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Received: May 7^th 2014
Accepted: September 23^rd 2014

Bioethics in clinical practice

Miguel Sánchez-Gonzaléz,^a Benjamín Herreros^b

^aFacultad de Medicina, Universidad Complutense de Madrid

^bInstituto de Ética Clínica Francisco Vallés, Universidad Europea

Madrid, España

Communication with: Benjamín Herreros
Telephone: (34) 630 906 473
Email: benjaminherreros@gmail.com

Bioethics has grown exponentially in recent decades. Its most important schools include principlism, casuistry, virtue ethics and the ethics of care. These schools are not exclusive. Within bioethics, clinical ethics addresses the inherent clinical practice ethical problems, problems which are many and very varied. Bioethics training is essential for clinicians to address these bioethics’ problems. But even the professionals are trained, there are problems that cannot be solved individually and require advisory groups in clinical ethics: clinical ethics committees. These committees are also responsible for education in bioethics in health institutions. Clinical bioethics is a practical discipline, oriented to address specific problems, so its development is necessary to improve the decision making in such complex problems, inevitable problems in healthcare.

Keywords: Bioethics; Clinical ethics; Ethical review committee on research; Decision making

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Healthcare has changed, and the traditional paternalistic vertical relationship between doctor and patient, where the patient must obey the doctor, has become a more complex relationship. In this new type of clinical relationship, factors have gotten involved that were not present just a few decades ago, including the patient's opinion on decisions that affect them, the need to distribute health resources and consider economic costs, ever more sophisticated medical technology, or biomedical research advances.¹

This has led to doctors having to share the work of diagnosing, treating, and monitoring patients with other parties, giving up a significant part of their share of power. Patients have changed their passive role for active participation in making decisions about their health. On the other hand, the family in Latino culture is involved in those decisions, giving advice, accompanying, or in some cases substituting the patient in the ability to decide. Another important player in clinical practice is the provider of health services, whether public or private. The obligation of the provider is to manage resources and organize care, inevitably affecting the decisions of health practice.

This complex multidisciplinary model of healthcare generates numerous ethical conflicts. Because taking into account the values ​​of all the individuals involved in decisions, inevitably there will be difference of opinion. And the conflicts that arise will not be merely technical, but ethical, because what enters into conflict is people’s values.²

If clinical decisions are not easy, decisions in clinical ethics, in which the complexity of clinical decisions are added to an ethical conflict, are even more complicated. The ethical problem increases the clinical uncertainty that already existed. For professionals to be able to address these complex problems, they must be trained in bioethics, not only in medicine, and have to have useful tools to help them when decisions are unduly complex, such as healthcare ethics committees.

This article on bioethics in clinical practice will serve as an introduction to a series of studies on clinical ethics. The series will address the core issues of bioethics for clinicians: from the most important concepts and terms in clinical ethics, to articles on the ability to make decisions or ethical issues in palliative care. This first article, noting the key historical events for the birth of bioethics, will try to define and clarify its goals, explain what the main schools of bioethics are, and finally make an approach to the aspects closest to clinical practice: what is clinical ethics, what ethics committees are, and what is their real use.

History of bioethics

Current bioethics is an international trend that began in recent decades. Its first manifestations appeared in the US in the early seventies. And this current has subsequently spread to all other countries.³

The word bioethics was coined in 1970 by Van Rensselaer Potter (1911-2001), who was a biochemist dedicated to cancer research. The researcher published an article entitled "Bioethics: The science of survival",⁴ and a year later his book Bioethics: Bridge to the Future.⁵ In these works he argued the need for a new discipline that would unite biological knowledge with knowledge of human value systems. And in 1971 André Hellegers (1926-1979), an obstetrician, used the term bioethics to name the first university institute dedicated to the discipline, Kennedy Institute for the Study of Human Reproduction and Bioethics, located in the city of Washington.

But the ultimate accolade given to bioethics was from ethics commissions appointed by the government of the United States. The first of these commissions was The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. This national commission, after four years of work, eventually published the Belmont Report in 1978. This report proposed three principles to govern research involving human beings. And a year later Beauchamp and Childress’ book Principles of Biomedical Ethics ⁶ was published, which displayed the principles that were to guide medical decision-making: the famous four principles of respect for autonomy, beneficence, non-maleficence, and justice. With this, bioethics moved from the realm of research to clinical practice.

