Paradigm shift, metamorphosis of medical ethics, and the ... · Paradigm shift, metamorphosis of medical ethics, and the rise of bioethics Transição paradigmática, metamorfose

15

Cad. Saúde Pública, Rio de Janeiro, 15(Sup. 1):15-25, 1999

ARTIGO ARTICLE

Paradigm shift, metamorphosis of medicalethics, and the rise of bioethics

Transição paradigmática, metamorfose da ética médica e emergência da bioética

1 Departamento de CiênciasSociais, Escola Nacional de Saúde Pública,Fundação Oswaldo Cruz.Rua Leopoldo Bulhões 1480,9o andar, Rio de Janeiro, RJ21041-210, Brasil.

José Luiz Telles de Almeida 1

Fermin Roland Schramm 1

Abstract Both the increasing incorporation of medical technology and new social demands(including those for health care) beginning in the 1960s have brought about significant changesin medical practice. This situation has in turn sparked a growth in the philosophical debate overproblems pertaining to ethical practice. These issues no longer find answers in the Hippocraticethical model. The authors believe that the crisis in Hippocratic ethics could be described as aperiod of paradigm shift in which a new set of values appears to be emerging. Beginning withthe bioethics movement, the authors expound on the different ethical theories applied to med-ical practice and conclude that principlism is the most appropriate approach for solving thenew moral dilemma imposed on clinical practice.Key words Bioethics; Medical Ethics; Medicine

Resumo A crescente incorporação de tecnologia médica e as novas demandas sociais, inclusivede saúde, que tiveram início nos anos 60, impuseram importantes transformações na práticamédica. Tal situação tem estimulado crescente debate filosófico em torno de problemas de éticaprática que não mais encontram respostas no âmbito do modelo ético hipocrático. Para os au-tores, a crise da ética hipocrática poderia ser caracterizada como um período de transição para-digmática em que se estaria formando um novo conjunto de valores. A partir do movimento dabioética, os autores apresentam as diferentes teorias éticas aplicadas à prática médica, concluin-do que a abordagem principialista seria mais adequada à resolução dos novos dilemas moraispostos à prática clínica.Palavras-chave Bioética; Ética Médica; Medicina

ALMEIDA, J. L. T. & SCHRAMM, F. R.16


Introduction

What common ground can one find betweenthe advent of the contraceptive pill and the per-sonal computer revolution, between geneticsresearch and civil rights movements, or be-tween the increased level of schooling in the USpopulation and the abortion rights movement?

All these phenomena have been observedmore frequently in the last three decades, main-ly in the United States, and have had either di-rect or indirect influence on health care in gen-eral and medical practice in particular. New so-cial demands have been raised, whereby tradi-tionally passive and obedient patients havebeen replaced gradually by health care con-sumers, who in principle are active and awareof their rights. We have reached a point wheremedicine at the turn of the century is said to befocused less on its role of curing human suffer-ing and more on promoting ‘customer satisfac-tion’, thus launching a new era of the medicineof desires (Pellegrino, 1979).

However, this transition has not been freeof conflict and uncertainty. After all, we are ex-periencing the age of the end of certainties,even in the field of ‘hard’ sciences like physics(Prigogine, 1996). As in any paradigm shift, andthis is true for the transition from a traditionalmedical care model to a new one (still not fullyconsolidated), ethical tensions tend to mount.

The emergence of bioethics in the contextof clinical practice has enriched the debate onchanges in medical ethics, because any prob-lem in bioethics, as suggested by Mori (1990),can be the object of at least two different levelsof analysis.

At the first level, one seeks to identify themost adequate solution for a ‘particular case’,assuming that there is agreement as to the rel-evant problems involved in the problem athand. Many of the quotidian problems facedby physicians in clinical practice are solved onthe basis of traditional (Hippocratic) medicalethics. It is thus a matter of properly applyingthe principles in keeping with the specific situ-ation. Yet the difficulty arises when one at-tempts to assess the different psychologicaland social conditions experienced by physi-cians and patients, keeping in mind that clini-cal knowledge does not reflect certainties, butmerely probabilities. It is thus necessary to pro-ceed to a second level of analysis.

The second level seeks to specify the veryprinciples applied to a given case and forcesone to adopt a broader analytical perspective,since the search for and specification of ethicalprinciples define the very nature of social life.

According to Mori, the most relevant prob-lems in contemporary bioethics are located atthis second level of analysis, since “the greatestdisagreement in this area concerns the princi-ples themselves” (Mori, 1990:199).

The current article presents the discussionon the process of change in references for med-ical ethics based on the theoretical contribu-tions of bioethics, according to the model pro-posed by Pellegrino (1995), characterizing thisstage as a ‘metamorphosis of medical ethics’.

Pertinence of the debate

Changes in medical practice caused by both thegrowing incorporation of technology and newsocial demands appear to suggest a special mo-ment in the history of contemporary medicine.However, can we really say that we are experi-encing a crisis period in the prevailing medicalmodel and the emergence of a new biomedicalparadigm? In the course of this article we seekto respond affirmatively to this question, con-sidering the emergence of bioethics as a strongindication of just such a situation.

The term paradigm was introduced intophilosophy by Kuhn in his essay The Structureof Scientific Revolutions, published in 1962,shedding great light on the history of sciences.According to Kuhn, paradigms are “universallyacknowledged scientific achievements which,for some period of time, provide model prob-lems and solutions for a community of practi-tioners of a given science”(Kuhn, 1996:13). Insuch periods of scientific development, whichhe calls ‘normal science’, the conceptual frame-work of a discipline (i.e., its paradigm) remainsinvariable and scientists are occupied in solv-ing its problems based on the unchallengedreference of the prevailing paradigm.

