Darryl R. J. Macer, Ph.D. Eubios Ethics Institute 1990
Now we can summarise how the principles that are found in the Hippocratic tradition, and in other approaches to medical ethics, stand up to the challenges of new technology. We can also see what the implications of genetics are for changing our ethics. I will start by a consideration of the profession, which while not being an ethical consideration, is perhaps the most dominant feature of the Hippocratic tradition that characterises physicians. It is also being adopted by other health care workers, along with their own similar ethical codes.
At the heart of modern medicine is the concept of a profession. There are several ways to view medicine, it can be viewed as an art common to Hippocratic language, or it can be viewed as a science, a vocation, a service and as a profession. The word profession originally comes from a theological source, for a public declaration of promises or vows which was made by a person on entering the discipline of a religious order. It became secularised, like the word, vocation, in the sixteenth century, and was first used in reference to the medical profession, then also applied to lawyers, clergy and military officers (Wilkinson 1988). It is now the most common word to refer to medicine. In Ancient Greece medicine was considered not only as an art, but more generally as a livelihood, something in common with today. The attitude of Greek society to the physician was based on this idea, as the physician competed for patients to obtain financial gain. Today there is much more security in being a physician, and it is viewed by many as a gateway for a good life. The average earnings of a physician in general practice in Japan are seven times that of the average person, and rising. For the physicians in clinics, this figure may be double. This inequality in wealth is also true of many other countries. Professionalism provides much of the ideal framework for medicine according to many within it
A profession could be defined as an occupation that involves mastery of a systematic body of knowledge and requires dedication to an ideal of service to others. At the core of professionalism is the acceptance of fees for services, the use of technical terminology, the wearing of profession symbols, the passing of formal training requirements, and licensing, a monopoly, the autonomy of the profession and higher social status (Unschuld 1979). Most professions are parties to a social contract with ethical overtones. The ideology of a profession provides practitioners with a set of behavioural standards to help resolve conflicts, which involves making a set of professional ethics (Pernick 1978). Most professions claim final authority for defining their own standards, though these change over time (Berlant 1975). Today, specialisation is the trend, but last century that would of been quackery (Shryock 1967). Many modern critics believe that professionalism must give way to reform (Illich 1975).
The physician's development of a formulated ethics needs to be understood from the perspective of the peculiar nature of the resources in question. In favourable situations, the physician and the patient benefit but in the unfavourable case there can be fatal consequences in some ancient cultures it could be fatal for both. There was the widespread suspicion that death or injury of a patient might be premeditated by the physician. In cases of success, the physicians were rewarded, but in the case of failure they were forced to protect themselves though today they are rewarded even if they fail to cure the patient. A necessity to protect themselves has been a major concern. Unschuld (1979) sketches three major mechanisms of protection. The responsibility for the outcome of individual cases has often been denied, and the results viewed as the outcome of supernatural powers, often putting the blame on the patient's sin. Prognosis was developed, which had two major functions. It can help to build up a good name if impressive forecasts of the outcome of disease can be made; and it has a protective function of separating the curable patients from the incurable. The ancient physician could accept profitable cases only. The third mechanism is to develop a formulated ethical code, such as the Hippocratic Oath, was seen in various cultures. It is better than prognosis as all patients can be "treated". It diverts the attention of the public from the outcome of medical activity to the process. The public is persuaded to believe that physicians who follow the code will be trustworthy. Any negative results are viewed as acts of God, or nature, beyond man's control. Formal medical ethics developed not so much from philosophical roots, but were guided by sociological principles shared with guild formation (King 1958).
There are three sources of guidance for professional conduct, the rules of etiquette between members of the profession, the codes of conduct to regulate the relationships between members of the profession and the general public, and any philosophical and religious beliefs underlying professional conduct. An example of etiquette is to call the physician "doctor" even though they do not hold a university doctorate, which dates from the thirteenth century at Salerno medical school.
In Britain the Royal College of Physicians (RCP) functioned to restrict the practise of medicine. The RCP was a guild in constant competition with the apothecaries guild, and this led to codes of medical ethics. In the seventeenth century there were not enough physicians, so apothecaries were needed. The RCP tried to follow their charter to protect the public, but it did not raise standards. In 1704 the House of Lords allowed apothecaries a new status. Also the previous educational situation changed from being solely the realm of Oxbridge, as Scottish Universities had better medical schools. The distinction maintained between Oxbridge fellows of the RCP and non-voting licentiates led to much trouble. This was the background for the elaboration of codes of medical ethics. In America restrictive licensing only became universal after the establishment of federal associations such as the American Medical Association (AMA) and the New York Academy of Medicine with their codes of ethics. Statutory legislation was later introduced by many governments, in accord with medical association codes. A precondition for the development of professional ethics was the breakdown of the patronage system, there must have been a desire for colleague control. In the eighteenth century control was by patronage, or client control. The aristocratic and wealthy client was the dominant partner in the physician-patient relationship. The physician identifies with his patron, rather than professional colleagues, so that there is little group solidarity (Waddington 1975).
We can see the thinking behind the development of medical ethical codes by reading works such as Percival's Medical Ethics (1803). Among Percival's section on general practice is advice in trust-building, to build up the trust of the public. These devices aid the process of monopolisation. Trust inducement increases the market value of medical services and helps convert them into commodities. It flatters the doctors, helping their integration into a professional group. It also maintains the paternalistic relationship. The patient is persuaded that they do not need to protect their own interests. The paternalism results in the profession dealing with fragmented individuals, who themselves want to be on good terms with the doctors. Trust inducement also legitimises licensing privileges, as only the fellow physicians are able to judge (Berlant 1975). Other measures can also be seen to increase monopolisation, such as the rules for consultation which encourage group solidarity rather than competition, and for the transfer of patients between different doctors, and many directives to avoid criticism of other physicians which would undermine the profession, or the building of the monopoly. The 1847 AMA Code states that the care for the sick constitutes an obligation "the more deep and enduring, because there is no tribunal, other than his own conscience to adjudge penalties for carelessness or neglect". The AMA Code said that the subject matter of differences should not even be made public, reducing the probability of public criticism and consumer organisation. This is bourn out up to the present day, where very rarely is action ever taken for malpractice. Percival was opposed to any form of competition. This is not explicit in the Hippocratic Oath, as it was practising in quite a different situation, however, it could be said to be part of the Hippocratic tradition. Percival's code shares some features with the RCP London statues of 1543-1563 regarding physician's behaviour (Clark 1963). John Gregory's system was very different, attacking monopolistic medical corporations. He challenged the ideas of common medical training and support of each physician as being the best ways of building up the professionality and excellence of medicine. He criticised the formalism and restriction of knowledge within the profession (Berlant 1975). He also criticised the self-regulating body of elitist experts, saying that confining practice "entirely to a class of men who live by it as a profession, is unfavourable to the progress of the art" (Gregory 1772).