Despite its short life, bioethics in the field of medicine has achieved extraordinary success. It has helped transform the paternalistic model of relationships with patients, and has significantly changed the way medical decisions are made. It has also served to ground research on human beings from an ethical point of view and has addressed the problems raised by health organizations, as well as generating debates about justice and distribution of resources.

Definition and objectives of bioethics

The bioethics projected by Potter had very broad objectives. This researcher understood it as a dialogue between scientists and humanists to preserve humanity from self-destruction and promote the quality of life. In his own words:

Mankind is urgently in need of new wisdom that will provide the “knowledge of how to use knowledge” for man's survival and for improvement in the quality of life. ... I therefore propose the term Bioethics in order to emphasize the two most important ingredients in achieving the new wisdom that is so desperately needed: biological knowledge and human values.”⁷

Hellegers, meanwhile, institutionalized the bioethics dialogue at the Kennedy Institute appealing to ethical systems to guide scientific and technical progress in the service of human progress. Daniel Callahan (born in 1930), founder of another major institute for the study of these issues, the Hastings Center, wanted to clarify interdisciplinary ethical problems and enlighten government policies with shared social values.

It is also worth remembering the stated objectives of another famous bioethicist, Hans Jonas (1903-1993). This author tried to overcome a "local ethics" to be open to the horizons of the future of humanity and our planet.

The Encyclopedia of Bioethics edited by Warren Reich in 1978 suggested the following definition of bioethics: "the systematic study of human behavior in the field of life sciences and healthcare examined in the light of values ​​and moral principles".⁸

Albert Jonsen,3 (born 1931), in turn, distinguishes between bioethics as an academic discipline, developed by institutions and experts, and bioethics as a public discourse that is the product of public opinion and is promoted by a variety of social participants. In this second sense bioethics would be a new space or forum for public debate, rather than a discipline strictly speaking.

In any case, all the definitions of bioethics proposed so far include the idea that bioethics is "an interdisciplinary study of the problems raised by scientific knowledge and technological power that we have over life." And it always recognizes the practical purpose of guiding important decisions.

It should be noted, too, that bioethics has ended up producing two lines of development. On one side is clinical bioethics, which deals with the problems of health and medical research. And on the other hand is bioethics, which deals with problems related to the environment. Potter proposed calling this second line of development global bioethics.⁹
The articles in this series will deal exclusively with clinical bioethics or medical ethics, which has prevailed over global bioethics in all quantifiable aspects.

Main methods and schools of bioethics

Bioethics in the beginning was understood as an applied ethics of a principialist nature, because it sought to solve problems based on ethical principles. From the first it seemed clear to bioethicists that principles were needed for laws and regulations to be based on. Albert Jonsen saw in it the expression of the American cultural need to subsume new realities under unambiguously clear principles. And he called this principialist ethical approach American moralism.¹⁰ Jonsen maintains that this approach originated in the religious tradition of Calvinism. A tradition that has generated a secularized moralism that maintains a rigid adherence to law, rules, and principles. However, principlism and moral deductivism were not only a peculiar feature of American moralism, since the tendency to deduce particular rules and judgments from universal principles has been a feature of most Western systems of ethical thinking since Aristotle, and therefore in the Latin American context principlism applied to bioethics has also been a huge success.

However, bioethics today tends increasingly to be understood as an ethical practice that tries to solve concrete problems using a variety of methods.

Principlism

The truth is that the first method implemented was based on the so-called "four main principles of bioethics". Recall that these principles were formulated in the wake of public scandals raised by research involving human subjects in the seventies of the last century. These scandals resulted in alarm in public opinion and the United States Congress was forced to intervene. The response of the US Congress was to create the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1974. The objective given to the national commission was: "Identify the basic ethical principles that should underlie human subjects research and develop guidelines to ensure that such research is conducted in accordance with these principles."