Yet no matter how long these periods maylast, they are not eternal, since from time totime scientists produce results that contrastwith consolidated theories, thus leading toproblems that cannot be solved within the pre-vailing paradigm. However, Kuhn emphasizesthat such problems, or ‘anomalies’, do notnecessarily lead to a paradigm shift. Yet assuch anomalies accumulate, “normal sciencesoon becomes disoriented. And when this oc-curs – that is, when members of a professioncan no longer avoid the anomalies that subvertexisting tradition in scientific practice – extra-ordinary investigation begins that finally leadsthe profession to a new set of commitments, anew basis for the practice of science” (Kuhn,1996:25).


Santos (1989, 1994), in turn, in analyzingthe crisis of modernity and its epistemologicaland societal paradigms, introduces the termparadigm, characterized “by the reconceptual-ization of existing science as a new science, theoutline of which is barely visible” (Santos, 1989:148). In fact, a transition period means that theprevailing model or paradigm has failed to pro-vide answers to given problems, although itsreplacement is not fully established. Thus wefeel that the use of the paradigm concept shedslight on the current stage of philosophical re-flection concerning medical practice.

Such paradigm changes in the sciences werealso observed in late 18th-century medicine. Assuggested by Foucault, during that period med-ical research began to correlate diseases andtheir signs and symptoms with anatomical le-sions and to define them as “a system of analyt-ical classes in which the element of pathologicaldecomposition was the principle for generaliz-ing morbid species” (Foucault, 1994:150). Fromthat point on, a conflict was established be-tween two figures in medical know-how: classi-ficatory medicine and anatomo-pathologicalmedicine. It is interesting to note that preciselyduring this period of medicine the philosophi-cal problems were the center of attention formedical debate (Wulff et al., 1995:18). As Kuhnexplains: “The emergence of new theories is gen-erally preceded by a period of professional inse-curity, since it requires the large-scale destruc-tion of paradigms and major changes in theproblems and techniques of normal science.”(Kuhn, 1996:95)

Recourse to philosophy would thus be themeans to overcome such a state of insecurity,since it “makes us perceive our ignorance andcreates the desire to overcome uncertainty”(Chauí, 1996:90).

Once this state of insecurity has been over-come, the emerging paradigm adds more andmore scientists and establishes a new periodof normal science. In medicine, this new phasewas characterized by technical and scientificprogress, which was increasingly successful inpursuing and establishing the cure for dis-eases as its main purpose. Throughout this pe-riod of ‘normal science’, ethical issues werelimited to the sphere of Hippocratic medicalethics.

Callahan points out that one of the valuesthat emerged was the moral and social demandfor unlimited medical progress, establishingthe duty “as if in a sacred military campaign, toalways march ahead of the frontiers of medicineand dominate the disease surrounding us at themoment”(Callahan, 1994:76).

PARADIGM SHIFT AND THE RISE OF BIOETHICS 17

Such determination in curing diseases andprolonging human life through advances inmedical knowledge meant that beginning inthe 1970s there emerged new problems thatfailed to find adequate answers within the Hip-pocratic ethical model. In the past, when physi-cians could do little for their patients, therewere no major ethical concerns beyond thoseprescribed by Hippocratic tradition. However,ethical ‘issues’ could no longer be ignoredwhen it became possible to transplant vital or-gans from one person to another, diagnosecongenital anomalies in utero, and prolong thelives of incurable patients.

As Wulff et al. stress: “The medical profes-sion finally realizes that clinical practice is notmerely an applied natural science, but that clin-ical decisions always entail value judgments.The result of this new awareness is that contem-porary clinicians speak not only of cure and sur-vival, but also of quality of life for their pa-tients”(Wulff et al., 1995:20).

The emerging ethical questions in medicalpractice indeed appear to indicate that thetraditional medical paradigm has been chal-lenged on the basis of a philosophical reflec-tion that we see as a moment of paradigmaticinstability, justifying the pertinence of this de-bate on the process of metamorphosis in med-ical ethics.

In the opinion of Pellegrino (1995), this per-tinence is justified by the following:

1) Medical ethics, like medicine, is a syn-thesis of theory and practice, and the quest forsolutions to practical moral decision-makingproblems is thus totally dependent on the con-ceptual framework used to define what is rightand wrong, good or bad.

2) Physicians should acknowledge thatphilosophers and philosophical theories haveexerted a powerful influence on the change inmedical ethics; nonetheless, the task of ethicalanalysis and reflection should not be reservedexclusively for philosophers or jurists.

3) Physicians should be aware of the philo-sophical arguments employed by their owncolleagues when they defend drastic changesin medical tradition.

Of the issues listed by the author, the onepertaining to practical moral decision-makingproblems may be most deserving of our atten-tion. After all, medicine has been seen as a sci-ence that grows on the basis of isolated or purefacts, and one that is thus in a neutral positionvis-à-vis value issues (Guillén, 1995: 192).

In fact, science, on the one hand, consti-tutes itself as a field that builds pertinent andtrue knowledge, i.e., establishes provable or



refutable enunciates. Axiological or ethical is-sues, on the other hand, pertain to the searchfor what can be judged as good according to agiven time and society. As Schramm empha-sizes, “the principal practical consequence ofthis is that we must distinguish between scien-tific knowledge stricto senso, i.e., the formula-tion of refutable hypotheses (and the discoveryof ‘truths’ about what such knowledge is) and itstechnical applications” (Schramm, 1997:208).

However, the development of science andin particular that of life and health sciences inrecent decades has established a new scientificconfiguration. Science has literally becometechno-science, that is, “a kind of knowledgewhich is increasingly a rational and operationalway of knowing” (Schramm, 1997:209).

What implications does this change have forethics? Increasingly independent from the ab-solute principles shared by religions and in partby the major universalist ideologies, ethics hasbecome more applied or practical (Singer, 1994).

