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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 334-343

Demystifying bioethics: The past, present, and future of a flourishing discipline

Medical Education, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission07-Jun-2020
Date of Decision18-Jun-2020
Date of Acceptance24-Jun-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Ruaim A Muaygil
College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_62_20

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Despite interest in bioethics being arguably at its highest, the history, development, and tasks of this practice remain elusive to many medical practitioners. This ambiguity is not without good reason; unlike its clinical counterparts, bioethics is not exclusively a child of medicine. Rather, bioethics also belongs to theology, philosophy, sociology, and the law. Its intellectual assumptions are multi-disciplinary and wide-reaching, in contrast to those of medicine-neatly delineated and perfected by the scientific method. Indeed, bioethics is contemplative where medicine is active, inquisitive where medicine is decisive, and measured where medicine is efficient. Although at first glance, bioethics may not appear to share much with medicine, the discipline has become an essential conduit of moral medical practice. This manuscript gives an account of the history and development of contemporary bioethics in both the Islamic and Western world, its current state of affairs, its tasks, and its future. Ultimately, it is hoped that this work will demystify the practice of bioethics and elucidate the role of the bioethicist as a partner to the practitioner, an ally to the patient, and an advocate for the moral practice of medicine.

Keywords: Bioethics, clinical ethics consultation, Islamic bioethics, Saudi Arabia

How to cite this article:
Muaygil RA. Demystifying bioethics: The past, present, and future of a flourishing discipline. J Nat Sci Med 2020;3:334-43

How to cite this URL:
Muaygil RA. Demystifying bioethics: The past, present, and future of a flourishing discipline. J Nat Sci Med [serial online] 2020 [cited 2021 Oct 16];3:334-43. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/334/297118

  The Ashley Treatment Top

Ashely X is a 6-year-old girl with static encephalopathy and significant global developmental delay. The etiology of her condition is unknown despite extensive evaluation. She is described to have the cognitive capacity of a 3-month-old. She cannot sit, ambulate, or speak. She is dependent on her parents for all necessities, including feeding, dressing, and transporting. Ashely's care team does not believe there will be any significant improvement in her condition. Despite her limitations, Ashely is still able to smile, vocalize, and respond to others. She is much loved and cared for by her parents and siblings.[1]

As Ashely continues to grow, her parents are concerned about their ability to care for her as she becomes an adolescent and eventually an adult. Tasks such as moving, picking up, and diapering Ashely will become more difficult as she increases in size and matures beyond puberty. They would like to continue to care for Ashely at home but are worried about the challenges presented by Ashely's continued physical development. Ashely's parents inquire about growth attenuation therapy for their daughter.[1]

Growth attenuation therapy involves high dose estrogen to close the growth plates, keeping the child small in size, and enabling parents to better care for them. Therapy also includes pretreatment hysterectomy and breast bud removal to mitigate the effects of hormones, prevent discomfort and pain, and eliminate hygiene issues from mensuration. Further, therapy minimizes secondary sexual characteristics, making the child less vulnerable to sexual abuse by stranger caregivers in the future when their parents are no longer around to care for them. After much consideration, Ashely's parents have come to believe that therapy provides the best outcome for their daughter. The hospital ethics committee agrees and finds growth attenuation therapy ethically justified in Ashley's condition.[1],[2]

On its publication in 2006, Ashley's case generated much controversy among bioethicists, disability advocates, and medical practitioners. Growth attenuation therapy presented a safe and effective method of improving Ashely's quality of life and ensured her parents' continued ability to care for her. Still, opponents condemned the decision to effectively “sterilize” Ashely, declaring it a violation of her human rights, and likening therapy to mutilation.[3] Although opponents recognized that a child with profound neurological, cognitive, and developmental disability lacked the awareness to experience the ramifications of growth attenuation, nor will they ever marry or become pregnant, they still regarded attenuation therapy as morally impermissible.

Is growth attenuation therapy- now commonly known as the Ashely treatment- ethically justified? Despite its touted medical and clinical benefits, are there larger moral considerations that should preclude this type of therapy? Just because medicine enables certain interventions, should these interventions be performed? Who gets to decide? These are the types of normative, ought, questions that permeate the discipline of bioethics. In the following pages, this manuscript will attempt to shed light on this developing practice through an account of its history, its intellectual assumptions, and its future, weaving between Islamic and Western contexts throughout.

