abuses in clinical research with patients, denounced in an article by Henri Beecher (1966). This complaint caused a reaction in American public opinion, forcing the government to create the “Belmont Commission,” tasked with considering the ethics of clinical research. After four years, in 1978, they released the document “Belmont Report,” with three ethical principles: respect for persons, beneficence, and justice. They were adopted by Beauchamp and Childress as a framework for clinical ethics in the famous book Principles of Biomedical Ethics (1979), proposing autonomy, beneficence, non-maleficence, and justice as ethical principles of the clinic, originating the principlism paradigm that came to dominate bioethics. However, thinking that these facts and people are responsible for the emergence of bioethics is superficial, because its origin has much deeper causes rooted in sociocultural and political-economic dynamics of life management that marked the 19th and 20th centuries, masterfully pointed out by Foucault in his analyses of biopower. Bioethics emerges as a “critical hermeneutic of these dynamics” (JUNGES 2011).
2 Latin American Bioethics
In Latin America, bioethics has been adopting a critical and social perspective in discussing the ethical challenges of health and life, formulating epistemological models more appropriate to this reality. The principlism bioethics, imported into the medical environments of our continent, solved problems in the “autonomy paradigm,” as if moral dilemmas were reduced to the issue of receiving the necessary information to give consent. Hence the centrality and importance of “informed consent” in addressing ethical problems related to human health. This perspective does not consider the health vulnerability conditions in which most of the population of the Latin American continent finds itself.
This realization leads to proposing the “vulnerability paradigm” as a model for thinking about ethical issues of life. The principlism bioethics paradigm cannot serve as a moral guideline for addressing and solving problems. In the vulnerability paradigm, human rights serve as ethical references. For asymmetric and unequal Latin American societies, the political perspective of equality and isonomy, typical of rich countries, where citizens have awareness and enforcement of their rights, cannot prevail. For these, the demand for rights is reduced to defending individual autonomy and initiative against state power. Where this full awareness and enforcement do not exist, people suffer specific social vulnerabilities against which the state has a duty to protect, ensuring social welfare rights.
Giving shape to this approach, protection bioethics is constituted as a more appropriate epistemological model to respond to the specific conditions and concrete problems of Latin America (SCHRAMM 2006). This bioethics aims to critically intervene in situations where populations vulnerable due to social conditions are not respected in their dignity and their fundamental rights are not fulfilled. Thus, Latin American bioethics has been adopting the same perspective as the origin of Liberation Theology: the option for the poor.
3 Bioethics and Theology
In the origins of bioethics, several theologians were involved due to their long expertise in ethical argumentation and their engagement in discussing medical ethics problems within the scope of Catholic morality. Subsequently, there was a movement of independence of bioethicists from theologians, emphasizing secularization and pluralism in reflection. This forced theologians to explain their specific contribution in a secular, interdisciplinary, plural, and rational discussion forum, without authority arguments (CADORÉ 2000). The theologian has no prominence in the debate nor can he pretend to give the final word on a particular problem. On equal terms, his word has the same value as any other intervention. He should be able to position himself between his theological tradition and the concrete situation for which, along with others, he will try to find a solution. In the words of John Paul II in Fides et Ratio (48, 2), “the parresia of faith must correspond to the audacity of reason,” that is, the courageous and free affirmation of faith must be allied to the bold and creative search for its understanding for our days.
To understand the relationship between bioethics and theology, it is necessary to understand which bioethics and which theology we are talking about (JUNGES 2006). One can develop a casuistic bioethics typical of committees that try to find ways to solve clinical or research cases. To formulate these solutions, practical wisdom in the line of Aristotelian phronesis is necessary above all. On the other hand, bioethics cannot lack a perspective of critical hermeneutics that reflects on fundamental issues, assumptions, and biopolitical dynamics involved in ethical problems.
If in everyday life practical wisdom and a sense of realism are needed, in the long run, critical hermeneutics cannot be missing for a more robust and consistent bioethics. In this second perspective, theology can play an important role in helping to reflect on fundamental conceptions involved in concrete solutions. Therefore, theology cannot offer ready-made recipes for concrete problems. Theology appropriate for this role assumes, therefore, a public perspective, that is, it reflects from faith in the public, secular, and plural social space, distinct from a theology that confirms the faithful in the ecclesial and confessional space.
