Is a genuinely European biomedical ethics possible?
Gonzalo Herranz, department , Bioethics, University of Navarra
class , in the Interfaculty Course at doctorate “Professional Ethics in the European Community”
University of Zaragoza
Zaragoza, February 26, 1991
3.Is it in our best interest to become more Americanized?
4.The Difficult Quest for Unity
5. Conclusion
First and foremost, I would like to thank the organizers of this Interfaculty Course on Professional Ethics in the European Union for inviting me to participate. But above all, my gratitude stems from the fact that they organized the course: I believe it is a great initiative to draw the attention of the general public and future doctors to the importance and significance of professional ethics for the future of Europe.
This is a very preliminary outline of a large-scale “ topic ” that deserves to be studied in depth and with careful reflection. Many people, convinced that we are moving steadily toward unity, take it for granted that there will be a common medical ethic in the European Community, just as there will be a common monetary system or a common traffic code. On the other hand, there are also many skeptics regarding the idea of a European biomedical ethic.
The landscape of biomedical ethics—in Europe as elsewhere—is a true reflection of the cultural, religious, and ethical pluralism that exists among and within today’s societies: a fractured landscape where fragmentation is the norm and the restoration of unity is an impossible or futile “ business .” For while some build bioethics upon the solid and rigid principles of natural law, others construct it using the light and malleable elements of situationalism, utilitarianism, or consensus-building tactics. At every level—among those who cultivate academic bioethics, in the texts of codes of ethics, and in the guidelines of medical professional organizations—there are differing positions and conflicting traditions. The disparity in attitudes is palpable, for example, in a bioethics “ guide ” between a Spanish Catholic moral theologian and a Dutch secularist philosopher, or between the policy “ publishing house ” of *Medicina e Morale* and that of the *Journal of Medical Ethics*. There is too much diversity, too many differences. The question now before us is: Can the ideal of an increasingly united European Community overcome local traditions and now serve as a unifying force?
However, in addition to this fragmentation—due to such divergent positions regarding the moral ends and means of medicine, as well as differences in doctrine and method—there are other sources of diversity in the field of medical ethics: as the term “European medical ethics” suggests, there are geographical divisions. Until now, the discussion has centered on medical ethics linked to the major religious denominations (Catholic, Protestant, Jewish, and Muslim medical ethics) or to certain philosophical or political perspectives (liberal, secularist, Marxist, and Buddhist medical ethics). To a lesser extent, attention has been given to the ethical peculiarities found in certain cultural or medical traditions of primitive societies, which—in stark contrast to those of modern societies—continue to persist among us. The “ topic ” is a fascinating topic and is the subject of study for those engaged in comparative sociology and the folkloric and transcultural aspects of medicine.
But what concerns us here today is the question of whether a genuinely European biomedical ethics already exists or, if not, whether such a thing is possible.
Let's start, then, by exploring the field.
When we examine the history of modern medical ethics—that which followed World War II—it is immediately apparent that, in the face of a spontaneous tendency toward diversification and the preservation of local traditions, there is a constant trend toward unification and universalization. We are moving toward a universal medical ethics. And we can say with pride that it was Europeans who provided the seed from which it sprang and the soil in which that seed was planted. It was Europeans who were both the sin and the penance, for the upheaval that the “ finding ” of Nazi Germany’s bioethical crimes caused for medical ethics was followed by the first major contemporary bioethical document: the Nuremberg Code. Moreover, the World Medical association t was established on European soil, on the ruins of the Association Professionnelle Internationale des Médecins, which had an almost exclusively European scope. In London, as early as 1945, an informal preparatory “ meeting ” was held, which led to the adoption of the “ project ” of the World Medical association t as an international forum to shed light on the field of medical ethics. The First Constituent Assembly of the WMA was held in Geneva in September 1947, and there, in September 1948, the Declaration of Geneva was adopted—in my opinion, the most significant document in contemporary medical ethics. In London in 1949, the International Code of Medical Ethics was adopted, and in Europe, landmark documents were discussed and approved, such as the Declaration of Helsinki on biomedical experimentation on human subjects; the Declaration of Lisbon on patients’ rights; the Declaration of Venice on terminal illness; and the Declarations of Madrid on euthanasia and on professional autonomy and self-regulation.