The medical profession in the United States was aided by the rise of science, as the profession obtained much more authority. Scientific expertise was defined as the primary professional qualification in medicine (Flexner 1910), and by the 1930's the number of medical schools had dropped significantly so that virtually all of them were following the Flexner curriculum (Pernick 1978). After the war the American Medical Association was powerful enough to defeat plans for a federal health insurance scheme (Burrow 1978). Development of a professional ethics was important in the professionalisation of medicine in China also (Unschuld 1979).
Some physicians ground their ethical obligations in a pledge and group loyalty, claiming that physicians are a privileged group given high rank and they have a special duty to promote the welfare of others (Ballantine 1979). They even claim that society has bestowed this special status on their profession. A code of professional ethics needs to be accessible to the general population, as it applies to them. The Hippocratic Oath contains a pledge of professional secrecy, which is certainly also found in the medical profession today. They attempt, at least in some countries, to close the discussion of medical ethics to within the profession. The pledges or promises made by the medical profession are not necessarily those desired outside of the professional group. It must be an interesting story why the Hippocratic Oath in-so-far as a Christian may Swear It, was not accepted. For the purposes of comparison I give this oath below (Jones 1924):
Blessed be God the Father of our Lord Jesus Christ, who is blessed for ever and ever; I lie not.
I will bring no stain upon the learning of the medical art. Neither will I give poison to anybody though asked to do so, nor will I suggest such a plan. Similarly I will not give treatment to women to cause abortion, treatment neither from above nor from below. But I will teach this art, to those who require to learn it, without grudging and without an indenture. I will use treatment to help the sick according to my ability and judgment. And in purity and in holiness I will guard my art. Into whatsoever houses I enter, I will do so to help the sick, keeping myself free from all wrongdoing, intentional or unintentional, tending to death or to injury, and from fornication with bond or free, man or woman. Whatsoever in the course of practice I see or hear (or outside my practice in social intercourse) that ought not to be published abroad, I will not divulge, but consider such things to be holy secrets. Now if I keep this oath and break it not, may God be my helper in my life and art, and may I be honoured among all men for all time. If I keep faith, well, but If I forswear myself may the opposite befall me.
The original version of the Hippocratic Oath is on page 46 (chapter 4). The unknown authors of this Oath have deleted the pledge of secrecy found in the original oath. Also deleted are the parts which talk of a brotherly club. It could be that the interests of guild formation lead to a preference for the original.
Demands for a professional oath do not seem to be compelling, as there is no known medical system capable of solving all health problems. Only if we seek to retain the dominance of medicine and the current medical paradigm, then a code is desired. There does need to be some system of medical law, but it is a very different thing to require physicians to swear it. In fact in Britain only one medical school apparently asks graduates to swear the Oath (Orr 1988). Virtually all of the professional codes, in contrast with the public codes, devote much attention to relationships between members of the profession. The longest section of the 1847 American Medical Association code was "the duties of physicians to each other and to the profession at large". The ethics of a profession are defended on several grounds. On "universal" grounds, that the public should accept that the profession is closed and regulated for the public good. On the grounds that it is a special profession and nonmembers should not be expected to share in the fraternal loyalty of a special group. There is also the idea that medicine is the most pure of the professions and the ethic of dignity and that of gentleman should govern the brotherhood. In the 1980 AMA statement on the principles of medical ethics there is more recognition of the duties to other people. It states, "As a member of this profession, a physician must recognise responsibility not only to patients, but also to society, to other medical professions, and to self." It goes on to say that a physician shall "strive to expose those physicians deficient in character or competence, or who engage in fraud or deception."
The profession can even judge cases in law of professional misconduct, which is different to the professions own speciality. Peer review of problems is encouraged before this stage, however, professional monitoring of members misconduct is a problem as the members will try to protect the profession as a whole (Veatch 1981). An ethic articulated by physicians only handles a small fraction of the ethical problems in medicine. Certainly, if a physician has been unethical it could be said that he no longer should be regarded as a brother, and should be exposed (Orr 1988), but very often this is not the result. On the otherhand, a sytem of confrontational medical malpractice, as seen in the USA, can be worse. It results in high medical costs when associated with unlimited viability, and erodes the trust between patient and health workers.
This narrow view of the medical profession is changing in some places. What we see from the use of new birth technologies and genetic counseling particularly, is that there needs to be many people involved in the process of aiding patients decisions and coping with the consequences of them. The knowledge that used to be restricted to the physicians is more widely available, though they should by virtue of their training retain more specialist knowledge. The days of a narrow medical profession who can claim only they are aware of the problems and make choices for patients is gone. However, many do not want to recognise that. These techniques require the cooperation of physicians with nurses, scientists, psychologists, counselors, and families of the patients in a coordinated way, beyond the patient relationship. In almost all parts of this book that considered ethical dilemmas, the word physician could be substituted by the broader term, health care worker. I hope that nonphysicians will excuse my continued use of the term physician. This is the way that is suggested by some recent writers and the need is especially highlighted by the use of new genetic and reproductive techniques.
The directive of the Hippocratic Oath to benefit the patient according to the physician's ability and judgement, is no longer regarded by medical ethicists' as the principle guiding principle for medical ethics. It can not be left up to the physician's prerogative or the elements of the Hippocratic tradition. There is paternalism implicit in the Oath's instructions that the physician may refuse his patients' requests in some cases, such as refusing requests for abortions or poisons, and to judge what confidences to keep. The instructions of Percival (1803) to doctors ends with "They should study, also, in their department, so as to unite tenderness with firmness, and condescension with authority, as to inspire the minds of their patients with gratitude, respect and confidence". It appears that it has long been assumed that paternalism and professional status wins the confidence of patients. There is no notion of consent in this tradition. In actual practice, the physician is influenced by many factors. Above all, is to benefit individual patients, in accordance with the most objective judgement available, legally being that approved by the consensus of the medical profession, but most importantly according to the patient's own judgement. Recognition of informed consent is not always going to lead to the most beneficial outcome for the patient, but it is the price of demcracy. We must accept people's autonomy, their own desires, as the most important principle for medical ethics. This means that the fundamental principle of the Hippocratic tradition has changed, and we must question the continued recourse to the tradition as one which expounds our system of medical ethics.
After a brief discussion of the context and validity of the concerns regarding new genetic technologies, we need to ask what are the key principles that are needed, and are these any different to ones governing behaviour already. The moral problems of genetics are not inherent in the process itself, but contingent upon their use.
