Green Bioethics and Hope

Many environmental problems are now more serious and urgent than ever. In high-income countries, health care is part of the problem. In Principles of Green Bioethics: Sustainability in Health Care, Cristina Richie focuses on medical developments, techniques, and procedures, and she proposes four principles for green bioethics: distributive justice, resource conservation, simplicity, and ethical economics. Richie is right to emphasize the need for green bioethics, and I admire her aim to bring environmental concerns back into bioethics, but I was disappointed with this book. Since Plato, much of ethics has focused on the characteristics or principles of the ideally just society. This work in ethics seeks to transcend the culture in which we live in order to provide guidance about what we should do. I think it would be better to start with the messy, problematic, and unjust situations in which we are enmeshed.     

Telos versus Praxis in Bioethics

The authors of “A Conceptual Model for the Translation of Bioethics Research and Scholarship” argue that bioethics must respond to institutional pressures by demonstrating that it is having an impact in the world. Any impact, the authors observe, must be “informed” by the goals of the discipline of bioethics. The concept of bioethics as a discipline is central to their argument. They begin by citing an essay that Daniel Callahan wrote in the first issue of Hastings Center Studies. Callahan argued in this 1973 piece that bioethics had yet to attain the status of a discipline, and he lauded the freedom of being able to define a new discipline. Callahan's essay shares with Mathews and colleague's a peculiarity: neither ever defines what it means to refer to something as a “discipline.” To define a discipline does mean attending to the intended end product of scholarly activity, so I concur with Mathews et al.’s focus on outcomes. But I am concerned that in their argument they confusingly entangle their understanding of an academic discipline's internal goals, its telos, with its potential to have an impact on the external world, its praxis. The confusion that this can bring exposes what I believe is a profound problem within bioethics, the discipline's peculiar and at times intellectually hazardous relationship with its institutional hosts.     

What Is Bioethics Worth?

What is bioethics to do when it strives to assess the quality of its research and scholarship and when it needs to justify its work to prospective funders, especially a funder like the National Institutes of Health that privileges empirical discovery? In “A Conceptual Model for the Translation of Bioethics Research and Scholarship,” Debra Mathews and colleagues take an important first step at advancing an answer. The authors describe what they call a translational process, whereby bioethics “outputs” are translated into changes of three types: in thinking, practice, and policy. It goes nearly without saying that bioethics research and scholarship must be held accountable for changes in thinking. What raison d'etre do we have if not to deepen thinking, question assumptions, and encourage ourselves and others to examine hard issues from novel approaches? Assuredly it is hard to assess quality, and even harder to assess specific changes in thinking for which high‐quality scholarship may be responsible, but it is a necessary goal and one for which we should strive without reservation. Bioethics should also affect policy and practice. We should document how it does and the extent to which it does as often and as prominently as possible. However, let us be wary of pinning too much on practice and policy changes as the primary way of establishing bioethics’ worth.     

Where Shall We Go?

This issue of the Hastings Center Report coincides with the annual conference of the American Society for Bioethics and Humanities, whose theme this year is “Where do we stand?” The issue addresses that theme with the article by Debra Mathews and colleagues and the set of brief response essays that follow it. Mathews et al., drawing on work carried out by the Association of Bioethics Program Directors, pose questions about how to understand and evaluate the worth of bioethics research. Those questions require them to think very broadly about what bioethics is, in the first place, and how it is related to medicine, health policy, science, and society generally. In short, they are thinking at the highest level about the question, where do we stand?     

Why Bioethics Has a Race Problem

In the September‐October 2001 issue of the Hastings Center Report, editor Gregory Kaebnick encouraged bioethicists to turn their attention toward “easily overlooked, relatively little‐talked‐about societal topics” such as race. In 2000 the president of the American Society for Bioethics had called for a more socially conscious bioethics. Race was risky territory, Kaebnick pointed out, but this challenge did not justify avoidance. Over the next fifteen years, the response to this editor's invitation to examine the racial dimensions of medicine in the Report was limited both in quantity and in terms of the range of topics covered. All told, the bioethics community has not responded to the editor's call for bioethicists to engage with the racial dimension of medicine, and the Report has not really come through on the tacit commitment made in 2001. The lack of interest in race matters evidenced in the Report as well as the American Journal of Bioethics has also prevailed in medical humanities journals, whose few pieces on race have tended to remove race relations from our current realities in two ways: some articles locate medical racism in the American past or in colonial Africa, while others analyze the medical disorders of fictional characters. Bioethicists have not embraced the opportunity to create a sociologically and historically informed bioethics that might be applied to the lives of black Americans and their unending health crisis.     