Certainly, Europe has played a decisive role in the WMA’s activities, serving as a unifying force and promoting the universalization of medical ethics. It must be acknowledged, however, that since the mid-1970s, the World Medical association , having come under the absolute control of the American Medical association , has distanced itself from Europe. It is not a source of European pride today, especially since the medical associations of the United Kingdom, the Scandinavian countries, and the Netherlands withdrew from it in 1983.
If we continue our search for the elements of a European medical ethics, we observe that it is precisely the national medical associations that have, through their Codes of Medical Ethics and Deontology or their Codes of Professional Conduct, created among us the most substantial and characteristic aspects of European deontological thought. All of this abundant material would need to be examined to determine whether there is—or whether it is possible to identify—a common core that could be called European biomedical ethics. The two major families of codes—to put it one way, those based on Napoleonic law and those based on common law, the northern and southern traditions—share significant areas of overlap, and many diverse elements are amenable to harmonization, which could serve to form an initial set of principles, rules, or criteria with which to begin building a European professional medical ethics framework.
There is also a large issue collection of documents—very formal and potentially very influential—that establish the guidelines for the ethical internship practice of the profession within the European Community. On the one hand, we have the Declaration of the Permanent committee of Physicians of the European Economic Community on the Practice of the Profession within the Community (article 57-3 of the Treaty of Rome), which was adopted at the plenary meeting of the Permanent committee held in Nuremberg in November 1967. This foundational document has been supplemented and expanded—to address an area of immense ethical significance—by the Annex C adopted in May 1970 in Luxembourg, concerning the contractual or statutory relationships that, in each member country, bind physicians to the organizations that administer national health services.
The Permanent committee , which acts as an intermediary between the medical profession and EU bodies, has published numerous standards in recent years that set the quality benchmarks for professional h internship . We are witnessing continuous progress in professional ethics within the European Community, a trend that is accelerating as the date approaches for the Single certificate to entrance .
Agreements are not only being reached to present a united front against short-term problems and to prepare for the transition from the medical “ internship ” to the single market. More ambitious projects have been undertaken. For example, in early 1987, following a laborious drafting process, the International lecture of Medical Associations approved in Paris—with the endorsement of the medical organizations of the twelve countries of the European Community—the so-called Principles of European Medical Ethics. The role assigned to these Principles—which are certainly well-intentioned but timid, eclectic, or minimalist—by the International Medical lecture t is to serve as a common “ guideline ” to which future changes in the ethical regulations of each member country must be adapted. In reality, these Principles are a hybrid between a brief code and a declaration of principles. Rather than serving as the seed for a common ethical rule , these Principles aim to prevent further centrifugal divergence among future versions of the codes of ethics or professional conduct in member countries.
For its part, the Standing committee t of the European Community Physicians, primarily through its Subcommittee on Medical Ethics—although not interested in creating a common code of ethics for EU member states—issues guidelines and standards that help harmonize the criteria regarding medical-ethical issues across different countries and bring some order to the deontological puzzle of Western Europe.
Let us not forget, moreover, that within the European Community, in addition to initiatives originating from medical organizations, there are other—and extremely important—initiatives that stem from the political sphere. The European Commission has gradually become aware of the importance of incorporating an ethical assessment t into the major research programs it promotes. Many members of the European Parliament and the European committee are deeply interested in bioethical issues and in the consequences that scientific progress has for citizens and society. Through resolutions, directives, and recommendations; reports and documents; ad hoc committees; and meetings of work , they are establishing ethical criteria and standards of conduct. Thus, the committee of Europe, in addition to creating and supporting an ad hoc committee to study bioethical issues, takes particular pride in its resolutions and recommendations on the rights of patients and the dying, on the legal protection of people with mental disorders and their potential institutionalization, on the harmonization of transplant legislation, on the rehabilitation of people with disabilities, on recombinant-DNA research , assisted human reproduction, medical research on human subjects, genetic screening, ethical aspects of AIDS, and on the use of human embryos and fetuses.