We must view medicine in terms of families and society. The implications of individual patient decisions are far wider then they used to be, as the power given by technology is greater. The human side of therapy is not the speciality of the medical profession, but it should be. The selection process for medical students in most countries pays very little attention to the ability for human interaction, rather selecting out those that can obtain highest marks in an academic examination system, together with family wealth and profession, and connections. The counseling ability of physicians is probably only average, unless it is trained. Trained counselors are essential for the new techniques. With the introduction of computer-based prognosis methods there is less need to concentrate on the academic selection, and it may be a good time to try to introduce more human factors.
In the decision making of medical ethics a multidisciplinary approach is desired. However, this requires an openness of physicians to allow others to advise and enter their decision making. There are still physicians to be heard that say that only physicians should be involved in making ethical decisions with patients (Sullivan 1990). Perhaps they feel their authority threatened, as people enter from outside the closed-doors of their profession. We must work to remove this elitism. The contrast between different countries is also very great. Hopefully after the transition period of another decade or two more common approaches that respect ethical principles are in place. Medical schools not only need to teach medical ethics, but to work on opening the attitudes of the next generation of physicians so they can accept the advise of others.
Policy making is a broader level, and is even more multidisciplinary. Questions such as whether health care is a basic human right, like education, have been officially decided in nearly all countries. However, the systems in use may not allow access to all people. The groups of different interests and specialities need to be represented and listen to each other. Some of these policies may involve limiting choices that the medical profession may make, such as laws on abortion, euthanasia, or reproductive technology. This conflict has occured, and will continue to, and less power will be in hands of the medical profession. We should hope that rather than this power moving into the hands of some new group, or politicians, that it is shared to represent the interests of democratic societies.
Part of the Hippocratic tradition is that the practice of the physician's Art is a calling, like a religious vocation. Despite the inadequacy of the Oath, it is still the most often-cited summary of the physician's own understanding of what is normally required to be a good medical doctor. However it must change the obligations are stated as absolutes without any reference to patient values. Today's complex decisions need to include patient values which can vary widely, not just between different religious and cultural groups. The patient's values must be respected whenever possible and whenever they do not create an injustice for others (Pellegrino 1987). The tradition focuses on the outcomes, it is consequentialist, like a utilitarian ethic, however, the physician can not judge the economic, spiritual and other nonmedical dimensions of benefit to the patient beyond physical health. There needs to be some way of assessing these, which is not present in the Oath.
There are many new technological innovations, and the potential to manipulate the human body, personality and life itself. Death and conception can be altered, which means some new issues are present. The Oath comments on euthanasia but it does not consider maintaining human life in some sort of vegetable state, or the survival of severely handicapped newborns after major operations. It prohibits abortion, but it does not consider the situation of prenatal genetic screening.
The professional's judgement about what is required does not decide ethical issues. For instance some ethical decisions may be extremely private, such as suicide. Usually there should be a private agreement between the medic and the patient to pursue what is the patient's best interests. Overall there must be an ethic fair to all, and there have been various attempts at defining principles of medical ethics (Veatch 1981, Engelhardt 1984, Brody 1988, Beauchamp & Childress 1989). In a simpler world, the Hippocratic ethics which has long sufficed to guide physicians in their service to patients and the community would remain useful, but today with the intersections of medicine with contemporary science, technology, and the different social organisation and changed human values, there are significant missing dimensions in the Hippocratic ethic (Pellegrino 1987). Having argued that the first part of the Hippocratic Oath is out moded and needs to change, let us consider the ethical principles that we need to use.
One of the underlying philosophical ideas of society is to pursue progress. The most cited justification for this is the pursuit of improved medicines and health. It has often been assumed that it is better to attempt to do good than to try not to do harm (Callahan 1979, Beauchamp & Childress 1989). A failure to attempt to do good, working for the patient's best interests, is taken to be a form of doing harm, a sin of omission. This is the principle of beneficience. This is a powerful impetus for further research into ways of improving health and agriculture.
The term beneficience suggests more than actions of mercy, for which charity would be a better term. The principle of beneficience asserts an obligation to help others further their important and legitimate interests (Beauchamp & Childress 1989). It also includes the weighing of risks, to avoid doing harm. While we may pursue techniques to make genetic screening possible, it may not always be in the best interests of the patient to use the tests. Genetic screening requires many decisions like this, and in a few cases beneficience is more important than autonomy.
Respect for Human Life and Autonomy
This is a very broad term, but is the basis for the principles of justice and confidentiality, and philantropy. It can also be expressed as "do no harm". The reason we do no harm is because we respect human life. This feature is found in the Hippocratic tradition and all other traditions of medical ethics. It is expressed more at an individual level, whereas justice is the expression of this concept at a societal level. This idea has been called the principle of nonmalefience. Those who claim the individual autonomy comes above societal interests need to remember that at major part of protecting society is because it involves many human lives, which must be respected.
Abortion and euthanasia are practised today, but they were also practised at the time of the Oath. They remain controversial. It is still a matter of intense debate how stringent the criteria must be, there will be exceptions to absolute prohibitions, much more reasoned argument is needed beyond the citing of the Hippocratic Oath to forbid them. The Oath does highlight these two constant areas of medical concern, that have remained so for 2,500 years.
We need much more refinement and guidelines when it comes to these questions. The feature that is emerging from modern thinking is to think in terms of human persons, both their birth and death. Respect for human persons is a more precise wording of this concept, and may clarify issues such as abortion or euthanasia.
Medicine until very recently, has lacked any full theory of justice or the duty of physicians to treat those in need, this is in contrast to many religious views which compel physicians to actively seek out the sick. Some of the major proscriptions of the Hippocratic Oath are already compromised - confidentiality can be violated under certain conditions of law and public safety, abortion has been legalised, dangerous drugs used everywhere, some human experimentation permitted, and euthanasia has been made legal in some countries.
The Hippocratic ethic is individualistic, very different to the approach of classical utilitarian ethics. Physicians still seem to maintain that the physician has a special ethical obligation to benefit the patient, independently of the net consequences for others who are nonpatients. In 1957 the American Medical Association instructed physicians that "the principle objective of the medical profession is to render service to humanity, not the individual patient", an idea also found in the current Soviet physician's Oath. We cannot be individualistic, the sick must not mean the individual only, but the plural. Public health questions are important, as is medical experimentation. Some public health decisions such as vaccination programs actually involve a small risk of fatality to the individual, which is judged to be offset by the reduction in deaths by the disease in the society as a whole. Justice and some egalitarian ideal are absent from the Oath, as the physician under the Hippocratic Oath could chose which patients to accept. Charitable medical care is an ethical duty without Hippocratic roots, but is a worthy ideal. However,with the runaway costs of modern medicine there will be times when individual patients can not be treated unless broader health policy is improved. The principle of justice will be essential in the next century because people can be genetically screened, and this information can reveal much sensitive information that can influence life choices for that person. We must seek a just health care system, so that all people can be fairly treated, despite our inadequacies and differences.
