Rev. Kevin D. O'Rourke, OP, JCD, STM
Professor of Bioethics
Loyola University – Chicago, Stritch School of Medicine
Maywood, IL
[email protected]
Introduction
Anyone working in the field of medicine or scientific research has heard the term "bioethics". However, 50 years ago, this term was not widely known. This presentation considers how bioethics came into being, how one becomes a bioethicist and what skills are associated with doing bioethics. I shall pose three questions:
- What is a vocation?
- What is bioethics?
- How does one prepare to practice bioethics?
The Meaning of Vocation
Vocation is a word with many meanings. The most basic meaning, taken from the Latin root, is a calling. Two more specific meanings are a calling to a way of life or a calling to a profession or a career. The calling to a way of life, for example, the calling to marriage, religious life, or the priesthood, involves a life-long commitment and a new set of personal responsibilities. This presentation will consider the call to a profession or career.
For those who believe in God, the call to a career or profession is considered a call from God which requires an answer, an answer based upon one's talents, desires and available opportunities. The call does not happen by accident. God is involved whether the person acknowledges it or not. Deciding upon a call from God to a particular profession requires careful discernment on the part of the one experiencing the call, as well as upon the professional community to which she expresses this call. For example, a person who faints at the sight of blood does not seem qualified for the health care professions as either a nurse or physician. One who has a tough time with numbers would probably be inadequate as an accountant. The call to a profession is not as permanent as the call to a way of life.
Finally, a more complete and accurate concept of vocation to a profession or career is that it is a calling from God to be of service to others as well as to deepen personal satisfaction or fulfillment. To serve others means to help people achieve important goals or needs in life. Pursuit of health and truth are among these goals. To attain them requires the help of others. Thus, professions have been developed to help people attain these goals, namely medicine and education. Some professions such as medicine, education, and ministry require the professional to be directly involved in the service provided. Some other professions do not require personal contact. You may never see the mechanic
who repairs the engine of your car, but he or she serves you by enabling you to travel safely. On the other hand, the person involved as a pupil or patient desires to have a personal contact with the teacher or physician.
Personal Satisfaction
Serving others in a profession is not entirely altruistic. Christ told us to love our neighbors, but to love our neighbors as we love ourselves (Mt.22:34-40). Thinking that service means sacrifice of personal satisfaction or being miserable is self-destructive and erroneous. Self- satisfaction is actually a significant goal of persons in a profession, especially in fields which require personal contact. Financial rewards also influence satisfaction. However, unless self-satisfaction is coupled with service, a professional may soon become jaded or dissatisfied.
In truth, a vocation to a professional career is a call from God to a particular type of work, based upon our talents and desires, which offers a service to others, and at the same time is personally satisfying.
What is Bioethics?
Bioethics is a discipline seeking to humanize the practice of medical care and research. It seeks to help health care professionals, whether they are nurses, physicians, technologists, or administrators, meet the needs of patients and their families in a holistic manner. It assists them in discerning the right or best course of action in the face of multiple possibilities for the good of those involved. In particular circumstances, ethical medical decisions require the consideration of other factors in addition to the patient's physical condition. Ethics helps to separate what is medically possible from what is beneficial for the patient. Moreover, bioethics sets norms for proper research upon human subjects. These norms set the good of the subject, not the success of the protocol, as the predominant goal of the research.
The Development of Bioethics
Ethical concerns have been intrinsic to medicine. The famous Oath of Hippocrates, tracing back to the beginning of medicine as a science, has been considered expressive of ethical or moral norms that should accompany the practice of medicine. If ethics has always been considered a part of medicine, why was it necessary to develop another discipline known as bioethics? In the 1960s, it became clear that many physicians and researchers did not adequately recognize the rights of patients and their families. Many times medical therapy was initiated by a physician and the patient had no idea what was involved or what would be the consequences of a particular medical procedure. "Doctor knows best" was the rule. Informed consent became a neglected aspect of the patient-physician relationship. Moreover, physicians often failed to convey truthful information in order "to protect the patient or the family."