In particular, there is a mandate from the European Parliament to the Permanent committee t of Community Physicians to harmonize professional ethics within the Community area , to which physicians—for perfectly valid reasons, given that the mandate stems from a politically radical initiative—have turned a deaf ear.
It is clear: many products and projects in the field of biomedical ethics can be described as European—they have been produced here and are intended for consumption among us. Some even circulate officially under the blue flag with twelve stars, as they have been issued by one of the high-level European bodies (the European Commission, the European Parliament, or the Council of Europe [ committee ]) and have attained the status of a resolution or recommendation. There is, therefore, no shortage of data and fragmentary materials to determine whether a genuinely European biomedical ethics exists, at least in embryonic form.
But is the content of those documents and projects truly ethical and, at the same time, genuinely European? This question compels us, before moving forward, to define what the requirements of European authenticity might be. I will not be the one to answer it, though I hope that some light will emerge from our discussion. This is an issue that is in great need of study, discussion, doctoral thesis , and team-based work . I am not aware of anyone who, to date, has attempted to compile a list of those requirements. And not simply because no one has set out to determine what the characteristics of a European biomedical ethics might be—to distinguish it, for example, from the American version—but because no one has even considered whether it is appropriate for such a European biomedical ethics to exist.
In Europe, for example, we have a European association of Bioethics Institutes, but none of its meetings or publications has sought to identify what constitutes “European-ness” in biomedical ethics. I conducted a literature search, with the disheartening finding finding that, as far as theoretical reflection is concerned, virtually nothing has been published on the subject. There are reports on what is happening in the field of bioethics in each of the European countries, but not a single report on the European Community or on Europe as such, as a single entity. In the latest issue issue of *Medicina e Morale*, Elio Sgreccia publishes his speech opening lecture for the academic year at the School of Medicine and Surgery Department of the University of the Sacred Heart in Rome, graduate titled “The Role of Bioethics in the training of the European Physician.” In it, he discusses the close connection that exists in Europe between human rights and bioethics, reviews European initiatives in the field of bioethics, and concludes—not without pessimism—that we are heading toward a future marked by the decline of personalist ethics and the establishment of an “ethical minimum” in which the “European spirit” might be preserved. It is an interesting project, but a solitary one.
Interestingly, the literature review I conducted in search of what is genuinely European in medical deontology has allowed me to confirm a fact that, although I had vaguely sensed it before, now sample to me as a confirmed reality of almost traumatic intensity: that, in the development of biomedical ethics, Europe plays the role of a second-rate power. The leadership lies in America. One could even say that, in bioethics, Europe is an American colony.
Judging by where ideas originate, by the backgrounds of the authors who publish books or journal articles, by the cities where the most influential meetings and conferences are held, and by the nationalities of the speakers invited to give lectures core topic at courses or meetings, biomedical ethics is primarily an American endeavor. subject ism prevails, and the finished products of biomedical bibliography are, for the most part, “made in the USA.” Those of us dedicated to the cultivation of biomedical ethics nourish our minds with products largely imported from America; we think largely in American categories. The standard structure of treatises and monographs on biomedical ethics, produced both within and outside the American subcontinent, follows a prototype designed in the United States. The language of biomedical ethics is rife with borrowings and calques from the American jargon of specialization program: here, too, ideas follow words, especially when they sound new. There is a widespread tendency to mimic American models. Generally speaking, the style, themes, and discussion in published articles; the cited “ bibliography ”; the exegesis of judicial rulings; and the bioethical principles for analyzing problems and subsequent decision-making—all of this has emerged from the bioethics “ Departments ” at U.S. medical schools and has taken hold of us, colonizing us. And this is because, as an academi discipline , biomedical ethics has been taken seriously—much earlier and with greater intensity—in the United States than here.