The key principle arising from the high value of human life is respect for autonomy of each individual human being. This means they should have the freedom to decide major issues regarding their life, and is behind the idea of human rights. This idea is found in many religions also. Part of autonomy is some freedom to decide what to do, as long as it does not harm others, also called individual liberty or privacy. Well-being includes the principle of "do no harm" to the patient, and to work for the patient's best interests.
The autonomy is limited by respect for the autonomy of other individuals in the society. People's well-being should be promoted, and their values and choice respected, but equally, which places limits on the pursuit of individual autonomy. Society should also include the future of society, future generations are also an essential part of society.
The emphasis on confidentiality as outlined in the Hippocratic Oath gains much support. The keeping of confidences is necessary to retain the patient's trust, and has been a common feature of medical ethics since. However, today the codes usually include the exception in the cases of criminal activity. It is very difficult to develop a good referral criterion for exceptions, and they will remain rare (Carrick 1985).
A feature of the ethical use of new genetics is the privacy of genetic information. This is one of the residual features of the Hippocratic tradition that needs to be maintained. It is not only because of respect for peoples autonomy, if that is not enough. It is also needed to retain trust with people. If we break a person's confidences, than we can not be trusted. It applies to all aspects of life. We need to protect individuals from discrimination that may come in an imperfect world, one that does not hold justice as its pinacle.
There may need to be exceptions if other people are directly at risk from not knowing the condition of a patient. However, in the case of a predisposition for a certain illness, or the case of the inevitable development of a illness, the informed individual should have the right to keep this information that will affect their future life. Only when symptoms show that will affect a third party should their condition be reported if they have not already voluntary done so. There must be care in the reporting also, so that it is not widely spread. We must be careful, because we use computer databanks that contain such information, and if they can not be kept confidential, the information should not be entered to such a bank.
An extension of confidentiality is privacy, the right to refuse questions. If medical insurance companies try to take only low risk clients by presreening the applicants, their should be the right to refuse such questions. The only way to ensure proper and just health care is to enforce this on insurance companies, or what is a better solution, a national health care system allowing all access to free medical treatment.
As has been apparent throughout this book, there needs to be a balancing of conflicting principles of ethics. Different people's interests will conflict, so that there are exceptions to the maintenance of privacy, confidentiality. How do we balance protecting one person's autonomy with the principle of justice, that is protecting all people's autonomy. In this regard utilitarianism will aways have some place, though it is very difficult to assign values to different people's interests and preferences.
Genetic engineering is challenging because it is a technology with which both benefits and risks are associated, and will aways be associated. Human beings are challenged to make ethical decisions, they have to. The benefits are great, but there are many possible risks. Although our life may have become easy, so that we avoid making very many decisions, we must. The more possibilities that we have, the more decisions that we make. Fortunately standards of education are increasing, but this is no guarantee that the right decisions will be made. People need to be taught more on how to make decisions, and the education system should accommodate this need of modern life.
Legislation or Consultation
The law has become very important in many aspects of life. The function of the law is to protect the individual autonomy of people so that they can have some freedom, while protecting the rest of society if they abuse that freedom. In the area of the use of new genetic technology the law has been challenged by rapid advances, that very few had foreseen, so it is predictable the law is lagging behind. In the rush to introduce laws, we must remember that technology continues to change, and we must be cautious that our laws allow for changing science, but also that they allow us to use technology when it is ethical to do so.
The law faces problems, should it be inflexible, in the form of rules to follow, that may soon be outdated, or should it be subject to challenge in the courts, so that case law can guide. There are several different views of the law, and these could be called the formal, the substantive and the reflexive (Jabbari 1990). An example of formal law, is the fixed law of contract, it generates fixed rules which would not be overcome even in the event of injustice. Certain classes of transactions have been outlawed, such as baby exchange in surrogate mother contracts, which are not recognised in many countries. Formal law is aimed at intervening in a process to obtain a clear result. Critics of this approach have been common when considering the medical issues, and they suggest that we should use a reflexive approach, that can change with the times. It aims to create procedures, like formal law, but procedures that would govern the way discussion occurs and decisions are made.
For the purposes of regulation of science, reflexive law involves the establishment of committees that can make decisions. The decisions in the best case can be made unanimously, after receiving expert advice. For instance the decision might be whether a procedure to use a human embryo for a certain experiment is ethical. It might be to consider the release for field trials of a new GMO. The emphasis is on self-regulation, or regulation by a specialist committee that is used to making that sort of decision (the members of whom should be interdisciplinary). In the recent British Human Embryology and Fertilisation Act, a Statutory Licensing Authority was established to regulate the clinics that perform IVF, and also to regulate human embryo experiments up to a limit of 14 days (HMG 1990). This is in the spirit of a reflexive law, however there were also some formal parts of the legislation, such that genetic manipulation of the embryo is criminalised, as is trans-species fertilisation (Jabbari 1990). In the few countries that are yet to introduce formal legislation, it will be interesting if they can trust such committees to make more decisions. It is appropriate if the committee is well defined, but it may take a while for lawmakers to change.
There have been bioethics committees established in some countries, with good success. There is a National Bioethics Consultative Council in Australia, which has been working well for two years. There has been a French National Bioethics Committee for 7 years, though it has 37 members, which may be too many for what is required. There is a National Ethics Council in Denmark, which is now working well after initial controversy. The President's Commission in the USA was very successful, between 1980 and 1983, but was disbanded. There is a Bioethics Committee in the Council of Europe, though it only considers medical issues. There are signs that people are realising that the nature of the technological advances is such that a flexible approach to regulation is the best in many cases.
In many developed countries it is apparent when you walk in the street, or read the newspaper, that the country is mixed. Ever more than before, universally applicable ethical principles are necessary. Many immigrants have come to North America, and to the old European Empires. The practises that immigrants are accustomed to differs from each other. Their religions are different, and cultures. In medicine, the patient-physician relationship is critically determined by these differences.
The Declaration of Geneva (WMA 1948) was amended by the WMA in 1983. They suggest an Oath that physicians could take upon graduation. I present it below for comment (WMA 1983):
At the time of being admitted as a member of the medical profession:
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets which are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honor and the noble traditions of the medical profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from its beginning even under threat and I will not use my medical knowledge contrary to the laws of humanity.
I make these promises solemnly, freely, and upon my honor.