  Introduction Top

The late physician bioethicist Edmund Pellegrino believed medicine to be the most humane of all sciences.[4] Pellegrino viewed medicine as an inherently moral practice;[5] as members of the medical community, practitioners were also members of a greater, moral community, entrusted with substantial authority that must be used for the good of patients.[6] Pellegrino's medical morality is based on the interpersonal “healing relationship” between patient and physician.[7] He defines this relationship by three components: The fact of illness which renders the patient vulnerable and dependent, the act of profession which implies a promise to help by specially trained and dedicated healthcare providers, and the act of medicine which denotes a “shared intentionality” between patient and physician to build a healing relationship.[5] Pellegrino's conception of a medical morality based on healing is exemplified in his work as a bioethicist, cementing his status as a founding father of contemporary bioethics, and facilitating the discipline's global rebirth as an essential component of effective and comprehensive healthcare.[8]

In Saudi Arabia, bioethics is undergoing a similar revival. Medical professionals, religious scholars, legal analysists, and social advocates all grapple with ethical topics arising in medicine. Palpable changes in social norms, new advances in medical technology, and imminent transformations in the country's healthcare system[9] have resulted in new questions and novel ethical dilemmas. In light of these newfound moral quandaries, the mindful practitioner is bound to ask herself: Am I acting ethically? Am I fulfilling my moral duty toward my patients, my practice, and myself? Answers to these pressing issues are sometimes not so readily apparent. The discipline of bioethics aims to contemplate and suggest answers to these oft fraught questions.

Despite interest in bioethics being arguably at its highest, the history, development, and tasks of this practice remain elusive to many medical practitioners. This ambiguity is not without good reason; unlike its clinical counterparts, bioethics is not exclusively a child of medicine. Rather, bioethics also belongs to theology, philosophy, sociology, and the law. Its intellectual assumptions are multi-disciplinary and wide-reaching,[10] in contrast to those of medicine-neatly delineated and perfected by the scientific method. Indeed, bioethics is contemplative where medicine is active, inquisitive where medicine is decisive, and measured where medicine is efficient.

Although at first glance, bioethics may not appear to share much with medicine, the discipline has become an essential conduit of moral medical practice. In the following pages, this article will give an account of the history and development of contemporary bioethics, its current state of affairs, its tasks, and its future. Ultimately, it is hoped that this work will demystify the practice of bioethics and elucidate the role of the bioethicist as a partner to the practitioner, an ally to the patient, and an advocate for the moral practice of medicine.

  The Rise of Bioethics: from Antiquity to Modernity Top

Bioethics can be understood as a deeply reflective and cautiously disruptive field of moral inquiry. Its modern iteration as an inter-disciplinary discourse on healthcare began as a natural consequence of scientific progress.[11] The practice of bioethics as the moral arm of medicine, however, preceded its formal academic identification by centuries. Although an exhaustive account of bioethics' origins is challenging-it is one with multiple influences, various actors, and numerous chapters-it is salient to locate its early beginnings in ancient Greece among the early meditations on morality.

Ancient Greece

A meticulous examination of morality is a defining characteristic of ancient Greek knowledge. In the enduring, widely-read The Republic, Plato details his mentor Socrates's dialogues in an effort to describe a just, i. e., moral, world.[12] Plato delivers long, complex debates concluding that justice is essential for human happiness, the ultimate form of moral good.[12] Similarly, Aristotle's Nicomachean Ethics contemplates morality, moral conduct, and virtuous character.[13] Aristotle championed the development of one's character as the basis of morality, asserting that virtuous character was inextricably linked to a moral life.[13] These influential works heralded further inquiries on the nature of morality, and gave rise to ethical theory guiding different practices, including medicine.

The connection between morality and medicine is long-standing. Like Pellegrino, the Greek physician Hippocrates understood medicine to be a fundamentally moral practice.[14] Hippocrates was first to locate the morality of medicine in the vulnerability of patients and the corresponding authority of physicians.[14] It is this imbalance of power under the most humbling of circumstances that ascribes to medicine its moral character and compels the physician to act ethically towards his patients. Hippocrates's convictions are preserved in the Hippocratic Oath, an oath demanding moral responsibility and ethical practice of physicians.[15] Hippocrates's teachings were further explored in the influential writings of the Greek physician Galen who was enamored by Hippocrates's description of the ideal physician.[16] Galen's commentaries examined his predecessor's writings on the patient-physician relationship and championed the ethical principles delineated in the Hippocratic Oath, ensuring their endurance for future generations of physicians.[16]

Greek thinkers were perhaps first to establish the foundations of modern bioethics through a centuries-long, comprehensive examination of morality and medicine. The Greeks were not alone in their attention to moral, medical practice; early Muslim scholars also explored the connection between moral virtue and ethical medicine.