Thus, as Schramm highlights, “ethics andscience, although methodologically distinguish-able, can also be seen as pragmatically linked”(Schramm, 1997:209).

This new techno-scientific configurationraises challenges for medical practice based onthe Hippocratic tradition. Pellegrino (1995)thus uses the term ‘metamorphosis of medicalethics’, a historical process consisting of fourperiods or stages, according to the author:

1st stage – begun by Hippocrates and hisdisciples and marked by a long period of tran-quillity in which the Hippocratic tradition (en-riched over the centuries by Stoicism andmonotheistic religious traditions) was seen asa given, a belief prevailing until the 1960s;

2nd stage – characterized as a stage ofphilosophical investigation during which moraltheories based on principles began to trans-form medical ethics (began in the 1960s andprevailed until the mid-1980s);

3rd stage – called anti-principlism, i.e., themoral theories that compete with each otherand have challenged the primacy of principles;this stage, dating to the early 1980s, is nowreaching its end;

4th stage – began in the 1990s, character-ized as a stage of crisis in which conceptualconflicts and skepticism in moral philosophyare placing in check the notion of universal,normative ethics for medicine.

We consider the author’s classification agood working outline for organizing the dis-cussion on the process of change observed inmedical ethics, as well as for situating the emer-gence of bioethics in the health care scenario.

The 1st stage, or the period of tranquillity in Hippocratic ethics

The point of departure for the metamorphosiswas the oath credited to Hippocrates (some2,500 years ago) and the deontological or pro-cedural books from the Corpus Hippocraticum.In fact, historical evidence suggests that theanthology called Corpus Hippocraticum wascollated in the early third century BC under anorder from Ptolomy. The compilers used limit-ed critical spirit in their selection work, lump-ing a mass of excerpts, abstracts, and fragmentstogether with legitimate masterpieces (Olivei-ra, 1981:75).

On the other hand, the Hippocratic oath in-cluded a major portion of the genuine moralprinciples and can be organized into four parts,according to its specific contents:

1) Introduction, in which the physician in-vokes the Greek gods Apollo, Aesculapius,Hygeia, and Panacea as witnesses to his oath;

2) Chapter 1, in which the physician ac-cepts the commitment, together with his mas-ter, to teach the art of medicine, free of cost, tothe latter’s children and other disciples takingthe oath in the future;

3) Chapter 2, including the moral principlesprohibiting abortion, euthanasia, surgery, andsexual relations with patients; and

4) Conclusion, reaffirming the commitmentto the terms of the oath, having as one’s recom-pense the esteem of all men, or the opposite,should the principles be violated (Guillén, 1989:45-71).

The principles contained in the Hippocrat-ic oath were accepted uncritically and venerat-ed until the mid-18th century, when there wasan initial critical reading of Hippocrates’ writ-ings by Emile Littrè, in 1861 (Littrè, 1861).

Until then, the principles were consideredsacred, not only because they were ‘invio-lable’, but also because the physician was con-sidered a kind of lay priest, acting in favor ofnature and the gods to cure the patient underhis care.

The ‘sacred’ principles of generosity, dedi-cation, and impartiality, according to Schramm,constituted the underpinnings providing legiti-macy to the medical art “in the form of an oathlinking medical know-how to a feeling of empa-thy and the principle of responsible freedom,making the ‘art of curing’ acceptable to thepólis, i.e., publicly” (Schramm, 1994:326).

The decision-making method over thecourse of these 2,500 years consisted of judg-ing whether a given conduct was in keepingwith Hippocratic principles.



Pellegrino (1995) points out that neitherancient nor modern philosophers devotedtheir attention to a systematic ethical justifica-tion of the physician-patient relationship onwhich to base physicians’ decisions and pa-tients’ well-being. Neither was there any signif-icant change during this period as medicalethics entered into contact with the mainmonotheistic religious traditions.

Among the latter, Christianity played anoutstanding role in shaping Western thinking.In early Christian religion, diseases were viewedas divine punishment or instruments to test afollower’s faith, thus denying the natural ori-gins of illnesses. The dichotomy between theart of curing founded on the Hippocratic tradi-tion and Christian religion was first challengedby the ideas introduced under the theologicaldoctrine of Saint Augustine of Tagaste (340-430AD), reconciling Christianity with classic cul-ture, drawing it progressively closer to lay phi-losophy and thus allowing for a conjunction of‘science’ and religion (Antunes, 1991:49-50).

The physician’s moral authority, based onHippocratic values, which persisted through-out the Middle Ages (reinforced by Christiani-ty), was gradually replaced by legal authoritybeginning in the 16th century. This legal au-thority, with the modern state as its paradig-matic framework, was based on the concept oflegally defined competence.

Guillén (1994) emphasizes that from themid-17th century to the present at least threedifferent types of human rights were devel-oped:

‘1st generation’ or civil and political rights;‘2nd generation’ or economic, social, and

cultural rights;‘3rd generation’ or ecological rights and

those of future generations.All three types of rights bear a close rela-

tionship to health and constitute the basis forclassic ethical principles.

The first rights, or those of the first genera-tion, began with the publication of John Locke’sTwo Treatises on Civil Government in 1690(apud Guillén, 1994), laying the groundworkfor the modern theory of human rights. Ac-cording to Locke, in the natural state, when hu-man beings had still not established the socialpact with which civilized life began, life wasregulated by a primary law, i.e., natural law,making all human beings their own masters.The importance of Locke’s work was based onthe following: a) for the first time a table of civiland political rights had been drafted, includingthe right to life, the right to health, the right tofreedom of conscience, and the right to prop-

erty; b) such rights were individual, and theirachievement depended exclusively on individ-ual initiative; and, c) the rights proposed byLocke imposed duties on ourselves, thus hav-ing a positive value. As stressed by Guillén, “Inthe final analysis, our ultimate duty to ourselvesis to lead our lives to perfection and to achievehappiness: the most ‘positive’ duty one couldimagine” (Guillén, 1994:32).