A personal example illustrates this fact. My own family was involved in a situation in the late 1950s. My mother developed cancer. It spread to her brain and she became severely disoriented. I was overseas at the time and my brother and sisters were caring for her. The physicians knew that cancer was the source of her illness, but told my family that my mother was suffering from a nervous breakdown. As a result of this diagnosis, my family put my mother through a series of psychological tests and psychiatric counseling, often treating her as a disturbed person. My point is not to criticize the physicians — they were caring, compassionate and skillful. But the ethos of medicine at that time was never to mention cancer, even if the patient or the family would benefit from a truthful diagnosis.
In addition to suppression of informed consent in medicine, in the early 1970s the scientific protocol became "an end in itself" for many researchers. The rights of human subjects involved in research, especially the right of informed consent, were not respected. There were many examples of this neglect. One famous, or infamous, research study which violated the informed consent of subjects was the Tuskegee Study. Many African-American men in rural Alabama were enrolled in the protocol to study the effects of syphilis. They were not informed when a cure for the disease was developed, and the study continued as if there were no cure.
Violations of informed consent and research protocols were not the only problems calling forth a new emphasis upon ethics in the life sciences. There were new and fast-paced developments in medicine that required ethical analysis. For example, the ability to transplant organs from dead to living people was developing. In order to have "fresh organs," it was necessary to obtain them as soon after death as possible. But when does death occur if the patient is on a respirator? Is it when the heart stops beating or when the entire brain ceases to function? What tests should be given to newborn infants to prevent disabilities? What norms should be followed in genetic experimentation? To answer these and other questions, the federal government in 1974 instituted the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the first of several federal commissions to recommend norms for ethical medical therapy and research.
As a result of the desire to humanize the activities of medical therapy and research, the term bioethics was applied to this discipline. It has been called the ethics of the life sciences. For the most part, in the secular community, bioethics was looked upon as a discipline separate from health care. In some cases the bioethicist was considered a decision maker in the medical or research context. To some extent, this is still true. A commentator on the introduction of bioethics into the field of health care, David Rothman, captured the essence of the situation in 1991 by calling his study, Strangers at the Bedside. How Bioethics and Law Transformed Medical Decision Making.
Though several academic centers were founded to study bioethics and some academic degree programs in bioethics were instituted, in practice, no clinical training or certification in bioethics was necessary in order for one to declare him or herself a bioethicist. Thus, many lawyers, philosophers, and theologians who had an interest in the field became bioethicists with little or no formal training or clinical experience. To date, there is no certification or licensing for bioethicists as there is for physicians, nurses, lawyers, accountants and many other professionals.
Bioethics in the Catholic Tradition
In the Catholic community, health care has always been considered a principal way of carrying on the healing ministry of Christ. In the United States for example, there are over 600 acute care hospitals, some 700 long-term care facilities, five medical schools, and scores of nursing schools sponsored by the Catholic Church.
Ethics has always been considered an integral element of Catholic health care. Catholic theological treatises presenting ethical norms for health care professionals have been written for over two centuries, well before the development of modern bioethics. Catholic theologians were early and significant contributors to the emerging field of bioethics in the late 1960s and early 1970s. Today, bioethicists offer guidance to physicians, nurses and researchers involved in Catholic health care. In the Catholic tradition, the bioethicist is considered to be a guide to the physician and the patient, not a decision maker. Socrates used the simile of a mid-wife to describe the form of assistance offered by bioethicists. The overall goal of the bioethicist in the Catholic tradition is to help health care professionals, the people actually caring for patients, internalize the habit of bioethics. In addition, the Church herself seeks to provide guidance with regard to the wide range of interventions and procedures in health care. The Pope, as well as Vatican congregations and councils, contribute to the science of bioethics through speeches and various types of written statements.
At the same time, however, the church is somewhat hesitant to separate ethics as a distinct discipline from the actual provision of health care. For this reason, the church calls upon health care professionals to accept a personal responsibility to look upon ethics as an integral element of their professional service. Hence, over the years the bishops of the United States have published The Ethical and Religious Directives for Catholic Health Care Services (ERDs), which are addressed primarily to health care professionals not to bioethicists. If there is one thing that the Catholic community has contributed to the field of medicine, it is the insistence that bioethics be viewed as integral to the very practice of medicine. It is not a separate discipline just for bioethicists. All who are involved in the delivery of health care ought to be concerned about the ethical dimensions of what they do and integrate ethical considerations and practices into their everyday work.