The Islamic civilization

No history of bioethics would be complete without an account of the contributions of early Muslim scholars. The period between the 9th and 13th centuries is often referred to as the Golden Age of Islamic civilization.[17] During this time, massive translation movements preserved Greek knowledge and helped transmit these works to Europe in later centuries.[17]

Muslim scholars were not just translators or commentators; they were also innovators and pioneers in a multitude of areas, including science, math, medicine, and philosophy.[17] They commented on, engaged with, and analyzed Greek texts, developing a rich epistemology and a vibrant, authentic tradition of moral inquiry.[18] As it was in ancient Greece, the examination of morality was linked to the ethical practice of medicine.[19] Unlike the Greeks, however, the efforts of Muslim thinkers were guided by their religious tradition. They developed an Islamic framework-defined by the teachings of the Quran and Sunna-with the purpose of arriving at ethical norms for medicine.[19] These initial efforts culminated in several influential works by prominent Muslim thinkers and left lasting contributions on modern Islamic bioethics.[20]

One such thinker is the physician Abu Baker Al-Razi who believed in a connection between medicine, religion, and morality and argued that a good physician must care for both soul and body.[17] Al-Razi gives an account of the physician's moral responsibilities in his volume Akhlaq Al-Tabib, “Medical Ethics,” one of the earliest Islamic ethics textbooks.[17] He reiterates these obligations in a companion edition to his most well-known book Al-Hawi fi Al-Tibb, “Comprehensive Volume,” named Kitab Al-Tibb al Rohani, “Book of Spiritual Medicine,” a collection of ethical advice for a healthy soul, once again showing his belief that good ethics, including attention to the spiritual, was good medicine.[17]

Like Al-Razi, physician Ishaq Ibn Ali Al-Ruhawi also believed physicians were responsible for the protection of both bodies and souls.[21] He considered the practice of medicine a great privilege and attached to it great responsibility. In his influential work Adab al Tabib, “Ethics of the Physician,” he articulated the moral obligations of practitioners, taking an Islamic approach in his exploration of moral conduct.[22] Like Aristotle, Al-Ruhawi believed that virtuous character was essential to moral action, and urged clinicians to strengthen their morality in order to be become better practitioners.[21]

Al-Razi and Al-Ruhawi were not unique in their concern for moral medical practice. The Muslim polymath Ibn Sina also wrote extensively on morality. In his book, Kitab al Shifa, “Book of Healing,” Ibn Sina meditates on curing the ignorance of the soul through a contemplation of various sciences, inextricably linking moral inquiry to science.[17] Two centuries later, physician and theologian Ibn Rushd similarly related medicine and science to rational, moral deliberation. In his book, Kitab al-kulyat fi al-Tibb, “Generalities in Medicine,” Ibn Rushd's valuing of intellect and reason was evident. Ibn Rushd maintained that in searching for truth in medical diagnosis, we must first understand and contemplate our realities,[17] a sentiment echoed by modern-day bioethicists.

It is clear that in this early Islamic period, medicine and moral practice were very much linked. Muslim scholars understood moral inquiry as an inseparable component of medicine and continued to develop both traditions together. This interconnectedness continued as European scholars began their own contemplative practices.

Europe, Enlightenment, and modernity

As Europe emerged from the Middle Ages-a period of significant economic and cultural decline-in the 16th century, a newfound emphasis on reason and intellectual thought signaled the age of Enlightenment.[23] The contemplation of morality was a key feature of some of the early efforts of European thinkers during this period. One of the most important works on morality, Groundwork of the Metaphysic of Morals, was written by the German philosopher Immanuel Kant.[24] The text outlines Kant's theory of Deontological ethics, in which he concludes that moral action results from rational deliberation that compels respect for humanity.[24] Kant's ethical norms are often understood in tension with those of English philosopher Jeremy Bentham's, the founder of Utilitarianism.[25] Bentham, along with his student, John Stuart Mill-who expanded his teacher's work in his text Utilitarianism-understood moral action as that which produces the most good for the greatest number, espousing an empirical calculus, rather than rational deliberation, as a measure of morality.[26] Together, Kant's deontological ethics, Mills' utilitarian ethics, and Aristotle's virtue ethics represent the three foundational theories of normative ethics[27] [Table 1].
Table 1: Foundational theories of normative ethics

Click here to view

By the 20th century, a modern, science-based movement permeated European scholarship and marked a shift toward a clear favoring of the sciences over the humanities.[23] This resulted in a strict separation between the disciplines; medical practice became increasingly removed from moral practice.[23] This seemingly unbridgeable divide allowed medicine to grow steadily technological and efficient, and progressively incognizant of the moral goods of its practice.[28]

The singular independence of medicine was unprecedented. Medicine's overarching authority was unfettered, its claims undisputed, and its practitioners unquestioned, but a well-timed confluence of factors was soon to disturb this historical dominance.

