From Hippocrates to Bioethics: (Bio) Ethical Principles and Models with Emphasis on Social Work Applied ethics is the application of ethical requirements to various spheres of social practice, in order to guide human conduct toward the protection and promotion of a good life. Social work is a field that, through specific professional methods, ensures social care for people on a professional basis with a similar goal. The aim of this paper is to point out the relevant normative foundations of social work and bioethics as one of the disciplines of applied ethics, and to show their interconnection by sketching selected (fundamental) ethical principles, such as the principle of respect for human rights and dignity and justice.
1. Bioethics as Applied Ethics and Its Subdisciplines
It is generally known that bioethics, as one of the disciplines of applied ethics, arose in the USA. The professional public learned about it from the work of Potter, who was the first to use this term. He emphasized that bioethics has to become a “new discipline” that combines biological knowledge with the knowledge of the system of human values. In bioethics he saw a “bridge” that could connect these two areas in such a way that humanity would be able to use scientific and technical knowledge rationally, knowledge that would support the survival of the human species and improve the lives of future generations.
A characteristic of “Potterian” bioethics is that in its original concept of /global bioethics/ it includes the whole biosphere, human beings, and their interaction in both near and distant perspective. It is also /bio/ethics /for/ the environment, and in this sense has a “wider” scope than traditional medical /physician, nursing, healthcare, health ethics/. Alongside this original orientation of bioethics it should also be noted what allowed some authors /Reich et al./ to speak of its dual origin. In about the same period, bioethics gained strong momentum in the works of Hellegers, the founder of the well-known Kennedy Institute of Ethics /Kennedy Institute of Ethics/, who used the term in a narrower sense, as the application of ethics in medicine and biomedical research. It is precisely such understanding that became typical of the views that bioethics is the ethics of medical practice and theory. We share the view that bioethics today is not merely an ordinary continuation of medical ethics of previous periods, but a broader discipline with a specific subject and working methods.
Bioethics is not only ethical reflection on problems that concern human life itself from the viewpoint of ethics as philosophical ethics, but also applied ethics, which may rightly be considered one of the most mature and well-defined applied ethics, covering a broader range of issues and bringing together several disciplines. The relevance of bioethics and applied ethics is pointed to by several foreign and domestic applied ethicists, e.g., R. Gillon, P. Fobel /and others/, according to whom bioethics is applied ethics because it is the study of ethical problems arising from practice in biological disciplines, i.e., medicine including veterinary medicine, nursing, caregiving professions, biological sciences, while medical and nursing ethics are the dominant part of bioethics.
From the above it follows that bioethics gathers several disciplines, recognizes the plurality of views and attitudes /which assumes that everyone has the right to their own opinion and the duty to tolerate and respect also other opinions/, represents a specific ethical-applied discourse with significant representation of the ethical component. Bioethics today has a broad-ranging scope, an expanded framework and context. According to Fobel, it is currently most influenced by:
- Ethics of research in the life sciences
- Environmental ethics, which today emphasizes such current problems as environmental pollution, relations between people, other living beings
- Ethical problems connected with sexuality, reproduction, genetics, and population
- Socio-political problems such as human health, unemployment, poverty, discrimination, crime, war, torture, etc. (Fobel, 2007, pp. 21-22).
Bioethics essentially represents the application of ethical requirements to medicine, nursing, as well as other areas of practical human action, with the aim of guiding human behaviour toward the protection and support of a good life.
2. The Value-Normative Content of Bioethics - History and the Present
Bioethics as an ethics of life /one of the life sciences/ formulates ethical principles and norms, and tries to justify them theoretically, which, however, is not easy given the plurality of views, ethical theories, and existing criteria /which often contradict each other/. For more than 25 centuries in European culture, various moral-ethical principles, rules, recommendations accompanied medical practice and changed. Is it possible to single out from this diverse spectrum those that have current relevance for contemporary bioethics? If we identify medical moral experience with the term /bio/medical ethics, we come to the conclusion that today it is represented in three forms or models: the Hippocratic model, the Paracelsus model, and the deontological model. These are part of bioethics and together form its value-normative content. In addition, bioethics itself, as normative ethics, adds to this spectrum of principles and norms others as well. Thus, historical specificities and logical foundations of each model, including the specificities of the contemporary era, make up the value-normative content of bioethics.
1. The first historical form of medical /physician/ ethics was the moral principles and norms expressed in the famous Hippocratic Oath. With the name of Hippocrates (460-380 BCE) as the father of medicine is associated the birth of professional medical ethics. The practical relationship of a physician to the sick and even to the healthy person, oriented from the start toward care and support, had already become the central feature of professional medical ethics. What later became an ideal norm of person-to-person relation in Christian ethics, “love your neighbour as yourself” and “love your enemies”, in professional medical ethics appears as a real criterion in choosing the profession and determining the extent of medical expertise. The norms and principles of physician conduct formulated by Hippocrates are not merely a reflection of specific relations in a particular historical period. They are filled with content conditioned by the aims and tasks in the context of the medical profession, regardless of place and time of their implementation. Even today they are still current, they do not lose their significance even if, in one ethical document or another, whether an ethics code of a physician, nurse, or social worker, its form and writing style has changed. Among the many norms and principles characteristic of this model, the principle of nonmaleficence dominates. In the cultural-historical context of Hippocratic ethics, the principle of nonmaleficence expresses the civic credo of the medical profession, the baseline professional guarantee, which can be understood as a condition and basis of recognition of the physician by society and by every individual who has entrusted his or her health and life to a doctor.