It retains much of the brotherly professional wording of the Hippocratic tradition. It is very individualistic, though given the efforts required to introduce informed consent in many countries, this neglect of society"s interests may be justified. It includes a useful sentence in this respect, not to let religious, nationalistic, racial, political or social influences influence the duty to the patient. While we need to consider societal interests because of justice, we must establish a value sytem in medical practice which recognises the autonomy of persons.
A country can impose laws, or screening policies, but the real focus needs to be on the point at which the public interacts with the system, the health care providers. There may be differences of language to further complicate the cultural difference. The human approach to this relationship is especially stressed in the difficult dilemmas faced in genetic counseling. Similar issues are in the rest of medicine. What we must do is apply the emphasis of genetic counseling on nondirective counseling back into the rest of medicine. To respect people's autonomy and obtained truly informed consent is required. In this way we can learn from the new genetics.
There are important duties on health care providers. They should be advocates for their patients, and attempt to ensure that society in general makes adequate provision for the needs of patients. The distribution of wealth needs to be changed, and the distribution within medicine needs changing. Economic factors are important in justice, but so are attempts to justly meet the different needs of people, some of whom will need more. Often genetics counseling is seen in light of a cost-benefit ratio, but that type of analysis is too simplistic. Financial considerations should not alter clinical behaviour, such as the encouragement of selective abortion because of the costs to society, even though patients as individuals may take that and especially their families' own costs, into account.
Between different people's there are many similarities. There are also universal human rights which should be protected, and international medicine should recognise these. More discussion of specific areas of applied genetics is presented after the next section. This book attempts to consider the broader issues of life, and beyond our interation with each other to our interaction with the environment. There are some implications of the use of genetic technology, and also some lessons, that we must discuss.
In the final decade of the twentieth century we should be becoming increasingly aware of the need for moving to a system of sustainable living. In order to accomplish this, we not only have to view the environment in its role as essential to human existence, but we should value the environment for what it is. We need to promote the awareness of the values of the environment and other creatures.
To those of us that live in developed countries that can be accomplished by directing people's focus to the beauty of nature or the diversity of animal and plant life. However, to the starving in the desert this concern is unimportant. If we put ourselves in their place we would also put the environment in a secondary place of importance, the primary concern being survival of oneself and family. If we want to provide food and housing to those people, we may need to use more of the forests or natural habitats for agricultural land. The causes seem to clash. The challenge is to attempt to alleviate the root problems.
Biotechnology will change the way we live. Already we see examples where it has changed the situation of some groups. For example, dwarfism caused by the absence of growth hormone should no longer afflict our children, as the hormone can be made cheaply, in unlimited quantities. Of course, in this example we see the case of a condition that while not being a major handicap, became one because of the social stigmatisation of people suffering from the condition. If we changed the way we think, it would be a better solution. Many more common products will become available. It may be the new range of washing powders, or the new ways of growing crops that have more daily impact. Medical care is also aided.
At a practical level this involves several major changes. Birth control is essential, to reduce the numbers of humans, this is a medical and political issue. Fairness in the distribution of food and materials would decrease the needs of the poor, an economic and political issue. More efficient agriculture will also reduce the the land that is required for agriculture, a scientific issue. Reducing consumption will aid this, an issue that the public as individuals must change.
The genetic technology described in this book considers the improvement of agricultural efficiency. There has to be further discussion of the commercial aspects of biotechnology. We need to implement these changes to succeed. Changing the way human beings behave towards each other is a supernatural task, that can be aided by all of us changing our attitudes. We must ensure that efficient and sustainable agriculture is encouraged, but recognise it is only part of a broader solution. Sustainable living involves not just efficient agriculture, but also minimising our energy use and pollution. It involves changing public policy. It involves changing the way people think. For the scope of this book the issue is our use of agriculture and including agricultural industry. We must realise how important the use of new technology is when it aids this process, and work towards this goal.
Sustainable agriculture could be defined as the appropriate use of crop and livestock systems and agricultural inputs supporting those activities which maintain economic and social viability while preserving the high productivity and quality of the land (Hassebrook & Hegyes 1989). Current research interests in biotechnology may not be the best way to provide sustainable agriculture. Large corporations are developing new techniques that may require constant, or at least annual, application. In the USA about 0.5 billion tonnes of toxic active ingredients are applied to farmland annually, with only 1% reaching their target. There has been little research into more longterm controls, and cynics can claim that this is because the companies will make more money out of repeated application products. The use of Bacillus thuringiensis against corn borers is one such trade-off; corn borers tend to persist in fields where corn is planted year after year in a monocrop system. It may in fact be better to use crop rotation for control of pests.
One controversial research application is the development of herbicide-tolerant plants. Herbicide tolerant plants may actually increase the amount of chemicals used, though this is denied by the companies producing them (Anderson 1989). One of Monsanto's projects is to develop soyabean varieties resistant to their herbicide Roundup. These varieties would increase the sale of Roundup, already the world's largest selling herbicide, by at least US$ 150 million. The insertion of Basta resistance into potato, tobacco and tomato plants is expected to earn Hoechst another US$ 200 million a year. The world's largest corn seed producer, Pioneer HiBred is using a gene given to them by American Cyanamid for resistance to the imidizolinone family of herbicides. In return the company will sell herbicide. Soybeans resistant to Ciba-Geigy's atrazine herbicides, could increase annual herbicide sales by US$ 120 million(Fowler et al. 1988). Restructuring of the seed and agrochemical firms is occurring. For example Calgene has patented the GlyphoTol herbicide tolerance gene for cotton, and in 1987 it acquired a cotton seed company, to establish control over the breeding of resistant cotton (Juma 1989).
To determine what effect herbicide tolerant plants will really have on herbicide use further study needs to be done. A recent American Report (BWG 1990) was very critical of the use of public funds to develop herbicide tolerant crops, and this may be stopped in the USA. They argue that research should be aimed at growing crops without herbicides and chemicals, even if they are biodegradable. An alternative would be to increase the tolerance of crops to mechanical cultivation which can also be used in weed control. Many chemical companies have obtained seed company interests, and will market the products together. The answer is not known.
The certainty is that there is a lack of research into biological controls, most developed countries use high input agriculture, and conduct little research into biological control. Biological weed control may be the only practical solution in some situations, such as the control of alien weeds in tropical forests. Overall, about one case in six has worked, but it is very cost effective (most projects cost less than US$ 150,000) (Crawley 1989). This success rate is still much greater than that achieved in searching for useful agrochemicals. It may be best to use government funding for more biocontrol, and leave funding for herbicide tolerant crops to those companies that will profit from such varieties through sales of herbicide.