  The Bioethics Revolution Top

In the late 1960s, advances in medical technology, a rise in social advocacy, and a flurry of troubling violations in human experimentation heralded a new era of bioethics.[8] Perhaps one of the first indicators of a shift from unbridled medical authority began with the 1966 publication of Henry Beecher's ground-breaking article Ethics and Clinical Research in The New England Journal of Medicine.[29] In his article, Beecher describes 22 incidents of ethical violations in human research.[30] Beecher's article was controversial; he was branded an untrustworthy whistleblower by colleagues and shunned by associates.[8] Nevertheless, Beecher's article helped establish new rules for ethical research, as subsequently outlined in the Belmont Report-an endeavor outlining the principles of ethical research practices on human subjects [Table 2].[31]
Table 2: The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research

Click here to view

The reverberations from Beecher's contentious article extended beyond research. As new advances in medical technology brought forth novel moral dilemmas, changes in the collective social conscious indicated that the public was no longer comfortable with medicine's unrestricted authority.[8] This shift was sparked by a series of ethically challenging cases that focused public attention on moral issues in healthcare. In 1962, the Admissions and Policy Committee of the Seattle Artificial Kidney Center became the subject of one of the earliest bioethical public debates.[32] The committee was tasked with choosing recipients of a new, costly, and scarce medial intervention-renal dialysis. Consisting of seven members-two physicians, a minister, a lawyer, a businessman, a homemaker, and a labor leader-the committee evaluated several medically appropriate candidates for two dialysis slots each month.[32] Faced with difficult choices, the committee implemented so-called social worth criteria; members considered candidates' marital status, religiosity, and community involvement as a sign of responsibility and decency, effectively becoming a measure of deservedness of dialysis.[33] The work of the committee was controversial; critics deemed social worth criteria unfair, biased, and ultimately, an unethical basis for deciding who gets to live and who gets to die.[32]

A few years later, a collection of cases at Johns Hopkins Hospital involving newborn infants with Down Syndrome ignited public debate once more. The infants were born with life-threatening intestinal blockages requiring immediate surgical intervention. As was common in 1971, however, physicians recommended withholding aggressive intervention and allowing the infants to die.[33] Similarly, at Yale-New Haven Medical Center, two renowned pediatricians disclosed that they had allowed 43 impaired infants to die without intervention.[33] These cases raised moral questions about the limits of intervention, the rights of disabled newborn children, the rights of parents to decision-making, and the sanctity of life.

Perhaps the most well-known classic bioethics case of this period is that of Karen Ann Quinlan. In 1975, 21-year-old Karen became unconscious after mixing alcohol and benzodiazepines.[33] After suffering prolonged respiratory depression, she entered into a persistent vegetative state without the chance of recovery or improvement and became dependent upon a mechanical ventilator.[33] After 6 months, Karen's family decided to withdraw ventilatory support and allow her to die. This decision inspired fervent public and legal debate regarding the moral permissibly of withdrawing life-sustaining intervention in nonbeneficial cases, as well as the rights of incapacitated patients to be free from unwanted medical interventions.[33]

During this transformative period, numerous other cases of a bioethical nature permeated social consciousness and set the stage for a new academic discipline. As a nascent bioethical discourse emerged, scholars argued that clinicians should no longer remain the sole moral keepers of the clinical encounter, proclaiming the social and moral components of medicine just as important as the technological.[8] Bioethicist Robert Veatch comments that medicine's “arrogance” in claiming unchallenged authority-even against the patient's wishes-seemed “so contrary to moral decency, it was only natural to challenge it.”[34] Similarly, after spending a year as an observer at Georgetown medical school, bioethicist Paul Ramsey details his experience as an outsider to medicine in his book The Patient as a Person: Exploration in Medical Ethics. Ramsey contends that moral dilemmas in medicine are not “technical problems” on which only the clinical expert may have an opinion, and concludes that medicine must be brought into the public forum.[35] Ramsay's conclusions echo earlier work by the theologian Joseph Fletcher who argues in Morals and Medicine that clinicians' monopoly must be broken and suggests approaching ethical dilemmas from the perspective of patients.[36]