I am going to offer concrete evidence of what I have been asserting. And it is this: the flow of ideas is unidirectional—that is, ideas travel from the Americas to Europe. I have reviewed the issues covering the five-year period from 1985 to 1989 of three highly regarded journals in bioethics and medical ethics (one American, the *Hastings Center Report*; one international, the *Journal of Medicine and Philosophy*; and one European, the *Journal of Medical Ethics*) and have classified the lead author of each article, based on their place of work, into one of three groups: American (if the institution where they work is located in the United States or Canada), European (if in Europe, including Israel), and the rest of the world (if based in countries not included in the two previous groups). I have excluded from the count—in addition to bibliographic reviews and letters to the director —articles appearing in supplements or special issues dedicated to providing an overview of the international bioethical landscape, as these are not strictly speaking articles of doctrine or research but are merely descriptive. The results of this review speak for themselves:
|
Source |
America |
Europa |
Remaining |
|
Hastings Central Representative |
348 |
3 |
9 |
|
J Med Phil |
125 |
11 |
10 |
|
J Med Ethics |
40 |
156 |
14 |
|
Total |
513 |
180 |
33 |
In other words, the American contribution to bioethical “ bibliography ” is nearly three times greater than the European one. Furthermore, while papers by American authors account for 20% of those published in the European journal, papers by European authors appearing in the American publication account for less than 4%, and in the international journal, they do not reach 9%.
All of this could be interpreted as yet another manifestation of American dominance in the research and application of science in general—and in medicine in particular. Just as most scientific and technological advances originate in the United States and we accept them without question ( Degree), so too in the fields of medicine and medical ethics, the United States is far ahead of us, and we must make do with what they produce and offer us. Just as we import new drugs and more efficient instruments and technologies from America—and just as we consult books and journals from across the Atlantic to stay up to date—we should not be surprised that we are also following the dictates of influential American biomedical ethics.
3. Is it in our best interest to become more Americanized?
This status sense of dependence is handled well by everyone here: it seems neither irritating nor even uncomfortable. After all, they and we belong to the same Western culture, and adapting to their customs—the “Americanization” of ethics—doesn’t seem to bother anyone. We could remain subject to this process of osmotic equalization indefinitely.
But the fact is that there are marked disparities between their society and ours. There are marked differences between the way American doctors practice medicine and the way our doctors do so—not in terms of scientific content or techniques, but in the social dimension. There are marked differences between what our patients expect from their doctors and what American patients expect from theirs. To illustrate this point, it is worth considering a couple of examples rich in ethical significance: the exaggerated autonomy of the American patient and the stifling role that the law is playing in shaping biomedical ethics in the United States.
The Excessive Emphasis on Patient Autonomy
In Europe, nearly the entire population has health insurance. Healthcare is largely socialized, and although the structural and operational models of the respective national health systems vary greatly from one country to another, physicians typically work as salaried employees or in close association with those systems. Although they may have—and in fact do have—issues with the administrative bodies of the corresponding national health service, they can almost always decide impartially on the subject of treatment to provide their patients and can remain, to a certain extent, indifferent to the possible outcomes of their interventions, since they derive no financial benefit from them. In Europe, medicine is predominantly a service-oriented profession, not one focused on results. This does not, in and of itself, lead to indifference or negligence—at least as far as primary care is concerned—since the doctor-patient relationship can reach a high Degree of continuity and familiarity. It is the physician who usually determines the Degree of medical care the patient is to receive, and does so sometimes according to an old-fashioned, paternalistic, and authoritarian patron saint —still preferred by most European patients and their families—and at other times by obtaining the patient’s informed consent, as recommended by the more modern approach consistent with the patient rights movement.