2. The second historical form of medical ethics became the understanding of the mutual relationship between physician and patient, which took shape in the Middle Ages. Its most prominent representative was Paracelsus (1493-1541), who was regarded as the discoverer not only of chemical medicines, but also of empirical mental treatment. The Paracelsus model is a form of medical ethics in which the ethical relationship with the patient is understood as an important strategy of therapeutic action of the physician. In contrast to the Hippocratic model, which focuses on gaining social trust of the individual, the Paracelsus model is centred on the emotional-psychological specificities of the individual, on psychical-spiritual contacts with the physician and the inclusion of these contacts in the treatment process. In this model, paternalism fully develops as a type of physician–patient relationship. Medical culture uses the Latin term pater-father, by which Christianity designated not only a priest but also God. The meaning of “father” in paternalism lies in expressing a pattern of relationship between physician and patient that is not limited to blood relationships, but characterizes positive psycho-emotional ties and socio-moral responsibility and the “healing” itself of the contact between physician and patient. The mentioned “healing” and “divinity” derive from good conduct of the physician, from his effort and will to cause the sick person “well-being,” “good.” The basic ethical principle that was formed in this model is the principle of beneficence (“do good, well-being, compassion”). The performance of medical profession is the organized realization of good.
3. The requirement of moral uprightness of the physician, expressed as an ethical norm, belongs to the very important in medical ethics. It is expressed in its deontological level, or deontological model. It is formed by rules about duties in this or that area of medical practice. Their violation can have concrete disciplinary and legal consequences for physicians. The principle of “fulfilling one’s duty” means fulfilling concrete requirements, and conversely, failing to fulfill duties means contradicting the requirements imposed on the physician by the medical profession, by society as a whole, as well as by his own will and reason. If the rules are clear and precisely formulated and set for each medical specialization, the principle of duty fulfillment does not allow excuses and justifications if they were broken and neglected. In this sense, the idea of duty is determining and sufficient regarding the physician’s conduct.
4. In the present time, in present-day medicine we can no longer talk only about helping the sick in the context of medical care. In relation to the use of new technologies, given the existence of pluralistic value assumptions, principles or orientation measures, even though we can guide, preserve, and “improve” people’s lives, often even at the cost of problematic “physical” and moral consequences for humanity as a whole (cloning of a human being, impact of GMO on health and life of the human population, etc.), moral conflicts and problems arise; we often speak about conflicts of rights (the right of the fetus to life versus the right of the woman to abortion, the right to a dignified death versus the right to euthanasia, or versus the right of the physician to fulfill his professional duty “not to harm” and “not to kill”). Therefore, one of the most important bioethical principles can be considered the principle of respect for human rights and dignity. Under the influence of this principle, the solution of the “main question” of medical ethics, the question of the physician–patient relationship, changes. Paternalism, based solely on the authority of the physician, is replaced by the patient’s co-participation in the process of accepting and selecting medical decisions. New forms of mutual relationships between physician and patient arise, each of which represents a certain form of protection of human rights and dignity.
Conflicts of rights, principles, values are a reality of contemporary pluralistic society. Bioethics as applied ethics, however, represents a full form of application of ethics, which seeks to apply its ethical component sufficiently and relevantly in ethical programmes and ethical assessments. A specific example of how to handle these problems in biomedicine is one element of the ethical programme of the ethics committee. Ethics committees are a form of institutionalization of /bio/ethics, and can be characterized as bioethical social organizations, including ethics committees in hospitals, scientific research institutions, and specialized bioethics organizations. Their task is (or should be) to deal with questions and problems that require the development of recommendations for concrete problematic situations in medical-biological activity, regarding both its theoretical and practical side.
In conclusion of this part we want to emphasize that historical and logical analysis of the development of medical (physician) ethics and its principles has led us to the conclusion that they are still part of bioethics today, still current and present in practically all important bioethical documents (the Convention on Human Rights and Biomedicine, the Universal Declaration on the Human Genome and Human Rights, the Universal Declaration on Bioethics and Human Rights). If we consider the further development of contemporary bioethics, we must state that several basic models gradually formed within it, “strategies of ethical application that have acquired the character of a method” (Fobel, 2007, p.40). We mean principles ethics, whose model we present as one of the earliest attempts (binding also with the previous part of our paper) to create the foundations of certain generally valid ethical principles that would be accepted by representatives of different cultural and moral traditions. In the well-known work of T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, four principles were chosen as fundamental: autonomy, justice, beneficence, and nonmaleficence. The principles of nonmaleficence and beneficence, as imperative in nature, are among the oldest. The principle of nonmaleficence, as we saw, is rooted in the Hippocratic tradition and can be considered a kind of basic requirement of all moral relations between people.