It was not only outsiders who supported the growing discipline of bioethics, however. It was a scientist, Van Rensselaer Potter, who first used the term “bioethics” in his 1970 article Bioethics and the Science of Survival.[37] Potter articulated the urgent need for new kinds of scholars and new methods to address fundamental moral problems in science.[14] A year later, the Joseph and Rose Kennedy Center for the study of Human Reproduction and Bioethics marked the first use of the term “bioethics” in the context of moral inquiry into medical dilemmas.[37]

As bioethics gained formal designation, defined goals, and growing public support, clinicians were understandably ambivalent-if not outright suspicious-of the interference of well-intentioned yet ultimately misguided intruders.[8] They challenged bioethics as an abstract practice with inapplicable, inflexible rules that would hinder rather than empower the delivery of medicine.[8] Even as religious scholars, moral philosophers, anthropologists, sociologists, and lawyers assembled under this new discipline, clinicians feared the meddling of “armchair experts.”[8] This increasing tension gave bioethics an oppositional and confrontational quality that persists even today.[8]

Despite this skepticism, the aims, efforts, and intellectual assumptions of bioethics proved beneficial. Bioethicists identified and examined moral dilemmas in healthcare, put forth ethical theory, bioethical principles [Table 3], and practice guidelines, establishing bioethics as an inseparable and integral component of moral medical practice.
Table 3: The four classic principles of bioethics

Click here to view

Such is, the much-abridged, history of bioethics. As the reborn discipline began to gain ground in the West, a burgeoning tradition of Islamic bioethics soon also came to pass.

  Contemporary Islamic Bioethics Top

In applying Islamic moral knowledge to modern medical dilemmas, contemporary Islamic bioethics continues the aforementioned Islamic tradition of moral inquiry.[22] The revival of Islamic moral discourse was inevitable; as Muslim patients and practitioners faced novel medical advances, they were confronted with new moral dilemmas. Islamic bioethics began in the interest of providing answers to these problems from within an Islamic tradition.[39] However, while there are indeed shared values between Muslims, there is also much diversity. Muslims are distinct in culture, in nationality, in ethnicity, and in religiosity. Amidst this diversity, it becomes difficult to identify a unifying methodology of Islamic bioethics. It is, however, this vibrant multiplicity that enriches the practice of Islamic bioethics and gives rise to dynamic and engaging moral deliberations.

In the absence of a shared approach to analyzing medical moral dilemmas, some Muslim bioethicists have put forth “Maqasid al-Shariah,” i.e., objectives, as guiding principles for Islamic bioethics.[40] Dictates arising from Shariah do so with the aim of preserving five essential interests: faith, life, progeny, intellect, and wealth [Table 4].[40] A bioethical approach utilizing the Maqasid in the analysis, evaluation, and resolution of ethical issues aims to preserve these five interests. Muslim bioethicists must ensure that proposed moral claims fulfill the underlying moral objectives of Shariah.[40] This method takes into consideration the intention, method, and outcome of the dilemma under examination, prioritizing resolutions that minimize or prevent harm, and ensure well-being.[40]
Table 4: Maqasid al- Sharia and Principles of Fiqh

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Elsewhere, other Muslim bioethicists utilize the principles of “Fiqh”-intention, certainty, injury, necessity, and custom [Table 4] in conjunction with the Maqasid in their Islamic bioethical analysis.[41] The principles of Fiqh determine the legal permissibility or prohibition of an action according to Islamic law.[39] They are often used concurrently with Maqasid for clarification or exception. In this manner, the permissibility or prohibition of morally complex medical matters is determined first by engagement with Shariah's objectives and moral aims, and second, by its abidance of Fiqh's legal principles. For example, when determining the Islamic position on “Do Not Resuscitate” (DNR) orders, one may, at first glance, find that DNR orders conflict with Shariah's aim of persevering life, however, when the principles of Fiqh are applied, DNR orders may be deemed permissible when there is virtual certainty that resuscitation would not be beneficial, and when the intention is not to kill but rather to relieve suffering.

As Islamic bioethics continues to expand as a formal academic discipline, it has experienced impressive growth in scholarship dedicated to understanding and addressing moral, medical issues from within an Islamic framework.[42] The cultural and academic diversity of Muslim bioethicists has created a dynamic and robust bioethical discourse, bound to enrich the debate on Islamic issues and empower both patients and providers.

Whether in the Muslim world or in the West, bioethics is thriving. It is time now to turn to consider the tasks and responsibilities of this vibrant, young discipline.