In the United States, doctors are often their own employers. Although there is a growing concern there about providing access to quality medical care for all, financial considerations still play an overly prominent role in the doctor-patient relationship. As a result, there are staggering pockets of medical poverty, affecting more than 30 million Americans who lack any form of health insurance. In the United States, doctors are much more dependent than their European counterparts on the “success” they achieve with their patients—that is, on the results of their treatment. If a doctor wants to attract patients, he must offer more guarantees or greater financial incentives than his colleagues; he must compete with them, which sometimes leads to levels of “ advertising ” that, in our view, are scandalous. As recently as 1980, the Current Opinions of the Judicial committee of the American Medical Association ( association ) offered the following commentary: “ skill s between physicians and between physicians and other health care professionals are not only ethical but should be encouraged when based on factors such as the quality of services, skill, the results obtained, experience, and other benefits offered to patients, such as installment payments, fee amounts, etc.” The physician no longer provides services; he guarantees results. And this radically disrupts the ethos of the profession. If the expected results do not materialize, the doctor-patient relationship becomes fragile and, worse still, threatening. The need to offer more than other colleagues, to meet patient expectations, to provide “ work ” commensurate with the high price charged for it, and to achieve results—if not guaranteed, then at least promised—has made the doctor-patient relationship in the United States very tense and demanding. Furthermore, the need to avoid at all costs any lawsuit for negligence or medical error has given it an antagonistic, potentially litigious bias. On the one hand, this has led to the development of defensive medicine: the doctor wants to cover his or her back against any possible accusation of negligence or incompetence and often resorts to what, among ourselves, would be described as excessive diagnostic testing. To appease the patient and make them share responsibility for unintended consequences, the doctor involves them in the decision-making process, grants them an unlimited credit of autonomy, and bends to their will. The short-term consequence is turning the patient into a consumer who chooses one of the various services the doctor offers. The doctor himself becomes a “ provider ” who receives and carries out orders: this is the medicine of desire, medicine on demand—abortion without medical justification, hedonistic sterilization, the administration of growth hormones so that parents can take pride in their children’s height, cosmetic surgery and cosmetic medicine, or psychopharmacological gratification.
At summary: In Europe, in general, patients place their trust in their doctors. They expect skill , and good attention from them, but they are generally tolerant of the shortcomings of the public health care system and understanding of any mistakes made by the doctor or the health care system. The idea that a doctor is a human being who can make mistakes still persists. In the United States, patients believe that, in exchange for the money they pay, they have the right to choose the quality and characteristics of the “product” they wish to receive. In the context of medical ethics, American patients approach their doctors armed with a sense of autonomy that, by European standards, seems arrogant.
Biomedical ethics regarding the doctor-patient relationship are, therefore, very different on either side of the Atlantic. We must not forget that the ethos of the profession is determined to a large extent by professional decisions made on matters that are seemingly peripheral or of little relevance, such as those related to the amount and significance of professional fees, the amount of professional liability insurance premiums, the “ advertising ” used to attract clients, granting consumers discretionary powers to obtain “medicine on demand,” or accepting the risks inherent in advances in diagnosis and treatment.
In Europe, we should not sacrifice the treasure of social solidarity for the sake of strict patient autonomy, nor should we exchange our notion of medicine as a service to humanity for that of medicine as a commodity, which leaves the physician financially satisfied and the consumer ethically victorious. There is much food for thought here as we seek to ground the traditions underlying our conception of medicine and translate them into operational guidelines. That is why we must follow with keen interest the British experiment in the reprivatization and corporatization of the National Health Service.
Law as a Defining Factor in Biomedical Ethics
According to the most widely accepted interpretation, a core element of the concept of a profession is the idea that its members are ethically bound by a mutual commitment to ensure the moral and technical quality of their services. Thus, it is part of the “social contract” established between society and the professions that these professions must self-regulate, and that this self-regulation is not established for their own benefit, but for the benefit of society. Codes of Ethics or Professional Conduct are the response that professional organizations provide to this public demand.
The history of professional autonomy and self-regulation has frequently been disrupted by judicial interventions. It stands to reason that if a professional fails to fulfill his or her social commitment or breaches ethical obligations, he or she must be promptly subjected to disciplinary procedure by the competent medical organization. If their conduct constitutes a misdemeanor or crime under the law, the judicial authority must intervene and may temporarily or permanently bar them from practicing their profession. This judicial intervention is fully justified: a physician is an ordinary citizen subject, like everyone else, to the country’s general laws.
It may also happen—and in fact has happened—that, in response to promote radical changes in model society or in the role that physicians play within it, the judiciary intervenes through its rulings, or the political branch intervenes through its legislation. Depending on their scope, these external interventions can either eliminate or alter larger or smaller aspects of professional ethics.
The interference of judges and legislators in medical internship , and ethics is a universal phenomenon, but in the United States it has reached an unparalleled scope and depth. This sets a precedent that we must view with great caution.