The medical profession was thus cloaked inlegal authority in the context of constitutingthe modern state, based on legally definedcompetence, thus meaning that the professionshould possess an objectively outlined set ofduties and services, the allocation of the neces-sary powers for their realization, and the closedefinition of admissible sanctions and the pre-supposition of their application in such cases(Guillén, 1989:86).

The Hippocratic ethical tradition did nothave any of its principles challenged until themid-1960s. From then on doubts began toemerge concerning the traditional moral un-derpinnings of society as a whole and medicinein particular, thus opening the way for criticalquestioning.

The 2nd stage, or the emergence of bioethics and principlism

The questioning of medical ethics was partiallydue to the widespread upheaval in moral val-ues in the United States throughout the 1960s.As a decade of mass demonstrations and socialtransformations, it was characterized mainlyby a higher educational level for the Americanpeople, expansion of democratic participationled by the civil rights and feminist movements,as well as consumer activism, a decline inshared community values, increased emphasison different ethnic origins, and widespreaddistrust towards authorities and institutions ingeneral. In addition, the very meaning of medi-cine underwent changes through the special-ization, fragmentation, institutionalization, anddepersonalization of health care. The numberand complexity of problems in medical ethicsalso grew as medical technology raised newmoral challenges to traditional values.

The demand to legalize abortion led by thefeminist movement in the 1960s was one of themoments of greatest social polarization in theUnited States, contrary to some European coun-tries, where the debate was limited to the po-litical and legal spheres. In the United States,the morality of abortion came under discus-sion, since physicians themselves often had



trouble judging certain clinical cases (Mori,1994:334).

In addition, this same period also wit-nessed growing concern over possible abusesby the power of science over the lives of indi-viduals, mainly after the work of Katz was pub-lished in 1972. An American psychiatrist, JayKatz performed a historical work-up of bio-medical sciences with regard to abuses in sci-entific experimentation on human beings (Katz,1972). For the first time there was a public ex-posé of cases that were to become paradigmat-ic in the awareness of the need to place limitson scientific practice. Three cases received themost attention:

1) A research project on 600 African Ameri-can men from Tuskegee, Alabama, from 1932 to1972, came to be known as the ‘bad blood’case. The researchers withheld information andproper available treatment (penicillin) from399 carriers of the disease in order to study itslong-term effects. The principle of informedconsent, which had already been formulated inthe Nuremberg Declaration in 1947, was fla-grantly breached, compounding what was alsoan explicit case of racial and social prejudice.The experiment was not interrupted until 1973,after being exposed a year before on the frontpage of the New York Times.

2) Another case involved the injection oflive liver cancer cells in 1964 in 22 elderly pa-tients at the Jewish Chronic Disease Hospital inBrooklyn, New York. In this case the physiciansalso believed that they could perform any kindof research as long as it was (supposedly) tobenefit scientific progress, but in fact the pa-tients were not sufficiently and adequately in-formed so as to provide their informed con-sent. The physicians were declared guilty ofbreach of professional ethics, fraud, and mal-practice.

3) Approximately 700 to 800 severely retard-ed children at the Willowbrook State School forthe Retarded from 1956 to 1970 were intention-ally infected with hepatitis virus.

Katz’ work had broad repercussions onpublic opinion in the United States in the early1970s and helped fuel the bioethics movement.

In 1966, Harvard Medical School professorHenry K. Beecher had already published an ar-ticle showing that in North American clinicalpractice, abuses were common against thehealth and life of patients submitted to scien-tific research, despite formal recognition of theprinciples of non-maleficence, beneficence,and informed consent, aimed at protecting thesubjects of scientific research (NurembergCode, 1947, apud Annas & Grodin, 1992). He

had also demonstrated how abuses were com-mitted almost exclusively against socially vul-nerable individuals such as prison inmates, thediseased, the mentally ill, soldiers, and mem-bers of ethnic minorities, thereby breachinganother principle of bioethics, that of justice(Beecher, 1966).

It was also in the 1960s and 70s that majortechnological innovations occurred in the bio-medical field which raised further major ethi-cal challenges. The following are some of themore important examples:

a) the work of James Watson and FrancisCrick, who discovered the structure of geneticmaterial, leading to the development of specialtechniques allowing for the precise mapping ofeach gene and serving as the basis for the mostambitious research project undertaken by hu-mankind, the Human Genome Project (HGP),the hub of debate involving a number of seri-ous ethical issues pertaining to all of society(Thomasma & Kushner, 1996);

b) the first heart transplant, performed in1967 by Christian Barnard, sparking a debateover the origin of the organ, the donor’s explic-it desire (or lack thereof ) to donate, and thevery concept of death; and

c) the problems raised by the impossibilityof making dialysis universally accessible. Thislast issue became emblematic of the dilemmain choosing between who could have access tonew technology for chronic hemodialysis andwho would be excluded from it. This occurredin Seattle in 1962, and the difficult choice ledto the formation of a small committee, most ofwhom were non-physicians. The criteria cho-sen for selecting patients most in need of he-modialysis caused considerable controversy tothe extent that they were not limited to clinicalaspects. Thus, “Only after much protest and nu-merous demands, a federal program was ap-proved in 1973 making dialysis accessible toeveryone, based exclusively on clinical criteria”(Berlinguer, 1996:93).