  The Tasks of Bioethics Top

Bioethics aims to further moral action within science and medicine. As an interdisciplinary, normative field, its practitioners are concerned with how things ought to be rather than with how things actually are as made evident by the aforementioned case examples.[43] Although bioethics' fundamental commitment to human flourishing is unchanging, its' methods and efforts are dependent upon circumstance and context.[43] Bioethicists engage with multiple disciplines, challenging and drawing on their methods and assumptions in order to arrive at normative intellectual claims guiding moral action. Bioethics continues the long practice of exploring morality, bringing a metaphysical conversation into the practical world of medicine and closing the gap between abstract and concrete, moral and medical.

How best to integrate the humanities and the sciences remains a topic of much internal debate.[43] Bioethicists are divided in their understanding of their discipline's responsibilities. Some view bioethics as a philosophical, contemplative endeavor whose primary focus is the moral exploration and the proposition of theoretical, intellectual claims.[44] Others, however, understand bioethics as a practical discipline which seeks to apply moral theory to real-world problems in order to find logical, ethical resolutions.[43] This division between the theoretical and the applied manifests readily in the roles bioethicists have assigned themselves across three major forums.

The public forum

The need to ethically justify healthcare policies was an essential impetus in the global rebirth of bioethics. As science reached new technological heights, bioethicists were summoned to morally examine these advances towards the development of ethical policy. Bioethicists consider knowledge-gathered from multiple sources and across disciplines-to arrive at morally justifiable recommendations. The exploration and discernment of moral pitfalls occur in multiple contexts, from DNR and abortion policies, to consent guidelines, to public health ethics, and spans international, national, and institutional settings.

In addition to formulating ethical policy, bioethicists are often also involved in establishing guidelines for ethical research. Through involvement with institutional review boards, bioethicists examine research proposals and ensure the protection of human research subjects through adequate informed consent and safe, beneficial research protocols.[45] Further, some bioethicists contribute to new knowledge in the subfield of research bioethics by engaging in rich debates over the moral boundaries of novel ethical issues, including paying participants, research on vulnerable populations, global research, social and behavioral research, and research with biospecimens.[46]

Regardless of the scale or nature of the moral issue, bioethicists' unique expertise and specialist contributions enrich the contemplative process. Moral reflection is an indispensable component of any policy setting measure; the bioethicist brings forth important questions about life, death, and human flourishing, enabling new insights into these oft-fraught endeavors.

Healthcare policy is often affected by public perception and engagement. Bioethicist Richard Ashcroft describes the bioethicist as a “public intellectual” conferring to her the responsibility of measured and carefully worded public statements.[47] Bioethicists frequently make moral claims regarding sensitive, contentious, and private issues that gather wide-ranging interest. Often, this conversation occurs through rigorous debate aimed at convincing others-typically fellow bioethicist interlocutors-but at times, nonexpert pursuers of specialist knowledge. This involves making and defending normative claims in support of proposed ethical recommendations. Public attention to certain moral issues in the practice of medicine is invaluable and often provides new insights. Indeed, public discourse is closely interconnected to the second task of bioethics-academic scholarship.

The academic forum

The discipline of bioethics is principally defined through academic scholarship through which the bioethicist expresses professional commitments, shapes collegial relationships, and performs her practice.[48] Although some empirical work has recently permeated bioethics literature, the vast majority of bioethics scholarship remains conceptual in nature.[49] Unlike scientific research, conceptual research does not require data, experimentation, or hypotheses; rather, it involves researching, analyzing, and thinking critically about a certain issue before arriving at an original position.[49] Bioethicists develop “arguments,” or ethical positions, through examining and challenging existing concepts in relation to a particular issue, before proposing and defending novel, normative ethical claims.

Bioethics' theoretical, position-based, normative scholarship utilizes a distinct methodology in the examination of ethical dilemmas. Generally, bioethicists begin by analyzing an issue, countering standard approaches, and presenting and defending a new resolution. Language is often in the first person; it is not uncommon to encounter the bioethicist author declaring, “I argue,” “I will show,” or “I suggest.” This style is aimed at inciting debate and provoking thought. In bioethical scholarship, ideas-not outcomes-are the intended goal. Similarly, there is immense value to articulating disagreements and explaining where and why disconsensus exists.[50] In bioethics, dialogue and debate through academic writing are powerful tools contributing to how the world comes to understand particular ethical issues.[50]