While there are valid criticisms about the development of herbicide-tolerant plants, they do have immediate environmental advantages. For example, maize growers make 4-6 herbicide applications a season, but if the crop was tolerant to a broad-spectrum post-emergence herbicide only one application would be needed. Not only the amount of herbicide would be less, but as mentioned, a biodegradable herbicide could be used. It is important that biodegradable herbicides are used, for example atrazine is not biodegradable, and Ciba-Geigy has recently dropped their soyabean project because of this. It would also been difficult to obtain Environmental Protection Agency (EPA) approval for large scale use. Roundup may also be persistent in surface water and is toxic to fish (BWG 1990). Reducing herbicide use and switching to biodegradable products is consistent with sustainable agriculture and is an important practical step in that direction. The safest herbicides may be those that interfere with the biosynthesis of essential amino acids in plants, such as glyphosate, sulfonylurea and imidazolinones (Schulz et al. 1990).
Criticism has also been made at the use of bovine somatotropin (BST). Although it increases milk production, it may have negative effects on farmers. It may leave the dairy industry in the hands of industrial type farmers. There are those that say that even if small farmers lose their farms, we should always work for greater efficiency. However, this has major social repercussions that should not be left in the hands of people of only one interest group. Industrialised countries do protect small farmers to avoid the social costs, as seen with the rice farmers in Japan. This was discussed in chapter 10. There are major consequences of the new technology and it may not always be right to pursue it.
One hundred years from now the earth will probably have ten billion humans, about twice its current population. There should be enough food production, but that is not the major question. Yields have been increasing linearly for the past three decades in major crops such as wheat, maize and sorghum. At least half of the gains are because of genetic improvements (Duvick 1984). Food production must expand in a way that does not destroy the natural environment. For this to happen, new technologies that minimise erosion, desertification, salinisation of the soil, and other environmental damage, must be introduced. The most difficult problem is not just developing technology, but getting farmers to use environmentally sustainable technology (Crosson & Rosenberg 1989). Alternatives to current practises need to be developed, including crop rotation, integrated pest management, health maintenance as well as using GMOs (CRAF 1989). All alternatives need to be tested. Current economics do not consider the environment and its value, and this needs to change. By taking into account the value of the environment, we are thinking of long term interests, something that is not considered in most modern economic policies. A target of genetic engineering is to increase the quality of foodstuffs, rather than the quantity. This is an important goal for world agricultural research to concentrate on.
From a consideration of the developments in molecular biology and genetics, and their likely applications in the near future, it is possible to decide which areas promise benefits and in which areas there are ethical dilemmas, and where we need to stop.
There have been a wide variety of concerns expressed over genetic engineering. These are genuinely important. They fall into two basic classes: those which depend on personal opinions, and those which depend on science (such as risk assessment). The concerns of the first type were the basis of chapters 3 and 6. They are important for the future development of genetic engineering and the limits to its application. With the wide range of implications to society, society needs to decide. However, in order to do this, public education is required.
Regulation of Genetic Engineering
The use of recombinant DNA techniques has aided the progress of biology and is now central to biological science. It should continue, within the containment facilities seen to be necessary by the established safety committees. The insertion of new genes into plants and microorganisms should be unlimited in the laboratory situation. Except all biological weapons research should be stopped.
Regulations need to consider international work, as considerable research has been conducted into developing safe regulations. The special concerns of each country need to be respected. Some questions, such as the safety of GMOs for industrial use or free release, and food safety, are scientific questions. The decisions whether to use a new organism are more open to the public, and will be determined in the end by consumer choices. Other questions, such as animal patenting, and the level of animal use that is permitted will be more subject to public opinion.
Agricultural Uses of Genetic Engineering
In agriculture there are definite advantages for some artificial reproduction, embryo transfer, clonal reproduction, and genetic engineering. This does not raise great ethical dilemmas if there is no harm done to the animals (further than their growth for human consumption).
The main concern about transgenic plants and microorganisms is the question of environmental release, and safety of the foodstuffs. The key principle involved is one of stewardship of the earth. We can see some of the many advantages that this new technology does have, but we do need to be careful in case it does result in the wide distribution of certain detrimental genes in the ecosystem. These advantages include increased production with reduced costs. The reduced costs include economic costs, such as reduced quantities and simpler use of herbicides and pesticides and environmental benefits from the reduced use of agrochemicals and the substitution of older toxic products with biodegradable products.
Need to Consider Broader Implications
Some concerns, such as commercialisation and sustainable agriculture are broader issues. They are more questions about how we should apply these techniques, who should use them, whether they should expect great profits from them, and other political concerns. While these concerns are important, they are not significantly affected by the actual use of the new techniques. However, we may need to focus more attention on the implementation of biotechnology itself, rather than the safety of individual GMOs. It has greater implications, extending to social changes, than do the low risks of ecological harm associated with small scale GMO release.
The decisions in the area of biotechnology must take into account many considerations, extending well beyond the scientific merit of a particular technique, or the opportunities suggested for its application. These decisions are often difficult or controversial which makes good public relations important. Independent regulatory control is well established in many countries. The procedures used in risk evaluation, and procedure, may need revisions.
The problems of transgenic animals come down to two major issues, environmental release and ecological dangers, and issues covered under the idea of vivisection, such as making animals that are diseased or for the sake of a better word, very unnatural. There is the need to develop the regulations further with criteria for judgement less based on pain as argued above. There is room for government legislation to supplement the regulations based on avoidance of pain and endangered species.
The insertion of new genes into animals should continue where necessary for the study of biology when there is no clear detrimental affect upon the mutant animals. There is a balance in situations between importance of an experiment and the effect and the status of the animal. We must examine where the boundaries could be drawn (Macer 1990a). In the case of higher animals such as primates or dolphins there is sufficient doubt regarding their status not to use them for animal experiments. In the case of trials of gene therapy if this type of animal does not possess the disease then it would seem unethical to inflict the disease and attempt gene therapy. The human trial will in the end be experimental, even after several primate trials. However, if an other animal such as mice or sheep can be used, it would be ethical to use a controlled number, provided that the animal is in plentiful supply. In certain cases such types of animals may be made diseased and bred as a strain, there are limits depending on the suffering and the example. The general question of under what conditions experimental use of animals is justified, should follow the existing law, i.e. only when a scientifically important result can be obtained with little animal suffering, and there are no alternative experimental subjects.
Regulate Use of Infertility Treatments
Techniques for the alleviation of infertility in married human couples should continue to be developed, and improved, especially IVF. However, the use of extramarital gametes should be under tighter control,with the recommendation of suitability being made by several independent physicians. The donors of the gametes should be anonymous, but with longterm medical records held by the central government. The children should be told of their origins, but I'm unsure whether they should gain access to the records of their genetic parents when they are 18 years old.