In this context of widely renewed interest inethical phenomena in general and the gradualyet widespread introduction of knowledge andtechniques in the biomedical sciences, the termbioethics was coined by oncologist Van Renss-laer Potter in 1970 and publicized in this bookBioethics: Bridge to the Future in the year 1971.According to Potter, bioethics was a ‘new sci-ence’ aimed at guiding human beings in theirrelationship to nature. It was to be a kind ofnew ‘scientific ethics’ aimed at guaranteeinghuman survival and quality of life, focusing ondevelopment and population problems, em-bracing the emerging problems in the field of



health. According to Potter, biology, which iscurrently extending its horizons beyond thetraditional descriptive sphere, should also in-clude norms and values in its own field of in-vestigation.

Potter’s professional experience as oncolo-gist was crucial to his stance, since he realizedthat the links between the various types of can-cers and deteriorating environmental condi-tions in general (but especially in the work-place) were beyond the measures traditionallyemployed by the sphere of medicine. It wasthus necessary to develop a ‘global ethics’ in-cluding humankind’s relationship to the envi-ronment (Reich, 1995:21).

Yet the term bioethics took on a differentmeaning from that originally proposed byPotter. This change was linked to the creationof the Kennedy Institute for the Study of Hu-man Reproduction and Bioethics in 1971,where bioethics was not considered a ‘scien-tific ethics’, but rather ethics applied to a newfield of study, the medical and biological field(Mori, 1994:34).

During this period, Beauchamp & Childress(1994) adapted the theory of prima facie prin-ciples developed by Ross. Sir David Ross hadpublished a famous book, The Right and theGood, in the 1930s, contending that moral lifehad grown out of given principles that werebasic and self-evident for all of Western soci-ety (Ross, 1930). Yet these principles were notmandatory or absolute; rather, they should beconsidered prima facie, i.e., admitting excep-tions under specific circumstances.

Ross also established a hierarchy amongstthe principles of justice, non-maleficence, andbeneficence. In his opinion, the principle ofnon-maleficence took priority over that ofbeneficence (Guillén, 1995).The reason wasthat all individuals, in principle, had the oblig-ation to not harm other individuals, while theobligation to do somebody good was limited tocertain professions, like medicine.

By adapting Ross’ principles, Beauchamp &Childress (1994) acknowledged that there werea number of difficulties to overcome in order toreach a consensus on the most important is-sues in ethics.

The prima facie principles chosen were thefollowing: non-maleficence, beneficence, au-tonomy, and justice. These four fundamentalmoral ideas share the merit of being compati-ble with the main theoretical currents of deon-tology and consequentialism. Deontology (fromthe Greek root deontos, meaning ‘duty’ and lo-gos, or ‘study’) was the basis for the develop-ment of medical deontology, a discipline deal-

ing with the range of obligations physicianshave towards their ‘professional world’: pa-tients, patients’ families, society in general,professional colleagues, the state (Segre, 1995:27). Consequentialism, meanwhile, derivesfrom the utilitarianism of John Stuart Mill andJeremy Bentham, comprising a set of ethicaldoctrines that measure the goodness or evil ofacts based on their beneficial or maleficentconsequences (Guisán, 1992:277). These twophilosophical schools exerted great influenceon ethical theories as applied to health.

The four principles scheme is attractive forclinical practice for the following reasons: 1) Itprovides quite specific orientation for the clini-cal act. 2) It offers an organized way of framingan ethical problem, analogous to clinical work-up leading to diagnosis or that of a therapeuticstrategy. 3) It allows for a direct approach tocertain problems causing great disagreement,like abortion, euthanasia, and a number of oth-er problems where consensus seemed impos-sible (Pellegrino, 1995:26).

The principles of non-maleficence andbeneficence were in keeping with the Hippo-cratic obligations of always acting in such away as to avoid causing harm (primum non no-cere) and to take the patient’s well-being intoaccount (bonum facere). On the other hand,the principles of autonomy and justice werenew, and in a certain sense they appeared torun against traditional ethics, based on med-ical paternalism and authoritarianism.

The autonomy principle has only been ac-cepted by physicians in recent years because itis essential for free, informed consent and is al-so in keeping with the North American individ-ualist tradition, with its emphasis on privacyand self-determination. In the opinion of Pel-legrino (1995), it was one of the most powerfuldriving social forces in the metamorphosis ofmedical ethics.

Of the four principles, that of justice is theone that most departs from traditional med-ical ethics. It entered the scenario first throughphysicians’ forensic duties and more recentlydue to disparities in the distribution of healthcare.

While Beauchamp & Childress viewed thefour principles as not having an a priori hierar-chy, Guillén (1995) proposed to divide them in-to two levels: the private sphere or level, includ-ing the principles of beneficence and autono-my, and the public sphere, including the princi-ples of justice and non-maleficence. Accordingto the author, public duties take priority overprivate ones, since public duties are part of the“classic procedural principle, long present in the



legal and ethical tradition, which affirms thesuperiority of the common good over the privatein case of conflict between them”(Guillén,1995:197).

Still, we do not view this hierarchical divi-sion between public and private duties as thecentral issue in the debate over ‘principlism’,which is usually translated into Portuguese asprincipalismo, but which we propose to trans-late as principialismo (with an i as indicated),to avoid the derivation from principal and tomark the derivation from princípios, since thefour principles were originally proposed to beapplied not automatically, but rather to be ad-justed to each given case, that is, within theirspecific context.

Since the principles are prima facie, trans-gression of any one of them must be justified.Beauchamp & Childress proposed four basicconditions for justifying transgression of aprinciple or prima facie obligation a) the moralobject on which it is based should be realistic;b) no morally preferable alternative should beavailable; c) one should seek the lesser trans-gression; and d) the agent should take mea-sures to minimize the effects of the transgres-sion (Beauchamp & Childress, 1994:34).

The four principles theory was the target ofobjections and attempts to overcome it basedon new theoretical contributions. This flourishof new theories dealing with the ethical dilem-mas in medical practice would be the thirdstage in the metamorphosis of medical ethics.