So the commission was asked for their principles. And it provided principles in its 1978 Belmont Report. This document proposed the three universal principles of human research: "Respect for persons, beneficence, and justice." It said that "broad ethical principles could provide bases on which to formulate, criticize, and interpret specific rules." The principles were defined as: "general prescriptive judgments... that serve as a basic justification for multiple specific prescriptions and assessments"; it also clarified that "they are formulated at a level of generalization that should help in understanding the ethical problems of research with human subjects". 

The Belmont Report principles were applicable only to research problems. But Beauchamp and Childress in Principles of Biomedical Ethics extended the principialist process to clinical decisions, and developed the so-called "four main principles" that came to be considered the "watchword" of bioethics:

1. Autonomy: active respect for the freedom of choice of the person; not only refraining from hindering it, but trying to create the necessary conditions to exercise it.
2. Maleficence: do not intentionally do harm.
3. Beneficence: obligation to act for the benefit of the patient, helping them promote their legitimate interests.
4. Justice: equitable distribution of resources, benefits, and burdens among all members of society.

These four principles should be considered prima facie (a priori), following the ideas of David Ross and William Frankena. They are not hierarchically ordered. In case of conflict there are no explicit rules: the circumstances and consequences establish the "current duty".

The initial principlism soon began to receive criticism. In 1990 Clouser and Gert¹¹ contemptuously called it principlism and defined it as: "the practice of using ‘principles’ to replace both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in medical practice". These authors also criticized that "The ‘principles’ are in fact not guides to action, but rather they are merely names for a collection of sometimes superficially related matters for consideration when dealing with a moral problem". And also they said that "The ‘principles’ lack any systematic relationship to each other, and they often conflict with each other. These conflicts are unresolvable, since there is no unified moral theory from which they are all derived".

Moreover, from a practical point of view, the principles have been criticized for having limited themselves to inspiring rules and fostering a legalistic ethics in which codes and laws proliferate. And the huge informative success of the principles may have led to a narrow, simplistic, and flat perspective, unable to defend other values than the principles.

To address criticism, Beauchamp and Childress in 1994 in the fourth edition of their book, opted for a "coherentism" rooted in common morality, distancing themselves from the deductivism of first editions. They redefined the principles as "normative generalizations guiding acts, but that must be interpreted, specified, and weighed in each case." They also recognized the need to introduce certain rules in addition to the principles. With all these clarifications, Beauchamp and Childress recognized that principlism may be an insufficient theory. And they considered that other ethical theories are not rivals principlism but complement it.

To overcome the difficulties of principlism, in recent years other schools of bioethics have emerged. Among them: casuistry, the ethics of virtue, and care ethics.

Casuistry

Casuistry has reemerged in recent decades as an alternative to principlism. Casuistry is an old way to solve moral problems that was recently revived especially by the work of Albert Jonsen and Stephen Toulmin.¹²

Casuistry is a method of arriving at justifiable decisions in concrete cases. For this it looks to the circumstances and maxims (particular rules applicable to cases), rather than theories and principles. Casuistic reasoning begins by describing the case-problem in detail and according to its circumstances. After that the case is typified: the paradigmatic case is looked for that most resembles it, i.e., a model case is looked for similar to the case under analysis. Finally, the current case-problem is solved by applying the maxim recommended based on the paradigm.¹³

Ethics of virtue

The ethics of virtue, resurrected by E. Anscombe and A. MacIntyre, have been applied to medicine by Edmund Pellegrino¹⁴ and James Drane.¹⁵

These ethics focus on the virtues of character, rather than isolated acts. They assume that good behaviors happen not because of applying principles or calculating consequences, but from the judgment of someone who has certain virtues. Therefore the ethics of virtue have been contrasted with the ethics of obligation, because they do not say what to do, but rather the kind of person to be. And this is achieved when certain virtues are incorporated into one’s character, which, in the case of medicine, are precisely the professional virtues.

Ethics of care

Care had never been an important concept in the history of ethics. This concept received a decisive boost from the psychological research of Carol Gilligan¹⁶ on the moral development of women. Since then, women's and feminist ethics have made significant contributions to the development of ethics centered on care; the work of authors such as Sara Ruddick and Nel Noddings stands out among these. In recent years, care has been incorporated into debates on the ethics of nursing, healthcare, and the environment.