Chinese Bioethicists Speak Out on Covid-19, and Others Follow

Shortly after Wuhan, the city where the novel coronavirus was first identified, was placed on lockdown in January, I received an email from two Hastings Center fellows in China: Renzong Qiu, of Renmin University of China in Beijing, and Ruipeng Lei, of Huazhong University of Science and Technology in Wuhan. Attached was a post for our blog, Hastings Bioethics Forum, that raised ethical and legal questions about China's response. “Hegel says, ‘We learn from history that we do not learn from history,’” their piece began. “The recurrence of the coronavirus epidemic in China proves his insight to be right.” This bold report from bioethicists in China was courageous and eye-opening. It was among the first discussions in bioethics of what has since become a global crisis, and it turned out to be the first in a string of commentaries in Hastings Bioethics Forum with insights about the crisis, the issues it raises, and how the world should respond to it.     

Bioethics Education

Bioethics education now takes place outside universities as well as within them. How should clinicians, ethics committee members, and policymakers be taught the ethics they need, and how may their progress best be evaluated?     

Bioethics and “Rightness”

If bioethics seeks to affect what people do and don't do as they respond to the practical issues that confront them, then it is useful to take seriously people's sense of rightness. Rightness emerges from the fabric of a life—including the economy of its geography, the events of its times, its popular culture—to be what the sociologist Pierre Bourdieu calls a predisposition. It is the product of a way of life and presupposes continuing to live that way. Rightness is local and communal, holding in relationship those who share the same predisposing sense of how to experience. Rightness is an embodied way of evaluating what is known to matter and choosing among possible responses. Bioethics spends considerable time on what people should do and on the arguments that support recommended actions. It might spend more time on what shapes people's sense of the rightness of what they feel called to do.     

How we developed a bioethics theme in an undergraduate medical curriculum

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.     

Innovative curriculum: Integrating the bio-behavioral and social science principles across the LifeStages in basic science years

Behavioral and social science integration in clinical practice improves health outcomes across the life stages. The medical school curriculum requires an integration of the behavioral and social science principles in early medical education. We developed and delivered a four-week course entitled “LifeStages” to the first year medical students. The learning objectives of the bio-behavioral and social science principles along with the cultural, economic, political, and ethical parameters were integrated across the lifespan in the curriculum matrix. We focused on the following major domains: Growth and Brain Development; Sexuality, Hormones and Gender; Sleep; Cognitive and Emotional Development; Mobility, Exercise, Injury and Safety; Nutrition, Diet and Lifestyle; Stress and coping skills, Domestic Violence; Substance Use Disorders; Pain, Illness and Suffering; End of Life, Ethics and Death along with Intergenerational issues and Family Dynamics. Collaboration from the clinical and biomedical science departments led to the dynamic delivery of the course learning objectives and content. The faculty developed and led a scholarly discussion, using the case of a multi-racial, multi-generational family during Active Learning Group (ALG) sessions. The assessment in the LifeStages course involved multiple assessment tools: including the holistic assessment by the faculty facilitator inside ALGs, a Team-Based Learning (TBL) exercise, multiple choice questions and Team Work Assessment during which the students had to create a clinical case on a LifeStages domain along with the facilitators guide and learning objectives.     

Making sense of ethics and law in the medical curriculum

The moment a patient comes into the treatment room, the medical professional is placed in both an ethical and a legal context. The task for medical teachers is to equip students for this clinical reality in a way that makes sense both to the learners and to the variety of medical educators in the school, all of whom will have their own interpretations of the nature of this subject area. Ethics and law in the medical curriculum (Dowie and Martin 2011), aims to provide an understanding of how ethics and law can be incorporated into the curriculum in a structured, coherent, and logical manner. It is essential that we begin with a vision of the primary purpose of our course, and clarify the overall domain of learning to which it relates. Rather than presenting students with a miscellany of ethico-legal topics, their learning can be reinforced by constructing a frame around the key emphases in law and ethics. A professional ethics frame is proposed, highlighting the everyday, theory-based, habits, intentions, consequences and society elements of this approach. The course also has to be mediated within the wider curriculum, and this benefits from a coherent and communicated course scheme that is directly meaningful within the educational setting of the medical school. Finally, within the Guide, examples of humanistic schemes are presented that centre on aspects of boundary in patient care, themed around body, person and community of practice.     

Toward Public Bioethics?

This issue of the Hastings Center Report (May‐June 2017) features a couple of interesting takes on the governance challenges of emerging technologies. In an essay on the National Academies of Science, Engineering, and Medicine report published this February on human germ‐line gene editing, Eric Juengst, a philosopher at the University of North Carolina, argues that the NASEM committee did not manage to rethink the rules. Juengst reaches what he calls an “eccentric conclusion”: “The committee's 2017 consensus report has been widely interpreted as ‘opening the door’ to inheritable human genetic modification and holding a line against enhancement interventions. But on a close reading it does neither.” In the column Policy and Politics, Sarah Chan, a chancellor's fellow at the University of Edinburgh, discusses the emerging science of “organoids,” “embryoids,” and “synthetic human entities with embryo‐like features” and calls for a sustained effort to rethink the rules for embryo research.     