The 3rd Stage, or the Period of Antiprinciplism

This period was characterized by critiques ofthe four principles theory, or so-called princi-plism (Clouser & Gert, 1990). It launched thedebate over the theoretical contributions need-ed to base medical decisions in an increasinglycomplex scenario of health care work. Despitethe debate not being resolved, we review themain bioethical schools questioning the pro-posals by Beauchamp & Childress in order toallow us to take a critical stance towards thisstage in the metamorphosis of medical ethics.

According to Clouser & Gert, the four prin-ciples lack a solid theoretical base, observingthat the principles emerged as ad hoc con-structs “It looks as if each principle simply fo-cuses on the key aspect of some leading theory ofethics: justice from Rawls, consequences fromMill, autonomy from Kant, and non-malefi-cence from Gert. Thus they represent some his-torically important emphases, but without the

underlying theories and worse, without an ade-quate unifying theory to coordinate and inte-grate these separate, albeit essential, features ofmorality”(Clouser, 1995:224).

The authors thus propose, as an alternativeto principlism, a common morality, “with itsrules and ideals, which in turn are grounded inaspects of human nature. As such, morality mustbe understood to be a rational, impartial, andpublic system that is incumbent on everyone”(Clouser, 1995:219). Based on common morali-ty, the authors propose that a study of themorality experienced in the daily lives of indi-viduals could constitute the outline for themoral domain. This domain should thus be-come the object of study and theoretical foun-dations. They emphasize that the central thrustof professional ethics includes the various in-terpretations of general moral rules and thatthe building of such theoretical foundationsshould contribute to improve these sameethics (Clouser, 1995:235).

We view the common morality espoused byClouser & Gert as a pretense of returning to astage prior to principlism. We do not feel it ispossible to define a universal moral theory ca-pable of establishing consensus in a context ofplurality in which tolerance is weighed againstauthoritarianism, the latter being incompati-ble with democratic societies.

Another line of thought in bioethics hasbeen developed by Hugo Tristram EngelhardtJr., espousing a radical understanding of ethicsin the secular context of Western societies. Hismost important work, The Foundations ofBioethics, published for the first time in 1986,was considered a libertarian paradigm (Neves,1996:12). Inspired by the philosophical tradi-tion of North American liberalism (in the de-fense of rights and individual property), Engel-hardt Jr. placed the principle of autonomy inthe first order of priority. His proposals not on-ly allow one to justify actions resulting from thepatient’s expression of free will, but also helpjustify the body as individual property, thusproviding legitimacy for the sale of organs andblood. The controversy arising out of interpre-tations by other authors may have led him inthe 2nd edition (Engelhardt Jr., 1996) to refor-mulate the priority ascribed to the principle ofautonomy, replacing it with the principle ofpermission, through free and informed con-sent. In the author’s words: “Because secularmorality cannot provide a canonical vision ofthe good or a canonical content-full account ofproper action, the principle of permission is thecardinal source of moral authority” (EngelhardtJr., 1996:288).



Free and informed consent, the basis forthe principle of autonomy, has been consid-ered the cause of the greatest changes occur-ring in the physician-patient relationship.

The individualist focus taken by EngelhardtJr. contrasted with the model of the theory of‘virtue’ (Virtue-Based Normative Ethics) devel-oped by Pellegrino & Thomasma (1988). Basedon the Greek, Aristotelian tradition of an ethicsof virtue, the authors turn the focus on theagent, especially health care professionals,while taking care to fully integrate the patientinto the diagnostic and therapeutic decision-making process.

Pellegrino (1995) contends that medicaltheory developed under three phenomena inrelation to cure: 1) the disease; 2) the healthprofessional’s action; and 3) the act of cure.(Pellegrino, 1995) The first phenomenon meansthat when people experience physical and psy-chological symptoms, they believe that theyneed help. In this context of vulnerability, physi-cians and nurses ask the patient, “How can Ihelp you?”. Implicit in this question is the com-mitment that such professionals have the nec-essary knowledge to help and cure the patient.The act of curing, in turn, directs knowledgeand techniques in such a way as to help theparticular patient. It is the telos in the relation-ship between the health professional and thepatient, i.e., restoration of health and contain-ment or cure of the disease.

What are the virtues of health profession-als? Despite admitting difficulty in defining a‘good professional’, the author lists some es-sential virtues for proper professional practice:a) faithfulness to the trust deposited in them;b) benevolence; c) compassion; d) freedomfrom self-interest; e) intellectual honesty; andf ) justice and prudence (Pellegrino, 1995).

The author’s analytical perspective is par-ticularly pertinent for cases of mercantilism orrefusal to treat certain cases (AIDS, highly con-tagious diseases, various types of discrimina-tion, etc.). The unresolved issue is how toawaken the value of virtue in health profes-sionals in situations that are often adverse togood clinical practice.

The care model proposed by Gilligan (1982)compares the care value of expression, whichthe author contends is typically female, withthat of justice, expressly male, and proposes toemploy it as the main thrust for the develop-ment of professional ethics in health.

Another idea that merits attention is the ca-suistic model proposed by Albert Jonsen andStephen Toulmin in 1988. The authors recom-mend a case-by-case analysis, without basing

decisions on any a priori principles to orientaction. In their opinion, the theoretical frame-work, i.e., ethical theory, is built on cases andremodeled from time to time ( Jonsen, 1996:251). Thus, the paradigmatic characteristicsof each case must be examined, establishingcomparisons and analogies with other cases.

In our view, amongst the various alterna-tives presented thus far, principlism providesthe best conditions for decision-making inbiomedical practice. The four principles ap-proach is not intended to dictate absoluterules or norms for moral conduct. On the con-trary, it identifies basic prima facie principlesthat should be weighed for each specific situa-tion. According to the authors defending prin-ciplism, such principles do not aim to elimi-nate conflicts, amongst other reasons becauseit appears difficult to find a moral guidelinethat would anticipate all possible situations(Beauchamp, 1994:9) The principles shouldthus be seen as a set of guidelines to aid deci-sion-making, making flexible, tolerant ethicalprofessional stances possible.