These ethics do not depend on abstract principles, which would be rather "masculine". Rather, they focus on interpersonal relationships and establish as priority the obligation of care, that the provision of care is an inclination to welcome and to address the specific needs of others.

The rules of care depend on context rather than abstract considerations, and they need to incorporate sympathy and compassion.

The ethics of care have had an impact on the way of conceiving of all healthcare. And they serve, especially, to develop an ethics of nursing. In general, the ethics of care emphasize that it is necessary not only to heal; one must also take care and relieve suffering. This ethic promotes habits of compassion, affection, and commitment to the patient.

Complementary methods

We can conclude by saying that to guide decision-making and develop protocols for action, no method seems complete and self-sufficient. However, all methods can be useful to point out elements that should be taken into account. And each has its own strengths when noting, for example, the relevant aspects of the cases, contexts, motivations and character, purpose, or significant personal relationships.

We find that the different methods are complementary. And we can take advantage of each while trying to offset their particular drawbacks.

Clinical ethics

Within the health field, bioethics has developed two fields, clinical ethics or bioethics, and research ethics. Clinical ethics addresses ethical problems that occur during healthcare, while research ethics deals with ethical issues arising from research on living beings. Environmental ethics and global bioethics deal with issues that go beyond the boundaries of the health field (environment, use of natural resources, population growth). On the other hand, fundamental bioethics addresses the theoretical bases and foundations that support the ethical argument, whether in the field of clinical ethics or research ethics.

Medicine and clinical ethics

Most of the decisions made by health professionals are clinical, since they implement the scientific technique specific to medicine. The basis of medicine is science and technology, and so the available resources and the circumstances in which the decision is made must be considered.

But there are many decisions in clinical practice that cannot be made only by using technique, because there is an ethical problem beyond the technical problem. Mark Siegler defines clinical ethics as "the practice area that helps patients, their families, and health professionals arrive at correct clinical decisions taking into account both the medical facts of the situation as well as the preferences and values ​​and of the patient and family". Further, he states that "the objective of clinical ethics is to improve patient care and the outcomes of that care." If this definition is analyzed, clinical ethics consists of applying Potter’s formula, including those "two ingredients [...] that are so desperately needed: biological knowledge and human values" in clinical decisions.
Clinical ethics is therefore not the mere analysis of the ethical problems in clinical practice, but to address decision-making. And so Mark Siegler insists that clinical ethics is a "field of practice".

Importance of clinical ethics for healthcare

The problems of clinical ethics have increased exponentially in recent decades.^1,17 In current clinical practice it is common for ethical conflicts to exist, because the values ​​of health staff, patients, their relatives, the institutions, or society all come into play. This increase in ethical conflicts in medicine is an inevitable consequence of living in pluralistic and tolerant societies with diverse values. Therefore the problems of clinical ethics are common due to the idiosyncrasies of current clinical medicine, in which decisions are not unidirectional and conflicts of values ​​are common.¹⁸

If a patient, for example, does not agree with the decision of their doctor, the professional is faced with an ethical conflict. In addition to the clinical problem, a conflict of values ​​also has to be resolved. "Caring for the patient" is opposed to "freedom of decision" of the patient. To the clinical problem, the ethical conflict is added.

In an article published on the ethical conflicts in hospitals that are most important for clinicians in Spain, the most prominent include ethical aspects such as problems of information or confidentiality, decision-making with incapacitated patients, informed consent, social-medical problems, problems of disagreement on admission or discharge of the patient, family conflicts, or disagreement with the patient about treatment (non-acceptance of treatment or requests incompatible with lex artis).¹⁹ Table I shows some of the most relevant problems of clinical ethics.

Healthcare ethics committees

There are two types of ethics committees. Healthcare ethics committees (HEC),²⁰ which advise, mediate, support, and make recommendations on ethical aspects and issues of healthcare, and clinical research ethics committees (CREC), which review and authorize research protocols involving human subjects.