The revolutionary scientific advances in medicine, their impact on ever-deeper layers of human life and behavior, and the massive economic cost that healthcare has reached in advanced societies: all of this initially sparks the admiring curiosity of ordinary people, politicians, economists, and legal professionals. But very soon, admiration gives way to uncertainty or suspicion, for it is inevitable to wonder what will be done with these advances, or how so much money will be spent. Thus arises public interest in biomedical ethics, which is not a theoretical or contemplative interest, but rather an instrumental and utilitarian one. Bioethics does not interest them in and of itself: it interests them for the sake of politics, for the sake of creating law. From a sociological perspective, biomedical ethics is the intelligible framework that makes biomedical science accessible to non-experts, thereby allowing ordinary people to express opinions on the complex advances in medicine. And, ultimately, it is thanks to bioethics that journalists, politicians, and judges are able to engage in the critique and regulation of medicine.
American medical ethics are not defined solely by the seven Principles of Medical Ethics of the American Medical association , nor by the Current Opinions of its Committee on Ethical and Judicial Affairs ( committee ) association, but rather—and above all—by the rulings of the nation’s Supreme Court or the state courts. The subordination of ethics to the law is practically absolute. Section 1.02 of the Current Opinions (1989) states the following regarding the relationship between law and ethics: “Ethical standards of professional conduct and responsibility may exceed, but may never be less than or contrary to, those required by law.” This prevents physicians from engaging in conduct that is ethical but illegal, such as refusing to testify in court regarding a confidential matter that, in good conscience, they believe cannot be disclosed, or objecting in good conscience to certain medical procedures imposed by the judicial system (capital punishment, eugenic or punitive sterilization).
In fact, court rulings—from Roe v. Wade, on abortion, to Cruzan v. Director, department de Salud de Missouri, on feeding patients in a chronic vegetative state—are not merely court rulings: they are mini-treatises on ethics, establishing moral conclusions that take on the status of legal precepts, enshrining rights that can be enforced against the physician. Biomedical ethics is not created or developed by professional organizations. Judges are taking on this task with increasing zeal.
We, too, are beginning to experience this same process: laws regarding abortion, sterilization, organ transplants, and assisted reproduction are steeped in ethical choices. Under the guise of minimalist civil ethics, they impose on physicians and the medical profession an inevitable submission to certain moral choices.
4. The Difficult Quest for Unity
In my view, the factor that contributes most to the lack of effort to identify European characteristics in biomedical ethics is that, in Europe, both individual physicians and the profession as a whole have been subjected to a long process of erosion of personality and ethical decline. In Spain—and the same is true, albeit to a lesser extent, in some other EU countries—neither medical students nor recent graduates receive serious, formative e teaching on in biomedical ethics. Public authorities seem to have reached the pessimistic conclusion that the poorer and more inarticulate physicians’ capacity for ethical judgment is, the easier it is to subject them to ministerial policies of service rationing and social utilitarianism.
Furthermore, professional organizations expend all their energy in the struggle to improve physicians’ working conditions and salaries, while neglecting other fundamental tasks in the field of biomedical ethics, such as continuing medical ethics Education and the measured yet firm enforcement of professional discipline . In this status, it is logical that a business of continental proportions—namely, the harmonization of biomedical ethics within the European Community—would be postponed.
I am going to share a very recent test on this topic. At the most recent meeting meeting of the Ethics Subcommittee of the Permanent committee of the EC’s medical associations, held last month in Barcelona, I proposed—as an exercise in harmonization—the advisability of adopting a unified stance among the Community’s medical associations regarding the hunger strike. Not long ago, the topic had become a dramatic issue in Spain. In September 1989, the Plenary Assembly of the Permanent committee had C adopted the so-called Madrid Declaration on Medical Ethics and Torture. It urged national organizations that had not yet done so to ratify the Tokyo Declaration of the World Medical association on the participation of physicians in torture and other inhuman, cruel, or degrading treatment. The Preamble and the five articles of the Tokyo Declaration contain an excellent set of principles—shared by all civilized physicians—regarding the rejection of any physician’s involvement in torture. However, the Declaration includes a “ article ” regarding the physician’s conduct toward a prisoner who refuses to eat. It establishes the physician’s obligations, which consist of informing the prisoner of the medical consequences of the hunger strike; verifying, with the partnership of a colleague, that the prisoner has made his decision consciously and with full knowledge of the consequences of continuing his behavior; and, finally, respecting the hunger striker’s will until the end. The physician may not force the prisoner to eat.
