Throughout our Human Practice, we mentioned the word “ethics” numerous times in relation to genetic engineering. But, what exactly is this bioethics we speak about? This post seeks to dissect the philosophical concepts behind the decision-making in biomedical ethics in order to appreciate the theoretical frameworks behind “ethics”.
Before looking into the monistic theories, let us examine the overarching ethical systems that can be adopted.
In deontology (duty ethics) and virtue ethics, these both focus on the motivation of action rather than the outcome. They justify an action based on the intent. Deontology compares a person’s actions against an imperative or a set or rules. The most prominent example would be Kant’s Categorical Imperative, which states that “act according to the maxim that you wish all other rational people to follow, as if it were a universal law”. On the other hand, virtue ethics works similarly but compares the individual’s action against a set of virtues. An example would be Aristotle’s 12 virtues, to name a few: courage, temperance and liberality. These two systems of ethics consider one question “Are my actions compatible with some imperative/virtue?”. It is extremely useful in the society for people to have a moral compass. However, that is a very big loophole for practical ethics. The bad points of duty/virtue-based ethics are that these ethical systems are not concerned by the end results, which could cause in an eventual reduction in the wellbeing of others The wellbeing of individuals is definitely of utmost importance. Especially in bioethics, the end results will inflict harm or benefit living organisms, thus necessitating the need to consider beyond the motivation and include consequences.
Thus, we examine the ethical system of consequentialism which states that the results matter, not the actions themselves - whatever has the best outcome is the most desired action. In today’s discussion, we will consider the most commonly adopted theory in bioethics – Principlism.
Principlism is a widely used form of bioethics, originating from Tom Beauchamp and James Childress. The theory is based on 4 main principles - autonomy (maximise the freedom for individuals, respecting individuality of choices), non-maleficence (no inflicting of harm), beneficence (maximize the amount of good, acting in the best interest of the outcome) and justice (treat equal cases equally and unequal cases differently). All these 4 principles are weighed and balanced to provide the optimal decision.
The moral basis of autonomy translates to the importance of informed consent, where any sort of treatment has to be discussed and decided by the patient (assuming a competent being). In the event of an incompetent patient (inability to make rational decisions), is paternalism justified? This can be argued, as some agree that only weak paternalism (acting for the benefit to restore competence or protect patient from harm) should be practiced, while some feel that taking a step forward, medical paternalism (overriding a person’s wishes to benefit or prevent harm) should be the preferred course of decision-making. However, in our society, weak paternalism is part of the code of conduct.
Non-maleficence and beneficence work hand-in-hand as they recognize the need to avoid harm and demand for positive benefit. This is imperative for any sort of treatment as the desirable end result will be to improve the wellbeing of the individual. Quoting our interviewee, Dr. Autios, “There are going to be risks, there's no way that all the risk can be taken out of the picture for any potential therapies. And the question becomes like what is the acceptable risk?” This question should be answered by scientists who conduct related research and regulated by medical regulatory bodies. On the doctor-patient level, what should be done when a procedure has both harmful and beneficial outcomes? In general cases, if the treatment has a higher chance of significant benefit accompanied by a small risk, it is obligatory within the limits of informed consent. If the variation between benefits and risks are insignificant, the treatment is optional. And finally, if the treatment were to bring about significant harm with minimal benefit, it is obligatory not to offer, even with informed consent. One ambiguity in these 2 principles will be – how exactly do we measure benefit and risk? There exist no defined ways to quantify benefit or risk, thus we rely on the medical experts to distinguish medical benefits and mitigate possible risks.
Justice states that we should distribution goods and services fairly, in order to maintain social justice. The challenge would be to define what exactly are the medical needs and how holistically can we gauge the non-medical needs (social situation, quality of life) of an individual. The topic of justice is not only relevant to current resources, but also should be considered for the impact of upcoming technologies. Referring to the bioethicist, Dr. Calvin Ho. “there are also broader social justice kind of issues, if this technology becomes more widely available- it might be only available to the rich for instance, because we’ve seen with other technologies, they tend to be accessible only among the rich until after a certain period of time.”
In conclusion, the decision-making process in bioethics is multi-faceted and requires extensive thinking from an intention-based or action-based approach. There exists no universal ethical system that is absolute. In order for ethics to better navigate the way for scientific advancement, more critical evaluation is needed to fundamentally examine the assumptions made in various ethics system and reconcile them to affirm a desirable decision. In our Human Practices, we sought to understand more about the ethical issues about genome editing technologies.
Team:NUS Singapore-Sci/Cas Writes Bioethics
Dissecting Bioethics