The following appeared in Volume 98, Number 1 (Fall, 1998) of the APA Newsletters

My aim in this paper is to define the role that professional philosophers can ideally play in bioethical research programmes commissioned and financed by national governments and international bodies. The presentation is divided into three parts. In the first part, I shall examine the nature of bioethics as an activity and as an academic discipline. In the second part, I shall describe those characteristics of bioethical research programmes which are relevant to my inquiry. In the third part, I shall study the proper role of philosophers in these programmes, and in practical ethics in general.

The concept of bioethics, or biomedical ethics, has, I believe, often been defined too narrowly. A 1983 edition of Webster’s Dictionary, for instance, defined bioethics as "a discipline dealing with the ethical implications of biological research and applications esp. in medicine."² The obvious deficiency of this definition is that bioethical studies have been gradually extended to moral problems which are not directly related to biology or medicine. Such problems include the dilemmas of nursing and the questions of justice in health care provision.

Other definitions of bioethics, or biomedical ethics, are restricted with regard to methodology rather than to scope. In 1983 Tom Beauchamp and James Childress, for example, defined biomedical ethics as "the application of general ethical theories, principles, and rules to problems of therapeutic practice, health care delivery, and medical and biological research."³ The difficulties of this view include, first, that bioethical studies are not necessarily restricted to the mechanical application of moral theories, and second, that laws and public opinions as well as moral theories should be accounted for in comprehensive bioethical work.

Another methodologically incomplete attempt to define bioethics is related to public decision-making. Medical choices can be called "ethical" when they conform "to accepted professional standards of conduct,"⁴ and many politicians and administrators seem to think that bioethical studies should be confined to this sense of ethics. For these individuals, bioethics has come to mean the national or international regulation and control of medical practices and health care provision. But although Beauchamp and Childress may have emphasized too strongly the importance of general moral theories in biomedical ethics, their view is at least partly correct. Bioethical considerations cannot be confined merely to the examination of what is accepted or acceptable in terms of professional standards or democratic and bureaucratic decision-making.

My own suggestion is that bioethics should be defined by reference to both its scope and its methods. The definition given in the Constitution of the International Association of Bioethics provides a good starting point. In Article 2 of the Constitution, bioethics is defined as "the study of ethical, social, legal, and other related issues arising in health care and the biological sciences." In what follows, I shall specify this general definition both with regard to subject matter and with regard to methodology.

The scope of bioethical studies, as I understand them, can be divided roughly into four fields, which are presented schematically in Figure 1.

 (A) First, medical decision-making which directly concerns the welfare of individual patients forms, historically speaking, the hard core of bioethical considerations. From the Hippocratic Oath to the Declaration of Geneva and onwards, the ethical codes of physicians have centred on issues like professional competence and the definition of malpractice, or medical immorality, in the light of prevailing religious creeds and moral views. Bedside behaviour also plays an important role in the more recent codes of nurses and other health care providers.⁵

(B) Another important field of bioethical interest is created by biomedical research and development.The moral issues of scientific research include the use of human beings and other animals in potentially harmful experiments, as well as questions related to human genetic engineering and biotechnology in general.

(C) The third area on which bioethicists can focus their attention is formed by the provision of health care and welfare services in modern societies. The central questions in this field concern the efficiency and respect for justice and autonomy displayed by the system which is under scrutiny.

(D) Fourth, in addition to the professional, research-related and social aspects of medical and health-care ethics, there are certain global issues to which bioethical studies can be extended. These issues include overpopulation, worldwide justice in the distribution of health, and the protection of our natural environment. Bioethical studies in this field provide, among other things, a global background against which the problems of affluent Western societies can be seen in a different light.⁶

Important as I think that these points regarding the content of bioethical work are, bioethics as an activity and as an academic discipline must be defined with reference to its aims and methods as well as to its scope. There are four approaches to the ethical issues of medicine and health care which are relevant here. These approaches are presented in Figure 2.

(a) The self-regulation of physicians and other health care providers has traditionally been regarded as the most natural way to deal with moral problems in medicine and related areas. The ethical rules and principles that professionals impose upon themselves in their voluntary codes usually serve, however, a dual function, and this creates tensions. On the one hand, the publicly advertized role of the codes is to make explicit the ethical guidelines which are, ideally speaking, respected by the members of the profession and which ensure that the professionals can in their work satisfy the relevant needs and preferences of their clients without inflicting unnecessary harm or causing offence. On the other hand, however, the codes can also be seen as a front which makes it possible for the professionals to seize andmaintain undeserved benefits and privileges, and to misuse their expertise and authority to obtain disproportionate shares of social and political power.