In contemporary thought, bioethics is a new discipline, separate from the practice of medicine and scientific research, directed to humanizing the life sciences. From a traditional Catholic viewpoint, however, it is an integral part of the practice of medicine and research.
How to Prepare for the Practice of Bioethics?
The remarks in this section apply, mutatis mutandis, to health care professionals, to those involved in research, as well as to those who will work with health care professionals as bioethicists. There are two kinds of science — speculative and practical. Bioethics is a practical science and for that reason it is an art as well as a science. The perfection of bioethics is not found in theory but in practice, that is, in the application of theory. For this reason, preparation for the vocation of bioethics requires knowledge as well as clinical experience.
The knowledge needed is not the comprehensive scientific knowledge of one preparing to be a physician or nurse, but a general knowledge of medical and research procedures and the ethical norms that guide such procedures. At a minimum, one preparing to be a bioethicist in Catholic health care facilities should be well schooled in the Ethical and Religious Directives. Hence, the study of bioethics begins in the classroom, but it does not end there. Clinical experience with people undergoing medical care should accompany and follow the academic study of bioethics. If possible clinical practice should be supervised by someone experienced in the compassionate care of patients. Some physicians I have worked with, without any special training, have the capacity to introduce neophytes to the clinical practice of bioethics.
Applying the knowledge pertinent to bioethics in a compassionate manner requires respect and affection, let me say love, for the people that one serves. When I mention the word love as the motivation for patient care, I am sure there are many who will have a mistaken notion of the word in this context. In English, we use the one word love for an attraction to other persons or even things. Thus, we hear people say "I love Elvis", "I love my cat", or "I love ice cream".
In the Greek language used in the New Testament, there are three words for love; eros, philia, and agape. All connote a different form of love. The word agape is used to designate the type of love I have in mind. This is the love that Jesus told us to have for our neighbors. Agape implies a love primarily founded upon a desire to help another person achieve important goals in life, not upon the personal needs of the one who offers service. Bioethicists and health care professionals have an opportunity to help others strive for important goals of life, and to help people make decisions that can better their lives. A well-respected mentor once told me that I could test the motivation with which I served other people by whether or not I was willing to waste time with them. "Otherwise" she said, "you are probably merely going through the motions."
Compensation
Both bioethicists and health care professionals receive monetary compensation for their efforts. In order to practice agape, there is no need to forfeit compensation. But if monetary compensation, rather than loving service, is the main motivation for the help that is offered, the bioethicist or health care professional usually becomes dissatisfied or disillusioned. In my lengthy career in bioethics, I have met several health care professionals who have become jaded or dissatisfied as they practice their professions. Rather than concentrate upon the good they can do for people and the respect and love which should motivate their activity, they become enmeshed in their own concern for recognition or financial reward. Every time I hear a health care professional indicate that she or he questions a career choice, I wonder about the original motivation.
How does one learn to respect and have agape for the people one is called to serve? This state of mind is not acquired overnight. There is no facile answer to this question, but certainly contemplation or meditation is needed — contemplation upon the good that can be found in each person and the need that everyone has for help and understanding. In order to contemplate, one must take the time to meditate upon the needs of others and how one can help people fill these needs. This can be difficult in a society in which hyper-stimulation is the norm.
Conclusion
In a certain sense, the issues involved in bioethics, especially the more far-reaching and significant issues such as creating a health care system that provides adequate and basic health care for all, or the effects of genetic manipulation upon future generations, is "everybody's business." But health care professionals and those who help them make fair and just decisions for individual patients are even more intimately involved in this discourse. Adequate preparation for applying the science of bioethics is a serious responsibility for everyone offering health care. Preparation to make this an integral part of one's abilities begins with a response to God's call. It is followed by study of the theory of bioethics and clinical experience which enables one to serve in a compassionate and beneficial way.
This is a talk delivered on October 9, 2009 at a program sponsored by the Nieswanger Institute, Stritch School of Medicine, Loyola University-Chicago and the Catholic Health Association. The Conference was titled "Contemporary Issues in Bioethics."
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