The text of the Tokyo Declaration was proposed to the World Medical association tion by the British Medical association tion, which, naturally, advocates this approach among its members. The Portuguese Medical Association and the Danish Medical association tion follow these same criteria. However, the Codes of Medical Ethics in Italy, Spain, and France, for example, establish—with slight differences in nuance—that the physician must inform a prisoner who is refusing food, must remain constantly available to care for him, and must hospitalize and re-nourish him as soon as his life or health is seriously threatened. In this conflict of duties, the duty to respect and preserve life takes precedence over the duty to respect autonomy. That strikes me as a more “European” solution than the opposite.
I wanted to hear the opinions of my European colleagues regarding both possible solutions: either universal acceptance of the Tokyo doctrine and the need to amend the dissenting codes, or its rejection and the consequent harmonization of the codes, enshrining the two-phase role of the physician—to respect, as long as possible, the hunger striker’s position and treating him or her when, in the physician’s judgment, the patient’s life or health is in serious danger.
After lengthy deliberation, the Ethics Subcommittee decided not to amend the Madrid Declaration and to leave it up to each national medical organization to determine whether or not to align its code of ethics with the provisions set forth in the Tokyo Declaration on this matter. Some members of the Ethics Committee reiterated that, for the time being, there is no interest in establishing a unified code of medical ethics for the European Community.
In * summary*: there does not appear to be a sincere intention to create a common deontological foundation that could serve as the first step toward a European biomedical ethics framework. At the root of this reluctant attitude lies an obvious defensive intent: ethical diversity must be preserved not only out of respect for local medical traditions—shaped by the religious, legal, and professional past—but also as a useful labyrinth that will facilitate the defense of professional interests against the political power of supranational institutions.
Biomedical ethics is not just a matter for doctors. Theologians, philosophers, legal scholars, and ordinary people—especially those who have been ill or have cared for the sick—must also be involved in its development and justification. But I have the impression that the power of doctors and patients has grown so much that biomedical ethics is no longer a matter that can be excluded from public scrutiny, given its incalculable public consequences. What is of the utmost importance, with an eye toward Europe’s future, is that it not cease to be ethics—ethics that inspire a moral elevation of the physician and their patient, of the Ministries of Health, and of the professional organization. It would not be desirable for European biomedical ethics to be modeled on that hybrid of biomedical ethics and law that all too often comes to us from America; nor would it be desirable for the Community Code of Medical Ethics to be a sort of Commercial Code designed to regulate the circulation and sale of consumer-oriented medicine.
Biomedical ethics is, fundamentally and inevitably, ethics. Politicians should not forget this. And while acknowledging that there are many obstacles, both within and outside the profession, we must recognize that there are reasons for hope.
Last December in Strasbourg, at the First International Symposium on Bioethics, organized by the European committee , Ms. Lalumière, General administrative assistant of that distinguished institution, addressed us participants as follows:
“...(Europe’ committee s are being challenged)... on three levels: first, on the level of human rights. Undoubtedly, bioethics concerns human rights: where the human person begins and ends; what is the meaning of the fundamental right to life, considered respectively from the parents’ perspective and from the child’s perspective; what is the meaning of the right to respect for physical integrity and the right to self-determination of each individual. These are, among others, some issues that closely concern human rights.
We are also challenged on the level of democracy. What is the best method, the best procedure for reaching a consensus on biomedical issues—or, at the very least, since it is by no means easy to reach a agreement consensus—for arriving at a socially acceptable solution, even if it is not achieved unanimously? As can be seen, this raises issues of democratic procedure . How can this be done?
Finally, we are faced with a challenge regarding the creation of law. Should we limit ourselves, in these matters, to applying existing law, or—since these are new issues and new problems—should we develop new laws?”
That concludes Mme. Lalumière’s “ quotation .” I would simply like to add that we must all feel compelled by the need to provide Europe with a set of biomedical ethics that lives up to its Christian tradition and its respect for the freedoms and dignity of all its citizens—especially the dignity and freedom of its patients and physicians.
Thank you very much.