No gametes, or embryos should be commercially sold. Commercial surrogacy is ethically unacceptable, despite its acceptance in some countries. In exceptional cases the offer of surrogacy from a friend or relation may be appropriate. The judgement of when surrogacy could be used in a noncommercial arrangement may need to be considered by the central licensing authority, after recommendation from several independent physicians.
Regulated Research on the Early Human Embryo
In some limited areas of clinical importance, when all possible, useful preliminary experimental results are known, it may be right to conduct experiments of human embryos up to the age of 14 days if there is no alternative. The use and licensing of such experiments, including the approved numbers of embryos and their source, should be in the control of a central licensing authority in each country. The status of the human embryo up to 14 days in my opinion is less than some higher animals that have a strong sense of self-awareness and some rationality.
Encourage Use and Development of Birth Control
The use of contraceptive, birth control methods, even if they involve the death of embryos up to 14 days old, are acceptable. Contraception in general, is not only ethical, but the alternative consequence of not using them may mean overpopulation which is undesirable for the proper stewardship of the world's population. It is wrong to impose compulsory birth control policies on the general population, but it should be strongly encouraged and possibly by financial incentives.
As with other medical services, within the priorities established for each country there should be equal and fair access to all genetic services for every person.
Use of Genetic Screening Early in Fetal Development
Abortion in general is ethically difficult, except if before the embryo is 14 days old. Selective abortion may need to be considered for some exceptional diseases, and should be done at an early an age as possible, up to a general age of 6-8 weeks. Beyond the beginning of brain life it is unethical, but is still not murder until the age of viability. There should be research into ways of screening at earlier times, and use of chorionic villi sampling where possible. As well as genetic screening, there should be education of other risk factors in pregnancy, such as alcohol or smoking, which may be the cause of some mutations, and birth handicaps. All approaches are required. For couples who have a high risk of transmitting a serious genetic disease, it may be ethically preferable to use IVF with a donated gamete.
Access to IVF treatments or embryo flushing/screening and embryo transfer clinics will increase, but it is probably only applicable to known carriers of genetic disease that do not agree with selective abortion. The general population screening requires a method for in vivo screening, which can occur only after about 6 weeks after conception with the best of current chorionic villi sampling. It is hoped that maternal blood screening will be developed. There are five important criteria for genetic screening followed by selective abortion the test must be accurate, the disease serious, the costs reasonable,there should not be effective therapy available, and the patient, with family, should decide..
Careful Regulation of Genetic Information
Our genetic knowledge is increasing at a tremendous rate, which is good. New genetic knowledge will result in cheaper, faster and more accurate genetic tests. However, society is not yet equiped to receive this information. After receiving it, it must be ethically used. There need to be decisions on what information to tell, to whom it should be told, when in life, and how. There will need to be coordinated programs after research is done on the implications of this knowledge at different stages of life, in peoples life decisions.
The establishment of government genetic registrars may be beneficial to overall health provision and genetic research. However, these registers have many problems arising from possible abuse. Even if a computer system is protected, we can envisage possibilities for illegal searches of such data. There are also many problems of family confidentiality. Until sufficient protection measures are in place, it is not good to begin widescale genetic registers.
It is important to protect individuals confidential data from several groups in particular; the employers and from medical insurance companies. Even if there is no systematic genetic screening of applicants for medical insurance at present, it is effectively carried out by asking questions about family genetic disease. This information should also be protected in a just health care system. In the case of employers, rather than screening workers they should clean up the work environment, as most risk factors work in terms of degrees. While some people are genetically very sensitive to some chemicals, other people will generally be somewhat sensitive to such chemicals any way, such as asbestos. The primary assessment should be in terms of job proficiency, which for certain jobs could be checked very frequently.
Ban on Nondisease Genetic Selection
Many "minor" diseases which are currently considered as grounds for selective abortion, do not seem to be sufficient to justify the use of abortion. In this category I would include those diseases which are currently treatable and curable by medicine (e.g. some types of haemophilia), and other diseases such as albinism which are just regarded undesirable. Sex selection or other nondisease selection is unethical. It is better for society to change than to mould birth control to please the current desires of some members of society, that may be based on prejudicial views.
Somatic Cell Gene Therapy Should be Encouraged
The use of somatic cell gene therapy should be promoted as a new medical technique which will complement bone marrow transplantation and other symptomatic disease treatments. Before it is widely conducted on humans it should have extensive trials, first on animals and then on humans. The first use of the therapy will depend on the estimated safety, efficiency and need of each individual patient. Initially it may require central control from a licensing authority, but once established it should be under the same control as for the use of other medical techniques. Excessive levels of committee approval is inefficient and unnecessary.
Temporary Ban on Germline Gene Therapy
Germ-line gene therapy should be banned until safety is assured, but the ban should be reviewed. The judgement on which diseases are to be treated can be made by the use of common sense, public discussion and a central licensing authority. Safety needs to be tighter than for the use of somatic cell gene therapy. Governments should never enforce germ-line gene therapy on consenting individuals, but therapy may be enforced on the fetus if necessary for survival.
Encourage Alternatives to Germline Manipulation
To examine the alternatives, it is important to look at the goal of the technique. From the parents perspective, it is aimed at producing a healthy child. At an individual level it is aimed at leading to a healthy life, including reproduction. At a societal level, it is aimed at reducing the number of people in the next generation who suffer from genetic disease. There are benefits to all. Society's goal must be accomplished without infringing individual rights.
With the advent of embryo screening, there must be serious doubts as to when positive germ-line manipulation is appropriate. It would not seem appropriate in the case of recessive genetic diseases, as it will be possible to select those embryos that do not have the disease-causing genes, implanting only those which are normal. Human beings share with the rest of living organisms the capacity to produce large numbers of offspring, so there will be sufficient embryos produced to satisfy most people's urge to have their own germ-cells involved in their offspring. At this stage of development the options are abortion or somatic therapy, it is past the time of what we could consider germline embryo manipulation. The alternatives should practically limit the application of germline manipulation, until some currently unthoughtof technological development.
While we may try to save the life of handicapped fetuses from 6 months after conception, is it worth saving the life of an 8-cell embryo, when others are present. Part of the answer to this rests with our ideas of a human embryo. This is a very contentious issue, especially when brought out of context. The ethical support for this alternative is supported by the concept of individual origins being after the formation of the primitive streak (Ford 1989), about 15 days after conception. However, there are important concerns about the considerable amount of resources necessary to make gene therapy a reality, and the limited number of conditions and persons to which it could apply.