The principle of beneficence is (so to speak) its continuation and presupposes action for the maximum good of the specific person and often corresponds to concepts such as charity, mercy, philanthropy, and others.
The principle of autonomy, together with the principle of justice, became preferred particularly in the period of emergence and formation of bioethics and, together with the application of “ancient” ethical principles, became the basis of the quality of relations between healthcare workers and patients by highlighting the principle of respect for the autonomous personality of the patient and his or her human dignity, which is considered the basis and goal of human rights. Through human rights, it should become possible to ensure human dignity, i.e. fulfilment of their guarantees.
The principle of justice, unlike the above-mentioned ethical principles, refers to the resolution of such moral problems whose actors are not only individuals but also social groups. It is understood as an ethical “measure” for appropriate distribution of resources, services, medicines, technologies, etc.
These are first-order principles, i.e., obvious at first glance (prima facie), accepted by different cultural and religious traditions, and should serve as guidelines for resolving all ethically conflicting situations. It should also be said that in specific cases these principles often contradict each other and do not allow moral problems and ethical dilemmas to be solved. The significance of this model of ethical application for bioethics (applied ethics) is, however, great, and relates to the fact that it offered the first integrative basis that was systematically developed for bioethics.
Another model is the ethics of care, whose basic moral credo is healing and care of the sick. Even though it lacks a unified formulation of care mainly in connection with justice, i.e., the equality of those who need it, ethics of care tries to understand concrete situations and cases from different perspectives, emphasizing care for the good life of concrete people.
The casuistic model of ethical application in bioethics also belongs to the original and basic ones. It compares and establishes concrete problematic situations and, by analogy with other similar cases, tries to solve them.
Among other models one may list utilitarianism, deontology (Kantian ethics, contractualism, communitarianism, liberal pluralism, religious ethics…).
Each offers a solution to moral problems through application of its own principles and established criteria.
In bioethics as a discipline of applied ethics, current attention is focused mainly on the model of a good life, to which priority is given over the model of the quality of life. “It calls more for the demand for a good life than for its level and distinctiveness” (Fobel, 2007, p.38).
Other models can, however, be listed that in the process of philosophical-ethical justification, and in applied approaches to bioethics, have important standing. These include virtue ethics with emphasis on ethics of the good life, narrative ethics, feminist ethics especially in connection with care ethics and gender issues, and discursive ethics as a theory of communication and action.
Social work is closely linked with (bio)ethics, (applied ethics). A social worker, due to the “object” of his or her activity, must perform this work in accordance with ethical principles. Therefore, their professional conduct presupposes the capability of ethical reflection and the capability of moral behaviour, action, and decision-making. Social work is based on regularities examined by ethics, and is oriented toward solving practical tasks related to social collisions into which people get involved. Fundamental ethical principles therefore play an important role, which are known from philosophical, general ethics and applied ethics (bioethics). It is clear that in social work these are developed and justified further, given its content and object.
Our attention has been paid to such fundamental ethical principles that, from our perspective, are relevant for both bioethics and social work. These are respect and esteem for human dignity, from which human rights (ethics of human rights) arise, and from which their normative expression is autonomy and justice.
Human dignity belongs beyond doubt to everyone without exception, is given by mere belonging to the human species and is justified by the capacity of human beings to be persons. It is inviolable and any violation of human rights, which are given to a human being by nature, is impermissible. In a sense this is a return to Kant’s claim that the human being is an end in himself, but especially to his demand to never use a human being as a means. For Kant, human dignity is expressed by the moral autonomy of the human person, which belongs to the main ethical norms also in social work.
Autonomy expresses the human way of life of a person who, as the subject of one’s actions, is responsible for them, as well as for the autonomous way of life of other people. It stresses respect for the person as a human being in all of its dimensions—bodily, mental, spiritual, and social.
Human rights are fundamentally interpreted as those that are intrinsic to each human being, without which we could not live as human beings. They are based on human dignity and humane values of the human being; these are universal rights, they cannot be denied to anyone and are the same for all.
Along with human dignity, not only rights but also duties of all actors in social work and in society are connected. In this sense we speak about social justice, which can be interpreted through the socio-ethical principle of justice. The principle of justice can also be understood as a moral attitude, a socially just counsel, as a measure of external relationships of persons, social structures, and also as a virtue needed more than enough for social work practice.
The principle of justice requires making no differences among people and providing optimal care to everyone who needs it without any discrimination.
Author: PhDr. Daniela Kovaľová, PhD. Fakulta humanitných vied UMB
List of bibliographic references
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The lecture was delivered at the international scientific conference Aplikovaná etika v sociálnej práci a ďalších pomáhajúcich profesiách, which took place on 20–21 October 2010 in Piešťany, and was published in the proceedings of this conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Aplikovaná etika v sociálne práci a ďalších pomáhajúcich profesiách. Zborník z medzinárodnej vedeckej konferencie. Bratislava : VŠZaSP sv. Alžbety. 413 s. ISBN 978-80-89271-89-4.