Both committees emerge because the complexity of modern medicine has made it necessary to discuss and regulate the complex ethical aspects of medicine and research, and often the clinician does not have the tools to make a good decision in an ethical conflict. But these committees also seek to improve the quality of care (HEC) and the quality of research (CREC). Therefore, the HEC and CREC must be multidisciplinary and diverse, and must have a methodology that facilitates open and participatory discussions.²¹

Appearance of the first HEC: responding to problems of clinical ethics

In 1962 in Washington the first outpatient dialysis center opened: the Seattle Artificial Kidney Center. Chronic renal failure was no longer a fatal disease thanks to the system developed by Dr. Belding Scribner. The center’s three beds could only provide treatment for a very limited number of patients. So a committee of anonymous people was created, known as the Life and Death Committee, because they were responsible for the selection of candidates for dialysis according to rigid criteria. This committee was subject to heavy pressure and criticism, and their work has been recognized as pioneer in bioethical discussions, especially for the later development of HEC.²²

The case of Karen Ann Quinlan was key to the creation of HEC. Karen Ann Quinlan (1954-1985, New Jersey, United States) was a 21-year-old woman who, after not eating, took diazepam, chlordiazepoxide, and barbiturates with alcohol at a party. She lost consciousness and suffered a 30-minute apnea, which put her into a vegetative coma. Her adoptive parents requested disconnection of the ventilator, but doctors refused. There was a legal process whose verdict was in the parents’ favor. After being disconnected, she lived another 10 years. Karen Ann Quinlan’s case led to a judgment of the Supreme Court of New Jersey in which a prescient phrase emerged: "no case like this should go to court; expert groups should be formed in all hospitals to give advice on situations like this". This suggestion of creating groups to advise on ethical issues to prevent such problems from reaching the courts, along with a request from the United States Congress to this effect, in the early 1980s led to the creation of hospital ethics committees, current day HEC.²³

HEC therefore appear from necessity: problems needed answers, and with the regulations or laws the answers were not sufficient.

The development of the HEC (and of bioethics in general) has been behind the problems and always has a practical interest. The HEC are created to make better decisions in complex ethical problems, because they must be close to the problems to understand them and to better confront them.²⁴

Functions of the HEC

The main functions of the HEC are training in bioethics at the institution where they are located, advising professionals at the institution (and patients of the center) on ethical conflicts, and developing recommendations on ethical conflicts that emerge in the institution. These recommendations can be formulated through protocols or guidelines and are developed to facilitate daily decision-making when ethical problems appear.²⁵

HEC therefore seek to clarify the moral questions that arise from daily clinical practice and, above all, to help make the best decisions. However, despite being hugely useful instruments, they are underused by both professionals and patients,^26,27 who are often unaware of their existence and their functions.

Utility of bioethics

First, it is important to note that bioethics has become necessary to deal with the huge changes in science, technology, and society, changes that have created new situations that the old professional ethics or simple good conscience were unable to solve.

On the other hand, bioethics can help develop the civil ethics needed by democratic societies, composed of independent citizens able to discuss and participate in decisions that affect them. Bioethics invites public participation, establishing procedures of public deliberation on all institutional and social levels. This has therefore helped overcome paternalism and the imposition of monolithic moral codes. However, a deliberative bioethics cannot be an arbiter to indicate unilaterally what is "morally right". Bioethics is an ethics of responsibility because it weighs the principles to be applied in every circumstance, takes into account commitments, and evaluates the consequences of decisions.

In short, bioethics establishes an ethic of open, approximative, and probabilistic responsibility, capable of evaluating risks, costs, and benefits. It also aims to achieve participatory and shared regulations in times of uncertainty facing new problems.
We conclude that bioethics can be a suitable vehicle for introducing into the moral life of our societies:

 

• Rationality and dialogue to solve conflicts.
• Deliberation to make decisions and achieve new social consensus.
• Transparency to avoid public distrust and to invite collaboration.
• Individual and social autonomy as a value that respects the dignity and potential of all.
• Possibility of participation of everyone in the improvement of society and in solving its problems.

 

By helping to make these moral aspirations real, bioethics can serve to develop and justify new social consensus needed by our world in everything that can affect life.

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