This public perspective of theology can offer important contributions to bioethics, in the sense of helping to reflect and question deeper issues of human life and existence, because a simple pragmatic approach of casuistic bioethics does not intend nor manage to point out these issues. Therefore, theology cannot offer ready-made recipes nor place itself at the moral level of “can or cannot,” typical of the legal approach. Its role is to raise fundamental questions and reflect critically. Otherwise, as Pope Francis (2013) says very well, we “will not be proclaiming the Gospel, but some doctrinal and moral emphases derived from certain ideological options” (EG 39).
The fundamental role of theology, in its public dimension, is to open the participants of a discussion forum to the original freshness, the novelty of the Gospel by awakening and activating a more accurate ethical sensitivity regarding life, deconstructing an ideological use of the Christian moral message.
4 Bioethics of the borderline situations of human life
An example of the reflective contribution of theology is in addressing ethical borderline situations of beginning and end of life, not taking a legal moral position of “can or cannot,” but leading to a deep reflection on the central ethical question of life limits. As for the beginning of life, it is necessary to reflect on the “status of the embryo.” According to Bourguet (2002), this question unfolds in two: “the embryo is a biological individual of the human species,” answered by biology, and, “being an individual, deserves the respect due to a human person,” answered by ethics.
The denial of the biological individuality of the embryo is linked to the assumption of adult individuality criteria and already outdated morphological parameters. Individuality does not depend on an observer, as it is not possible to fix a moment through external signs because it is a continuous process. Therefore, it is not possible to define the status of the embryo by marking a moment of individuation through external morphological signs of adult individuality, as it depends on a process managed by genetic criteria. The individual is defined by its genome. The very appearance of identical twins does not negate this finding, according to Bourguet (2002), as the first individuality is not negated, but a second one arises from it, made possible by pluripotentiality, separated in time.
Defined the biological individuality of the embryo, the second question arises: does this embryo deserve the respect due to a person? Here person is not an ontological category, but an ethical one. This means that the personality of the embryo can be defined by reference to collective rules (legal order) or from the perspective of the moral agent (ethical order). The difficulty of the first is that the embryo is not an alter ego that can participate in the social contract, accepted as equal to me. There is no symmetry, but asymmetry for which only the ethical perspective is adequate. It is about the position of a moral agent concerning a human individual, not equal to me nor another subject. To capture the other as totally other, according to Levinas, it is necessary to dispossess the ego from imposing conditions for defining the other. Ethics starts from the initial asymmetry and not from symmetry, a typical situation concerning the human biological individual embryo. This means assuming the relational paradigm, not the individualistic-liberal paradigm of each one’s rights, to think about the relationship with the embryo. According to Kant, humanity is the criterion of evidence that has the objectivity of nature to guarantee the morality of respect. Respect for the person is coextensive to all those who are human individuals, part of humanity, not being allowed to impose conditions for their definition. Thus, the embryo as a human individual deserves the ethical respect due to the person.
If the relational paradigm is assumed to think about the borderline situations of the end of life, how does the meaning of the “dying process” appear? In the individualistic-liberal (liberalism) perspective, the moment of death is a matter of autonomous decision. Here it is possible to question how death, the moment of assuming the existential totality of a human being, can be a matter of decision, always particular. There can be no autonomy in a decision of such magnitude. If the beginning of life is defined by its processuality, being impossible to determine a moment, death is also a process with several stages (KÜBLER-ROSS 1981).
