Ethics in health: some current: perspectives

World Health • 48th Y eor, No. 2, Morch- Aprill995 IS Ethics in health: some current • perspectives Sev S. Fluss Kidney dialysis: a great many people con not afford cast/y life-soving techniques - on economie fact of !ife thot has an important bea ring on health ethics . The technological revolution in medicine over the last few decades has been accompanied by a no Jess striking phenomenon - the growth of the new discipline of "bioethics" and the emergence of a sub-branch tentatively named "health care ethics" . Perhaps the most remarkable features of this phenom- enon have been, on the one hand, the intense, and seemingly indefatigable, interest of the media and of profes- sionals and the lay public alike in these issues, and, on the other, the extent to which ethical discourse and debate in many countries has given rise to legislation. When did modem bioethics begin? Many would say that the seminal event was the publication on 9 November 1962 of an article in Life magazine entitled "They decide who lives, who dies". As described by one of the founding fathers of the new discipline, Albert Jonsen, that article was prompted by the setting up of a committee in the U.S. city of Seattle to examine which of a number of patients should have access to the newly discovered, and life-saving, technology for kidney dialysis. In September 1992, Jonsen brought together, in Seattle, sorne 40 leading figures in the field for a Conference on "The Birth of Bioethics". The term itself was probably first used in 1970 by Van Rensselaer Potter, a cancer researcher at the University of Wisconsin, while an eminent his- torian of bioethics, Warren Reich, notes that its first institutional use occurred in 1971 at Georgetown University in Washington, D.C. Others would argue that bioethics is much older. Thus, a remarkable bioethical debate -on the ethics of animal experimentation- occurred in the House of Lords in London nearly 120 years ago. Speaking on 22 May 1876, the Earl ofCamarvon described the legislator's dilemma in graphie terms: On the one hand there is the danger of going too far; on the other, the danger of not going far enough: on the one side there is the strong sentiment of humanity; on the other, the re are the claims of modern science. ft is a sea strewn with rocks, and it is not easy to steer safely through them. There are, of course, many earlier historical events that occurred in the development of contemporary med- ical ethics- Thomas Percival's Code of Medical Ethics in En gland in 1803, William Beaumont's Code of 1833 in the USA (the American Medical Association issued its first Code of Medical Ethics in 184 7), and, in France, Claude Bemard's Introduction to the Study of Experimental Medicine (1865). In what was then Prussia, the issue of the permissibility of human experi- mentation attracted considerable attention in the press, Parliament, and the courts at the end of the !9th century and culminated in the first known legislation on the subject, a 1900 Directive of the Minister of Religious, Educational and Medical Affairs . Where are we today, nearly a century after that epoch-making legislation was enacted? Here are sorne of the key features of recent developments. • Many countries, and severa! international organizations (both intergovemmental and non- govemmental), have established special committees, commissions, boards and the 16 World Heolth • 47th Year, No. 6, November-December 1994 Key issues Every individuel in the warld shauld have access to a minimum of essen fia/ health ca re. What are the key issues in bioethics and health care ethics as we move towards the 2lst century? Most of the readers of World Health will not have the time (or patience) to consult the newly published revised edition of the massive Encyclopedia of Bioethics, or indeed the annual Bibliography of Bioethics. Nor will they necessarily wish to consult such major works as the fourth edition of the Principles of Biomedical Ethics (by T. L. Beauchamp and J.F. Childress) or Principles of Healthcare Ethics (edited by R. Gillon), both of which appeared in 1994. equivalent to examine bioethical issues. Perhaps the best known are the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in the USA, which issued a number of influ- ential reports during the period 1980-83, and the French National Ethical Consultative Committee for the Life and Health Sciences, whose innovative and influential work has now entered its second decade. • A leading role in the global debate on bioethics has been played by WHO's "sister" organization, the Council for International Organizations of Medical Sciences (CIOMS). • Conferences and meetings on bioethics are now being held regularly in developing as weil as developed countries - witness the 1 st International Congress on Bioethics, held in Mexico City on 3-6 October 1994, the Second World Congress of the Internation- al Association of Bioethics, held in Buenos Aires on 24-26 October 1994, and the Journées Internationales de Bioéthique, held in Yaoundé, Cameroon, on 14-17 February 1995. • The flow of new, and sorne times innovative, legislation in the field of bioethics has been substantial in recent years- examples are the proposed Death with Dignity Act of the State of Oregon in the USA and, of course, the three major laws on bioethics enacted in France in July 1994, marking the culmination of severa! years' debate in that country. • UNESCO's International Bioethics Committee is currently developing an international instrument for the protection of the human genome, the Council of Europe is in the final stages of formulating a Bioethics Conven- tion, and WHO is endeavouring to establish a comprehensive in- ventory of key issues in the field of health and ethics to be addressed by the Organization. Suffice it to say that the follow- ing are among those "micro-ethical" and "macro-ethical" issues (not listed in arder of priority) that are currently receiving particular atten- tion, bath on the part of professional groups, the media, and the public: - equity and justice in access to health care; - ethical issues in reproductive health, including medically assisted procreation; - biomedical research on human subjects; - ethical issues in mental health and the neurosciences; - ethical issues in biotechnology; A recent/y married couple receives counselling in contraception. The righi to information and to make an enlightened choice is essential for health developmenf. World Health • 48th Y eor, No. 2, Morch-Aprill995 17 The righi to heolth is a fundomental human righi. - embryo and fetal research; - genetic technology, including gene therapy; ' - organ and tissue transplantation ; - patients' rights; - withholding or withdrawing life- sustaining medical treatment; - euthanasia and physician-assisted suicide; - allocation of scarce resources; - confidentiality of medical data. While WHO has, at least at present, no major substantive role in many of these areas, it is continuing its efforts to compile, validate and disseminate relevant information on develop- ments in these and other areas of bioethics. This is in line with one of its constitutional functions, namely the provision of "information, co un- sel and assistance in the field of health". As the Preamble to the WHO Constitution points out, "Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people". This certainly applies to bioethics and cognate areas as much as to the more classical aspects of persona! and environmental health services. • - treatment decisions for seriously ill neonates; - eth ica! issues in the HIV 1 AIDS context; - the safety of blood and blood products; The rightto health The Constitutional basis - the conceptual framework • WHO's Constitution proclaims "The enioyment of the highest attainable standard of health is one of the fundamental rights of every human being ... ". • The Organization's objective is "the attainment by al! peoples of the highest possible leve! of health ". The Health for Ali approach -a guide for humanity ln 1977, the World Hea lth Assembly resolved ta formulate the above aspirations in concrete terms , namely "Health for Ali by the Year 2000", committing governments and W HO to the attainment of the Constitutional objective. T owards Health for Ali -a template for action WHO has just published ils Ninth General Prog ramme Mr. Sev S. Fluss, is Adviser on Health Legislation to the Oirector, Division of Publishing, Language and Library Services, World Health Organization, 1 2 1 1 Geneva 27, Switzerland. of Work (for 1996-200 1). Here are some extracts: • "Much more attention must be pa id ta ... ensuring equity in health core and services ... " • "The Constitution, the hea/th-for-a/1 goal and the concept of health as a human right, expressing succinct/y the conviction thot al! people should have opportunities ta improve and maintain their health, represent important aspirations for the world community." • "WHO will continue ta use ils position ta stress the im- portance of hea!th as a human right and point out inequities in heafth and access ta health services. lt will emphasize the need for more equitable access ta core and services, defending the rights of vulnerable groups and countries most in need, and drawing the attention of governments and the public ta unacceptable health situations ."