An article by bioethicist Griffin Trotter concerning medical futility is a good illustration of a theoretical argument resulting in a normative, ethical claim.[51] Trotter explores and challenges two contrasting essays seeking to determine when medical intervention may be deemed futile, and as such, its provision no longer ethically obligatory. Both essays center discussion on defining goals. The first establishes a right for patients to determine goals and an obligation for physicians to help them achieve these goals, intervention is only futile if it does not achieve intended goals.[51] The second contends that physicians should take part in choosing goals, interventions which do not meet physicians' goals are futile even if they meet the patients'.[51] Trotter believes both views are mistaken since they focus on a conception of futility and ultimately disagree on interpretations of this concept; which goals serve as standards for determination of futility? Who gets to choose these goals?[51] Trotter presents an alternative view, arguing that the debate over futility should be focused on medical authority instead, and locates this authority in the greater medical community. He puts forth that medicine is an inherently social activity grounded in moral norms reflecting wide social and public consensus. Trotter concludes that futility determinations should stem from medicine's ultimate governing body, the concerned public.[51]

Trotter's article represents a methodical, conceptually rigorous, bioethical academic effort that challenges preceding works. Another important feature of bioethics scholarship can be found in its multi-disciplinary nature. Although all aspects of bioethical practice are characterized by a multi-disciplinary approach, this method is of particular relevance in scholarship. Authors from diverse academic backgrounds contribute to bioethical literature, adding both complexity and nuance through new methods and perspectives.[52] As inter-disciplinary the body of bioethics literature is, individual bioethical papers remain predominantly single-authored. As is the case in the humanities, collaborative work remains rare in bioethics.[53] Still, the long bioethical tradition of rich engagement with preceding scholarly works-spanning both decades and centuries-seldom renders any work truly singular.[53] Bioethical scholars are often in tension with others (as can be seen in Trotter's article) this tension itself bringing much necessary complexity to ethical issues.

As a normative, evaluative effort aimed at producing rigorous debate on human behavior and moral action, bioethical scholarship is an essential companion to any public or professional debate on scientific and technological advancements.[50] While bioethics scholarship remains largely theoretical, bioethics' third task-clinical consultation-has direct implications for clinical practice.

The clinical forum

The third task of bioethics is most demonstrative of how the field applies its theoretical knowledge to real-life ethical dilemmas. Through clinical ethics consultation (CEC), bioethics gained validity in the medical setting. The American Society for Bioethics and Humanities (ASBH) defines CEC as a service aimed at helping patients, families, and providers address uncertainty or conflict regarding value-laden issues in healthcare.[54] ASBH has since spearheaded efforts to develop professional guidelines for CEC, promoting two essential goals: Identifying and analyzing ethical dilemmas, and facilitating principled resolutions.[55] ASBH also developed “core competencies” for CEC, requiring a certain level of interpersonal, process, and assessment skills as well as knowledge of moral reasoning, ethical theory, and bioethical concepts.[55]

CEC may be performed by a large group (committee or subcommittee). The involvement of multiple bioethicists is useful; it allows for various perspectives and diverse backgrounds. Unfortunately, the presence of multiple actors also results in diffused accountability, depersonalized patient communication, and closed-ended encounters.[56] Alternatively, CEC may be performed by an individual, qualified bioethicist enabling open-ended process, ongoing discussion, and flexible, first-hand knowledge that is more conducive to trust-building, transparency, and accountability.[56] Still, an individual bioethicist runs the risk of biased or nonexpert ethical opinion.[56] At present, there is no widely accepted standard; institutions often utilize more than one approach.

It is salient to consider how bioethicists approach CEC and justify ethical recommendations. There are various methods of analysis, most popular of which is the “four boxes” method as outlined in Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine by Jonsen et al.[57],[58] Its practicality and simplicity in identifying pertinent facts and assigning them to one of four categories-medical indications, patient preferences, quality of life, and contextual features-facilitates analysis and discussion [Table 5]. Each topic connects particular ethical principles to individual cases, enabling thinking through complex ethical issues via a systematic method of identifying and analyzing ethical problems. No one topic has priority over the other; all must be worked together.
Table 5: The four topics

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There are other, lesser utilized methods of CEC, most of which depend on established systematic process and procedure. In an effort to standardize an approach to CEC, ASBH launched its Healthcare Ethics Consultation Certification (HEC-C) in 2018.[59] Geared at setting a standard of practice for CEC, an HEC-C is attainable after passing a rigorous examination assessing the applicant's core competencies, knowledge of fundamental bioethical concepts, and their interpersonal skills. Applicants become eligible after completing 400 h of CEC and submitting references upon request. As of the last exam period, there are over 300 certified clinical ethics consultants, including the author of this paper.[60]

Those are the fundamental tasks of bioethics. Still, as a burgeoning practice, bioethics must locate its legitimacy and earn itself a place within medicine.