The overriding factor at present is the experimental risks to the growing child, after germline therapy. Parents do make decisions regarding the future of their children already, as does society. There is some prerogative for future germline therapy. However, if there is no proven therapy, early selective abortion is an option that many parents consider preferable.
Laws Needed to Prohibit Genetic Discrimination
There needs to be some laws made to prevent genetic discrimination. This may mean making genetic information private, or else having an effective and fair public health service. To allow genetic discrimination is clearly unethical, and one of the major social implications of the new genetic technologies. It may be desirable to screen every fetus or individual, but only if they can be protected from discrimination, and only when it is accompanied by sufficient counseling and education. We all carry genetic disorders and it is important that we work to help those people who have them. The United Nations could support a call for genetic equality.
Not only is discrimination a problem, but so is stigma. People can misinterpret information in idiosyncratic ways. Parents may feel guilty of transmitting a abnormal allele of a gene to children, even if they are only carriers. We must stress the universality of recessive disease alleles, we all have them. People may be afraid to tell others once they learn they have an abnormal gene. In some countries the young adults may be encouraged to hide the information so that they do not become nonmarriable. They may be later guilt reactions, and other psychological problems.
Education of Genetics
The new techniques will be of no use unless people are educated about them. There are different levels that need to be targetted, and all information should be appropriate for those people, including cultural and religious factors. The health care workers need some basic training in genetics, and genetic counseling. Specialist genetic counselors are also required, as are laboratory personnel to develop and run the tests. Voluntary counselors may also be necessary, as the number of people trained is much less than the need. The public must know some basics before they can be informed consumers and users of these services. This means that this information must be given at early school stage, and beyond. The language of probability and risk is important, how to perceive a 25% risk of a child with a serious disease.
Unless the public is educated, and informed about a genetic screening programs, even if it is voluntary and non-directive, in effect it can be the same as if the program was mandatory if the government was authoritarian. It is therefore essential for the public to be educated to ensure they can chose.
New Possibilities should be Pursued
The approaches used here provide a basis for approaching other issues in bioethics, as the progress in biology and medicine continually opens new doors which society must decide whether to enter. Morality concerns itself with the rightness or wrongness of human conduct. Law, or public policy, is concerned also with the public good. The important criteria of feasibility is important, involving questions such as whether the policy will be obeyed, whether it is enforceable, are there other bad effects on society? We need to examine what conclusions are appropriate to put into law. If attempting a compromise between incompatible moral positions and of proposing arbitrary legal limits, there will be many critics, as was seen of the Warnock, Committee report, and most other similar proposals. The law can not be an expression of everybodies moral feeling, the law applies to everyone and must be enforceable. Rather than what is ethical, we have to ask where a law should intervene to control a process, and when it should make something criminal. We can not always follow some imagined "common morality", as no set of principles is yet to be agreed on, but we must try.
All of society has to decide the moral problem, not only the scientists. Scientists must be held responsible for their actions. We need to examine what type of society we are making for ourselves. Science is the most powerful agent of change in our world, and genetics promises much more than a revolution in our medical treatments. We should learn how to handle it so that it is not misused, and learn how to anticipate the new directions the use of gene therapy may take. It must be clear to all of us that science will not solve our social problems, but it is an important part of our management of the earth.
Changing Our Perspectives
When we think of life on this planet we have different images. Our picture of life is changing, shaped by the world. Within different religions we have seen that there are different perspectives, and at the grassroots level, we may not yet even be aware of what the real feelings of people are. Our views of life are challenged and to some degree moulded by new technology, new circumstances in which we find ourselves. There may be some good in this, if our view violated someone else's autonomy, such as sexism or racism. It may also be good if it makes us more respectful and appreciative of the world in which we live.
A fundamental part of the process is to discover what images of life are. This should be pursued in different cultures and is a prerequisite to understanding the impacts of new technology (Morioka 1988). Life may mean many things, and it constitutes many things, interacting together.
We should develop a view that is applicable to all of life. The development of this view will require participation by people from all walks of life, and from all types of research speciality. The term bioethics should mean the study of life ethics, but it has often been viewed only as a part. The concern with medical ethics has meant that while many people, or committees, are called "bioethics" committees, they only consider medical ethics. There is also a point for those who consider environmental ethics apart from human-human interactions, again it is an incomplete perspective. I hope that this book, which attempts to combine both topics in the same cover, may help those in one field grasp more of the issues in the other. We have much to learn from our approaches to genetic technology, not just the nature of our genes, but the nature of our thinking about what is important in life.
Genetic engineering makes us challenge our technology, and think about limits to advance. We are probed into searching for answers to questions. At the end of this book, more questions follow what may have been some answers. We need to consider many questions, some are:
* Why do we think genes are so fundamental, and should we?
* Why do we value nature, and what occurs naturally? Disease is a natural event, but we try to cure or treat it. We must grow food at least, even if we don't eat meat. We accept the idea of living in a city, where are the limits?
* Why should we object to mixing the genes from different species?
* What is our reason for placing limits on animal abuse, and does pain make the difference, or some other type of property, such as life itself?
* Are we happy about eating genetically modified food, when we already eat food made from genetically breeding of crops and animals? Do we want to avoid using pesticides, which pollute our environment? The vegetables and crops that are made, also the meat and fish, are much healthier for us than the softdrinks and crisps and beer that we consume. Will it make us more conscious of our diet?
* What is the cost versus benefit ratio we are prepared to accept? What risks will we accept, for example of a GMO upsetting the ecological balance of an area? Will we accept the risks of continued pesticide use? There are many other issues.
* Do we object to commercialisation of genetic material, and animal patents?
* It makes us think about what a human person is;
Should we do genetic screening and selective abortion?
At what stage during fetal development does an embryo become a person?
What diseases justify this selection?
Should we allow eugenics?
Should we allow germline genetic therapy, or manipulation?
What do we value in our lives and in others?
* Should people have reproductive freedom? What are the limits? Should we ban sex selection? Should we allow positive genetic selection of gametes, or genes; we allow people to use cosmetic surgery?
* Should governments control reproduction?
* How much technology should we use? Enough to fix the mistakes of the past, enough to sustain a large human population living in a sustainable way on the planet? When will our pursuit of technology be reduced?
* What will happen in fifteen years when we know the entire human genome sequence? The problems of genetic discrimination by employers or medical insurance are so great that it may force national health systems. A good result, but it may also lead to genetic determinism. People may think they can only do what their genes allow them. There must be limits to the use of this knowledge. It is justified by all the medical benefits, but it has many challenges.
* What will humanity become? Do we want to preserve parts of our society's values?
* What are our responsibilities to future generations, can we become responsible?
Basically, genetic engineering makes us think about life.
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