Being autonomous (moral autonomy) is becoming a subject of this process, assuming it in the perspective of living the sense of existence as a whole and the human relationships that wove life. The dying process is settling accounts with life. Therefore, the dying person needs to be accompanied by different therapists to overcome their pains, receive solidarity in loneliness and suffering, finding meaning in this process. Viktor Frankl pointed out, from his own experience, that the seriousness and density of a life are revealed in suffering, due to its cathartic and challenging nature. Christian theology, like other religions, has long experience in offering symbolic and spiritual resources to face this moment. But postmodern individualistic-liberal culture finds no meaning in suffering nor wants to face its cathartic and challenging nature, preferring to interrupt this process through euthanasia. This rational ethical reflection defending the dignity of the embryo and the dying person is an example of how theology can act in the secular context of bioethics.
5 Clinical Bioethics
Contemporarily, the relationships between doctor and user are ethically defined from the autonomy paradigm, as the primary principle of clinical bioethics, expressed in informed consent, to be requested by the professional for any intervention on the patient’s body. The principles of beneficence (providing benefits) and non-maleficence (not causing harm) are defined in their applicability from autonomy, and if there is a conflict between these principles and autonomy, the consideration generally leans towards the latter (BEAUCHAMP, CHILDRESS 2002). It is clear that the professional cannot comply with a request that goes against a legal law nor accept a request for an intervention that directly endangers the patient’s life. The only possibility of true ethical conflict in the principles is between autonomy (individual pursuit of personal goods) and justice (collective distribution of common resources), when there is a request for the health of an individual that harms the acquisition of basic resources for the collective. In general, doctors have difficulty seeing this conflict because they think only of the well-being of their patients, hardly reasoning from the “health of the collective” (public health).
To prevent bioethics principles from being applied mechanically in the clinic, without considering the context or weighing the circumstances, Jonsen, Siegler, and Winslade (1998) propose ethically analyzing a clinical case, taking into account, on the one hand, the doctor’s indications and the patient’s preferences concerning the case and, on the other, the patient’s quality of life in that specific situation and contextual factors shaping the case.
These four data allow a more balanced and thoughtful application of bioethics principles. However, to analyze the case, it is necessary to consider, in addition to the data, the ethical demands manifested in it. These demands are expressed by different ethical models, not exclusive, but complementary to each other: utilitarianism, which evaluates action by consequences; the liberal approach, which has subjective rights as a criterion; the Kantian perspective, which proposes the utmost respect for the person; the Rawlsian viewpoint of justice, which considers the relationship between equality and difference to achieve equity; and the Aristotelian virtue model, which considers morality from attitudes.
In analyzing the clinical case, it is good to bear in mind and evaluate all these possible ethical demands of action, not contradictory to each other. In the clinical aspect, theology is invited to contribute with the symbolic resources of the rich Christian tradition concerning facing pain and suffering.
6 Sanitary Bioethics
A fundamental ethical principle for health systems: individual health cannot be taken care of without worrying about promoting collective health; nor can the health of populations be universally protected without particular care for the health of individuals. This assumption is the basis for any public health policy and the foundation of what could be called sanitary bioethics, which proposes to reflect on the ethical challenges of public health. At the collective level, it is about creating public risk prevention policies that protect populations from sociocultural and political-economic conditions that endanger their health and health promotion policies that provide spaces of sociability that enable the social reproduction of life. Therefore, public policies aim to protect the population’s health against risks and create social conditions that ensure the citizen’s right to health as a moral duty of the state. The ethical principles that guide these policies and their realization in a collective health system are universal access (everyone has the right to care for their needs), comprehensive care (focused on the needs of the whole person and extended by the care network in seeking solutions), and equity in the distribution of budgetary, human, and technological resources according to the vulnerabilities and differentiated needs of social groups. The realization of these principles, in achieving the right to health and protecting against social conditions of vulnerability, primarily occurs in Primary Care Units (UBS), entry points of the health system, embedded in the territory and cultural context of the population assigned to the health team and responsible for primary and longitudinal care of users. The individual and collective realization of the right to health is a demand for social justice for which theological reflection on the Kingdom’s justice can contribute to understanding.