  Future of Bioethics Top

Locating legitimacy

Who gets to claim expertise when ethical dilemmas occur in healthcare? Does one need a special skillset, expert training, or specialized certification?[61] Must one follow an established process, or could a qualified individual arrive at ethically appropriate resolutions without formal training?

As bioethics seeks to establish its profession and legitimize its role within healthcare, it must delineate evidence of specialized, expert knowledge and skill. Bioethical expertise is akin to any other expertise; it is a special skill within a specific context. The expert bioethicist must have knowledge of bioethics, medicine, theology, the law, professional codes and policies, and the social climate. She must be able to conduct ethical analysis, facilitate dialogue, mediate interpersonal conflict, and contribute to intellectual, scholarly debate.

The bioethicist's specialist skill and knowledge seek to enhance the way medicine is practiced and to improve both patients' and practitioners' experiences. As a complement to medicine, bioethics seeks to respond to questions clinicians are unable to address. Bioethics is not, of course, an attempt to usurp the authority of the physician, rather it is a means to enrich and improve healthcare delivery. It is from within this essential expertise that bioethics derives its legitimacy and its utility as a practice.

The need for bioethics to locate its legitimacy is perhaps even more pressing in the Saudi context where the discipline is still in its early stages. Saudi bioethicists must decide who gets to lay claim to the title of bioethicist, they must define the terms of their practice and outline its intellectual assumptions and practice methods.

Saudi bioethics

Bioethics' first venture into the Saudi setting occurred in the 1990s as medical schools introduced bioethics courses into their curricula.[62] Bioethics' full integration into the Saudi healthcare system, however, was difficult. Two factors compounded bioethics' initial slow growth; first, rapid expansion in healthcare infrastructure-focused primarily on medical research and empirical, evidence-based practice-necessarily relegated bioethics to a secondary, oft-forgotten, position. Second, bioethics itself was still finding its footing as a distinct discipline and had not yet achieved self-sufficiency. According to two studies by Saudi bioethicists, most medical academic institutions lacked bioethics departments, most bioethics courses were taught by nonexperts, and a majority of bioethicists were self-taught; only a few held terminal degrees or received formal bioethics education.[63],[64]

Three decades later, amid imminent, significant transformations in the healthcare system,[9] and palpable changes in social norms, a renewed interest in bioethics has emerged. The unique needs of this rapidly evolving and expanding medical community marked a transformation point for bioethics, as bioethicists, medical professionals, and academic scholars expressed a need for a more robust bioethics discipline[65] including formal education, CEC, and professional bioethics organizations. The Saudi Commission for Health Specialties (SCFHS) published bioethics guidebooks and interactive seminars available for all professionals through their website.[66],[67] Gradually, seminars and conferences addressing bioethical issues increased, as did postgraduate research and education, indicating a clear rise in interest in bioethics. In 2020, the Saudi Society for Healthcare Ethics was established under the auspices of SCFHS, cementing the progress of bioethics.[68]

As bioethics continues to grow and develop in Saudi Arabia, it has come to experience some of the same challenges encountered by the discipline elsewhere. The question of legitimacy presents itself for Saudi bioethics in the form of certification and credentialing. As yet, there is no official pathway for the credentialing of bioethicists practicing in Saudi Arabia. Saudi bioethics needs an overarching authority to guide and regulate its practice, set professional standards, and ensure that those who claim expertise are qualified to do so. It must also strive to establish a place for its practitioners within universities and medical institutions, and in policy setting and administrative decision-making. Only once Saudi bioethics has found its place within healthcare and academia, will it have earned its legitimacy and proven its utility.

  Conclusion Top

The preceding pages examined the history, tasks, and challenges facing bioethics in both the global and local context. They illustrated the potential value and utility of bioethics as an integral component of safe and effective medical practice. Through its use of logic and reason, bioethics defends shared moral values and enables human flourishing. It supports competent, ethical healthcare delivery by facilitating discussion, mediating disputes, and supporting practitioners and patients.

It is hoped that this essay has helped elucidate some of the questions surrounding this nascent discipline, inspiring thoughtful contemplation, and encouraging further dialogue and examination. As an essential partner to science and medicine, bioethics' potential is indeed promising, and its future, bright.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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