Ethical issues in the managed care setting: a new curriculum for primary care physicians

Several challenging ethical issues have been associated with the shift to managed healthcare in the United States. Our objective was to develop, implement, and evaluate a curriculum designed to help physicians identify and examine ethical issues encountered in the managed care setting. The curriculum was developed during a year-long workshop at Johns Hopkins Bayview Medical Center. The content of the curriculum was established through literature review, focus group discussions with physicians, and a needs assessment of targeted learners (primary care physicians practicing in managed care settings). Some of the key issues addressed in the curriculum include: changing professional responsibilities of physicians; fair use of resources; and threats to the doctor-patient relationship as a consequence of the new healthcare delivery system. The 7.5-h curriculum was taught over five sessions using varied teaching methods. Evaluations demonstrated that the curriculum was successful in increasing learner awareness of ethical issues confronted in the managed care environment and improved learner knowledge in these areas. The physician-learners reported that this educational experience would change their teaching of medical students and residents. After completing the curriculum, learners felt that they were at least somewhat better able to cope with ethical challenges encountered in the managed care setting. Future research might examine whether such a curriculum could positively affect physician behavior or enhance physician satisfaction with the managed care setting.     

The Birth of Bioethics

Book reviewed in this article: Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making . By David J. Rothman     

How we derived a core curriculum: from institutional to national--Ankara University experience

As the first phase of a major curricular change in a large medical school the core curriculum had to be determined. The criteria for the inclusion of topics in the core curriculum were defined for both clinical and basic sciences. A large group of faculty members have worked in 11 sub-groups to determine the core knowledge, skills and attitudes for undergraduate medical students. During this work 608 clinical topics have been reviewed. Four-hundred and eighty five of them (79%) have been included in the core curriculum. Clinical and basic science knowledge, skills and attitudes relevant to these topics have been defined and classified. A total of 1610 cognitive, 428 psychomotor skills and 247 attitudes have been named. Thus the core curriculum defined is not just a set of diseases, conditions and symptoms but also includes the details of each and every topic. Starting from this point the medical school has participated actively in defining the national core curriculum, which has also been determined according to the same criteria.     

Bioethics and Addiction

Bioethicists have sometimes regarded the opioid epidemic as a problem with obvious answers and thus no need for the field's conceptual analysis. Yet, as three essays in the July-August 2020 issue of the Hastings Center Report demonstrate, the opioid crisis contains a knot of distinctions and puzzles to be sorted out. Travis N. Rieder examines, for example, what is fundamentally driving the crisis—access to the drugs or large societal problems such as poverty and joblessness. The role of choice in addiction, the effects of moral condemnation on approaches to addiction, and what treatment should look like are among the puzzles Hanna Pickard explores, while Daniel S. Goldberg focuses on the common and harmful conflation of the public health problems of substance misuse and pain. These philosophical and bioethical questions point in widely different directions, lying both inside and outside bioethics. They point toward systemic societal factors that determine health and well-being yet have seemed outside bioethics' largely clinical boundaries. And they point toward a deeper look at the very idea of autonomy—an examination of a topic clearly within bioethics yet occurring at the fringes of its usual constructs.     

Global bioethics

This August, I participated in the conference “Genome Editing: Biomedical and Ethical Perspectives,” hosted by the Center for the Study of Bioethics at the University of Belgrade and cosponsored by the Division of Medical Ethics of NYU Langone Health and The Hastings Center. The prime minister of Serbia, Ana Brnabi?, spoke of the significance of bringing together an international community of bioethicists, acknowledging that ethical, social, and legal issues surrounding gene editing technologies transcend national boundaries. Europe's Oviedo Convention prohibits human germline gene editing, and UNESCO's Universal Declaration on the Human Genome and Human Rights says that germline editing “could be contrary to human dignity,” an assault on humanity itself. Whether one agrees or not, engaging with the idea forces us to think about what it means to be part of the global human community and about the moral significance of the human genome to creating that community. The conference highlighted for me how challenging having international, much less global, conversations about bioethics can be .     

Annual Award for an Essay by an Early‐Career Scholar

As part of the celebrations of The Hastings Center’s fiftieth anniversary, we are launching an annual prize, The David Roscoe Award for an Early‐Career Scholar’s Essay on Science, Ethics, and Society. The award is named in honor of David Roscoe, an accomplished essayist and recent past chair of the Hastings board. The award is intended to highlight the good scholarship that will take the field of bioethics forward into the next fifty years. It will recognize an early‐career scholar—someone who either is currently pursuing a relevant academic degree or has earned one within the last six years—for a published essay on the social and ethical implications of advances in science and technology. More information about the award, along with online submission forms, is available on The Hastings Center’s website.     

Theology, religious traditions, and bioethics

The social and medical ethos within which bioethics emerged in the late 1960s and early 1970s was constituted in part by religious questions and religious thinkers. However, this identifiably religious influence on bioethics subsequently seemed to decline. How has this diminished impact come about, and what significance, if any, does it hold for the ways we now do bioethics? What difference, finally, do religious perspectives make for bioethics? These were the overarching questions that led the Hastings Center to initiate a research project on the relation of Religion and Bioethics, culminating in this special supplement to the Hastings Center Report.