Pellegrino adds that despite the limits ofprinciplism, the principles will probably notdisappear, since: a) every ethical system hasprinciples, at least implicitly; b) any theory pre-senting itself as an alternative to principlismwill have other severe limitations; c) the needfor and usefulness of principles become clearerto the extent that we attempt to apply othertheories to concrete cases; and d) the principlesare not intrinsically incompatible with othertheories (Pellegrino, 1995:29). Besides, we wouldadd, there is nothing to prevent other principlesfrom being added to the list of four, if thisshould prove necessary in the future.

The 4th Stage, or the period of crisis:the immediate future

This fourth stage is characterized by a strongdose of nihilism and skepticism in contempo-rary philosophy and ethics. The position re-sults from a very specific reading of authorslike Nietzsche, Heidegger, Rorty, and Derridaby Pellegrino, according to whom they have incommon the notion that one single truth ismerely an illusion.

One could thus say that there is a kind ofradical relativism leading one to think thatmedical ethics is a Western product incompati-ble with other cultures as pertains to the issueof autonomy.

However, Pellegrino himself casts a relativelight on this reading of our contemporary reali-



ty as applied to the discussion of medical ethics,since the universal nature of the disease/curephenomenon and medicine’s medium- andlong-term objectives lead to hope for reach-ing a more solid basis for the principles, rules,virtues, and moral psychology of medical ethicsthan in any other ethical domain.

Viewed from this perspective, clinicalbioethics is one of the hopeful signs. The fieldis still not fully defined, but it proposes to ap-proach the realities of moral options faced byhealth professionals in their daily work: “It isnot at all clear where the continuing metamor-phosis of medical ethics will lead us in futureyears, given the problematic current state ofphilosophy and ethics itself (...) A continuing di-alogue with the moral philosophers is a requi-site for physicians not to lose the benefits deriv-ing from a rigorous and critical analysis of theirown decisions. Medical ethics is too old and es-sential to the lives of physicians, patients, andsociety at large and should not be abandoned toeither the vicissitudes of philosophical styles orthe unfounded assertions of physicians” (Pelle-grino, 1995:32-33).

Conclusions

In the contemporary Western world, techno-logical changes are accompanied by new so-cial and cultural attitudes making the individ-ual the main decision-making authority on is-sues relating to life-style values and personalgoals. Thus one of modern society’s funda-mental characteristics is a plurality of ideasand values, leading educated citizens andclients and providers of services to reach tacitagreements over the risks and benefits provid-ed by given services, especially health services.

As emphasized by Cherry, “The fragmentedcharacter of modern contemporary society leadsus to re-examine the institutional roles andnorms of medical practice” (Cherry, 1996:367).

The emergence of bioethics in this contextsparks a discussion of ethics for the practicalfield of the relationship between biomedicalscience and society. As pointed out quite ap-propriately by Kottow, bioethics was born as a

contingent discipline, i.e., required by concretedilemmas demanding analysis and solution(Kottow, 1995:81).

The current article stresses that the bioethicsmovement is not limited to changes in medicalpractice stemming from the growing incorpo-ration of technology or to use a more specificterm, “biotechnosciences” (Schramm, 1996:114).We emphasize that one of the fundamental fac-tors in the process of change was the wave ofmass social mobilizations in the 1960s, placingsociety in a participant, decision-making posi-tion rather than in a mere spectator’s role vis-à-vis the changes for which it is both subjectand object. Participation by the social body inthe bioethics movement requires both a deep-ening and radicalization of participant democ-racy and broader access to formal and informaleducational means. Brazil’s social indicators,especially those related to education (Almeida,1996), suggest that much remains to be done toachieve effective social participation in the de-bate over bioethical problems.

In the sphere of medical ethics, the princi-plist approach appears to be the most ade-quate for solving the dilemmas posed by clini-cal practice, since it serves as a guideline giventhe impossibility of shaping a unitarian, uni-versally accepted ethical theory in plural, de-mocratic societies.

In addition, the necessarily multidiscipli-nary and transdisciplinary nature of bioethicshas allowed it to include other approaches, en-riching medical ethics and broadening its ana-lytical horizons.

Finally, it is our belief that the bioethicaldebate applied to clinical practice must bedeepened as an urgent condition for medicalethics in particular and health-related ethics ingeneral in shaping health services in keepingwith Brazilian society’s real aspirations andpossibilities.

In short, the emergence of bioethics in thefield of biomedical sciences demands that so-ciety in general and the health professions inparticular engage in a deep reflection on thenew ethical dilemmas which in the final analy-sis will define the kind of society we build forthe future.



References

ALMEIDA, J. L. T., 1996. Bioética, Educação e Serviçosde Saúde: Novas Abordagens para Velhos Proble-mas. Série Estudos em Saúde Coletiva, no 145. Riode Janeiro: Universidade do Estado do Rio de Ja-neiro.

ANNAS, G. J. & GRODIN, M., 1992. The Nazi Doctorsand the Nuremberg Code. New York: Oxford Uni-versity Press.

ANTUNES, J. L. F., 1991. Hospital: Instituição eHistória Social. São Paulo: Letras and Letras.

BEAUCHAMP, T. L., 1994. The ‘Four Principles’ ap-proach. In: Principles of Health Care Ethics (R.Gillon, ed.), pp. 3-12, Chicester: John Wiles andSons Ltd.

BEAUCHAMP, T. L. & CHILDRESS, J. F., 1994. Princi-ples of Biomedical Ethics. New York: Oxford Uni-versity Press.