(b) Laws and statutes have been increasingly employed in modern societies to regulate medical matters. Preventive measures like quarantines have been enforced by law for centuries, and during the last few decades research ethics and ecological and population problems have caught the attention of the legislators. Criticisms levelled at medical paternalism have also brought the professional conduct of physicians and nurses in clinical situations under closer legal scrutiny. The main difficulty with this approach in the present context is that the relationship between medical law and bioethics is not well-defined. Public decision-makers could regard ethical principles as the ultimate basis of law, but they usually take ethical considerations to be subordinate to the law.

(c) Political and administrative decisions are often based, at least allegedly, on the results of scientific research. The moral choices concerning the provision of medicine and health care are no exception to this rule. Many social sciences, including epidemiology, psychology and nursing science, have been recruited to gain knowledge concerning different health care systems, and to learn about the effects of these systems and other sociopolitical factors on the morbidity, mortality and life quality of the population. The facts acquired by scientific methods do not, in and by themselves, yield normative conclusions, but they can certainly be suggestive if they are publicized in a social environment which is not, from the moral point of view, completely numb. Epidemiology and statistics, for instance, can shed light on the questions of justice and equity by examining the quantitative distribution of health, welfare and access to health care in present-day societies. Psychologists and nursing scientists, in their turn, can estimate the impact of health policies on individual patients by assessing qualitatively their physical and mental well-being.

(d) Academic philosophers have for some time now thought that they have something to contribute to bioethics. The supposed advantages of the philosophical approach include impartiality, conceptual clarity, and an unhindered recourse to traditional moral theories. I shall return to the nature and methods of philosophical bioethics in the third part of the paper.

Bioethical research programmes financed by national governments and international bodies can be generally characterized by examining their actual and potential scope, and by studying their standard approaches.

As regards the scope of publicly funded bioethical program, there are, theoretically speaking, no limits. Medical practice, scientific research, health care provision and ecology all embrace questions which can be of interest to political and administrative decision-makers, and which can thus become the subject matter of research schemes commissioned by them. In practice, however, there seem to be areas that attract considerably more attention than others. These areas are usually marked off by at least one of the following features.

First, treatments, policies and medical procedures which are expensive and in some sense extraordinary tend to be more noticeable than those which are inexpensive and commonplace. Haemodialysis has been the object of many ethical studies during the last four decades, whereas, for instance, the ethical dimensions of prescribing aspirin have been far less frequently discussed. Second, technological developments which seem morally suspect, but which can be expected to produce vast economic profits, usually seem to arouse more interest than less lucrative enterprises. Inquiries into the morality of genetic engineering have, of late, been generously funded by the public authorities, while, say, the ethics of plumbers has been virtually forgotten. Third, issues which are religiously controversial often attract more funding than purely secular concerns. Many committees and concerted action groups have been appointed by political decision-makers to study abortion, euthanasia and reproductive technologies, but few politicians have been keen to finance the study of the underlying, more mundane problems of, say, moralism, paternalism and patient autonomy.

To take a closer look at just one example, it is easy to see that AIDS is a natural topic for publicly-funded bioethical programs. The treatments are expensive, the development of drugs, therapies and vaccines is economically tempting, and the mode of transmission makes it possible to focus on issues like sexuality, contraception, homosexuality and intravenous drug use. The difficulty here is that the threatsand promises involved in the issue can be interpreted in many ways, and it is not always obvious which angle those financing the research would like to choose. For responsible ethicists, the high price of treatments is alarming in terms of equality, because not everybody can afford costly drugs without public support. Those funding the work, however, may expect moral philosophers to justify the exclusion of so-called self-inflicted diseases, along with their carriers, from national health programmes. Again, business executives can welcome the opportunity to develop new drugs and vaccines, while those infected by the HIV can quite legitimately fear that economic duress will force them to become human guinea pigs for the medical corporations. And where liberal ethicists are troubled by the negative impact of AIDS on sexual enjoyment and on the rights of sexual minorities, religious moralists can see the spread of HIV as a warning against what they consider deviant and ungodly behaviour.