7 Environmental Bioethics
Martínez Alier (2009) points out three trends of environmentalism. The “economic eco-efficiency” of the sustainable development proposal and the green economy, which, without questioning the current capitalist system, offers solutions to the crisis, considered efficient, in coherence with the economic dynamics of this system, considering nature as a stock of resources. The perspective is anthropocentric, centered on human interests. Another trend is the “wilderness cult,” present in many first-world ecology NGOs that defend a museum-like vision of nature because they strive to preserve certain ecosystems as untouchable without human presence. This trend is biocentric, focused on the interests of living beings. A third trend is the so-called popular environmentalism, typical of indigenous and peasant populations in Latin America, who defend nature as oikos, home, a place of survival and social reproduction of life, not accepting that it is reduced to a stock of resource extraction, as happens when large oil, mining, and agribusiness companies settle in their ancestral territories.
The environmental struggle of these populations is accused by their governments as contrary to the progress of their countries, when it is necessary to question what development and for whom, as these native peoples defend their biosocial sustainability ecosystem in integration with other living beings that inhabit there. They are driven by an ecocentric perspective, the only suitable approach for ecological ethics and facing the environmental crisis. In this confrontation, there is an antagonistic and irreconcilable vision of nature: as a stock of resources for extraction or as an ecosystem of survival and vital sustainability. Another version of popular environmentalism is the “Environmental Justice” movement (ACSELRAD, MELLO, BEZERRA 2008), which denounces the disposal of environmental damage from industrial, agrarian, and governmental economic processes to the territories of poor populations, who suffer the negative consequences of the current social metabolism of the globalized economy.
Environmental injustice is the mechanism by which economically and socially unequal societies assign greater loads of environmental damage from development to marginalized populations. This popular environmentalism approach, which conceives nature as an environment of ecosystemic sustainability and denounces the social metabolism of discarding environmental damage to vulnerable populations, can offer an ecological perspective to rethink the traditional theology of creation in other ways (JUNGES 2001), conceiving created nature not as a stock of resources, but as a vital ecosystem for all living beings.
José Roque Junges, SJ, UNISINOS, Brazil.
8 Bibliographical References
ACSELRAD, H.; MELLO, C. C. A.; BEZERRA, G. N. What is Environmental Justice. Rio de Janeiro: Garamond, 2008;
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BEAUCHAMP, T. L.; CHILDRESS, J. F. Principles of Biomedical Ethics. São Paulo: Loyola, 2002.
BEECHER, H. K. Ethics and Clinical Research. The New England Journal of Medicine, 274 (24), pp. 367-72. 1966.
BOURGUET, V. The Being in Gestation. Bioethical Reflections on the Human Embryo. São Paulo: Loyola, 2002.
CADORÉ, B. The Theologian between Bioethics and Theology. Theology as Method. Revue des Sciences Religieuses, 74, pp.114-29. 2000.
FRANCIS. Evangelii Gaudium. Vatican, 2013.
JAHR, F. Bioethics: an Overview of Ethics and the Relationship of Humans with Animals and Plants. Kosmos, Gesellschaft der Naturfreunde, 24, pp.21-32. , 1927.
JUNGES, J. R. Hermeneutic and Casuistic Bioethics. São Paulo: Loyola, 2006.
______. Ecology and Creation. Christian Response to the Environmental Crisis. São Paulo: Loyola, 2001.
______. The Birth of Bioethics and the Constitution of Biopower. Acta Bioethica, 17 (2), pp.171-8. 2011.
JONSEN, A. R.; SIEGLER, M.; WINSLADE, W. J. Clinical Ethics. A Practical Approach to Ethical Decisions in Clinical Medicine. 4th ed. New York: McGraw Hill, 1998.
KÜBLER-ROSS, E. On Death and Dying. São Paulo: Martins Fontes, 1981.
MARTÍNEZ ALIER, J. The Environmentalism of the Poor. São Paulo: Contexto, 2009.
POTTER, V. R. Bioethics. Bridge to the Future. Englewood Cliffs: Prentice Hall, 1971.
SCHRAMM, R. F. Bioethics without Universality? Justification of a Latin American and Caribbean Bioethics of Protection. In: GARRAFA, V.; KOTTOW, M.; SAADA, A. Conceptual Bases of Bioethics. Latin American Approach. São Paulo: Gaia, 2006. pp.143-57.