BEECHER, H. K., 1966. Ethics and clinical research.New England Journal of Medicine, 274:1354-1360.

BERLINGUER, G., 1996. Ética e Saúde. São Paulo:Hucitec.

CALLAHAN, D., 1994. Porre dei limiti: problemi eticie antropologici. L’Arco Di Giano: Rivista di Med-ical Humanities, 4:75-86.

CHAUÍ, M., 1996. Convite à Filosofia. São Paulo: Ática.CHERRY, M. J., 1996. Bioethics and the constructions

of medical reality. Journal of Medicine and Philos-ophy, 21:357-373.

CLOUSER, K. D., 1995. Common morality as an alter-native to principlism. Kennedy Institute of EthicsJournal, 5:219-236.

CLOUSER, K. D. & GERT, B., 1990. A critique of princi-plism. Journal of Medicine and Philosophy. 15:219-236.

ENGELHARDT Jr., H. T., 1986. The Foundations ofBioethics. New York: Oxford University Press.

ENGELHARDT Jr., H. T., 1996. The Foundations ofBioethics. New York: Oxford University Press.

FOUCAULT, M., 1994. O Nascimento da Clínica. Riode Janeiro: Forense Universitária.

GILLIGAN, C., 1982. In a Different Voice: Psychologi-cal Theory and Women’s Development. Cam-bridge: Harvard University Press.

GUILLÉN, D., 1989. Fundamentos de Bioética. Madrid:Eudema.

GUILLÉN, D., 1994. I diritti in sanità nella prospettivadella bioetica. L’Arco Di Giano: Rivista di MedicalHumanities, 4:29-44.

GUILLÉN, D., 1995. Hard times, hard choices: found-ing bioethics today. Bioethics, 9:192-206.

GUISÁN, E., 1992. Utilitarismo. In: Concepciones de laÉtica (V. Camps, U. Guariglia & F. Salmerón, ed.)pp. 269-295. Madrid: P. Editorial Trotta.

JONSEN, A. R., 1996. Casuistry, an alternative or com-plement to principles? Kennedy Institute of EthicsJournal, 5:237-251.

KATZ, J., 1972. Experimentation with Human Beings.New York: Russel Sage Foundation.

KOTTOW, M. H., 1995. Introducción a la Bioética.Buenos Aires: Editorial Universitária.

KUHN, T. S., 1996. A Estrutura das Revoluções Cientí-ficas. São Paulo: Perspectiva.

LITTRÉ, E., 1861. Hippocrate-Oeuvres Complètes. Paris:Ballière.

MORI, M., 1990. La bioetica: la risposta della culturacontemporanea alle questioni relative allavita. In:Teorie Etiche Comtemporanee (C. A. Viano, ed.),pp. 187-225, Torino: Bollati Boringhieri.

MORI, M., 1994. A bioética: sua natureza e históriaHumanidades. 9: 333-341.

NEVES, M. C. P., 1996. A fundamentação antropológi-ca da bioética. Bioética, 4:7-16.

OLIVEIRA, A. B., 1981. A Evolução da Medicina: até oinício do século XX. São Paulo: Pioneira/Secre-taria de Estado da Cultura.

PELLEGRINO, E. D., 1979. Humanism and the Physi-cian. Knoxville: University of Tennesse Press.

PELLEGRINO, E. D., 1995. La metamorfosis de la eticamedica: una mirada retrospectiva a los 30 años.Cuadernos de Bioética 1:21-34.

PELLEGRINO, E. & THOMASMA, D. C., 1988. For thePatient’s Good: the Restoration of Beneficence inHealth Care. New York: Oxford University Press.

POTTER, V. R., 1970. Bioethics, the science of survival.Perspectives in Biology and Medicine, 13:127-153.

POTTER, V. R., 1971. Bioethics: Bridge to the Future.Englewood Cliffs: Prentice Hall.

PRIGOGINE, I., 1996. O Fim das Certezas. São Paulo:Unesp.

REICH, W. T., 1995. The word ‘Bioethics’: the struggleover its earliest meanings. Kennedy Institute ofEthics Journal, 5:19-34.

ROSS, D., 1930. The Right and the Good. Oxford: Cale-don Press.

SANTOS, B. S., 1989. Introdução a uma Ciência Pós-Moderna. Rio de Janeiro: Graal.

SANTOS, B. S., 1994. Pela Mão de Alice: o Social e o Po-lítico na Pós-Modernidade. Porto: Afrontamento.

SCHRAMM, F. R., 1994. Toda ética é, antes, uma bio-ética. Humanidades, 9: 325-331.

SCHRAMM, F. R., 1996. Paradigma biotecnocientíficoe paradigma bioético. In: Biosafety of TransgenicOrganism in Human Health Products (L. Oda,org.), pp. 109-127, Rio de Janeiro: Fiocruz.

SCHRAMM, F. R., 1997. Eugenia eugenética e o espec-tro do eugenismo: considerações atuais sobrebiotecnociência & bioética. Bioética, 5: 203-220.

SEGRE, M., 1995. Definição de bioética e sua relaçãocom a ética, deontologia e diceologia. In: Bioética(C. Cohen & M. Segre, org.), pp-23-29, São Paulo:Edusp.

SINGER, P., 1994. Ética Prática. São Paulo: MartinsFontes.

THOMASMA, D. C. & KUSHNER, T., 1996. Birth toDeath: Science and Bioethics. Cambridge: Cam-bridge University Press.

WULFF, H. R; PEDERSEN, S. A. & ROSENBERG, R.,1995. Filosofia della Medicina. Milano: RaffaelloCortina Editore.

Documents

Paradigm shift, metamorphosis of medical ethics, and the ... · Paradigm shift, metamorphosis of medical ethics, and the rise of bioethics Transição paradigmática, metamorfose