The self-evident aim of publicly funded bioethical programs is to facilitate political and administrative decision-making. In many cases, the main point of these programs is to assess the prevailing professional codes and practices, and to examine whether or not they need legislative control or support. But the approach assumed by commissioned project groups can seldom be categorized simply as "public decision-making" or "professional self-regulation." Rather, the methods chosen for most bioethical studies are, to some extent at least, scientific or philosophical. This means, among other things, that the recommendations given by the research groups usually lack the normative strength that ethical codes derive from the group solidarity of professionals, and laws and regulations draw from the legitimate authority of democratically chosen decision-makers. The conclusions reached within bioethical programs can, of course, be expressed in the form of hypothetical norms: "If these ends are desirable, then those means ought to be chosen." As far as the results of purely scientific research are concerned, this is, in fact, the only type of normativity that can be reasonably allowed. But philosophical work in bioethics is not necessarily restricted to the creation of conditional norms. Other viable options can, I think, be found by studying the methods moral philosophers can employ in this field.

There are four basic ways in which philosophers can undertake to examine the moral problems of medical practice, biomedical research, health care provision and ecology. These ways are presented in Figure 3.

(i) Metaethics, or "the study of the meanings of ethical terms, the nature of ethical judgments, and the types of ethical arguments",⁸ is a prerequisite for all systematic ethical studies, including comprehensive studies in bioethics. Reliable moral judgements cannot be based on considerations which lack a firm conceptual foundation. Some scholars of the analytical school have thought that linguistic clarification is the only legitimate task for philosophers in practical matters. But the popularity of this view has been steadily on the decline since the 1950s.

(ii) Theoretical studies in normative ethics, in their turn, provide answers to regulative questions concerning the value of states of mind and states of affairs, the rightness of human actions, and the desirability and worth of various character traits. Without the support of normative theories and principles, bioethicists would seldom be able to offer solutions to the moral dilemmas they unearth and analyse. But there are two features which make the straightforward application of any traditional moral doctrine to real-life issues problematic. First, there are situations in which no standard ethical theory can provide an intuitively acceptable and universally valid solution. This is characteristically the case when the basic needs, or basic interests, of individuals or groups are in conflict. Second, even the solutions proposed to less difficult questions by traditional ethical views vary considerably, compelling moral agents to make a choice between the theories. But on what grounds should this choice be made? Is it possible to find fundamental axioms on which all valid moral principles are based? Answers to these questions have divided philosophers for centuries.

(iii) One feasible line of argument is to say that there are, as a matter of fact, no ultimate principles on which moral theories could be founded, and subsequently no valid reasons to prefer one normative theory to another. Early proponents of this view thought that philosophers should forgo their customary ethicalspeculations concerning the absolute rightness and wrongness of actions, and concentrate instead on the relative rightness and wrongness of actions according to the customs, laws and shared moral feelings that prevail or have prevailed in contemporary or historical societies. This approach, which can be labelled psychological ethics or moral sociology, has many advantages in the study of social and cultural phenomena, as it prevents anthropologists from judging, and thereby distorting, the views of those they observe. But although ethical relativism may be a necessary methodological assumption for descriptive social scientists, it is not a view that could be fully condoned by the majority of today’s moral philosophers. Despite the genuine need for toleration towards unfamiliar opinions and ways of life, there are limits beyond which Western ethicists do not usually want to extend their moral acceptance.⁹

(iv) The approach which enables philosophers to present normative solutions to practical issues without evoking all the difficulties of traditional ethical theories has come to be called applied ethics. This method should be kept carefully apart from the mechanical application of moral doctrines to the real-life problems introduced by concerned citizens and public decision-makers. The latter view, the so-called engineering model of applied ethics, is open to many thorny questions regarding the identification of moral problems, the scope of ethical inquiries and the impartiality of professional moral philosophers.¹⁰ Applied ethics proper, on the other hand, can be employed quite successfully to examine controversial practices, policies and situations.

The work of applied ethicists proper can be divided into two closely related tasks, which both involve the assessment of moral responses as well as the analysis of conceptual coherence and logical consistency. I have coined¹¹ the phrases "cognitive deprogramming" and "rational reconstruction" to denote these tasks, which have been outlined in Figure 4.12