Bioethics

Introduction

Bioethics is concerned with the ethical dilemmas produced by biology and medicine, particularly those raised by human action in society and the environment through the use of biotechnology. It examines concerns that affect all living organisms and the environment, from a single creature to the whole biosphere. It is the branch of ethics that studies specific, contentious moral issues such as abortion, animal rights and euthanasia, and it uses moral principles to help us think through these dilemmas.

When weighing the benefits and the problems of a medical procedure, bioethicists often return to four main principles of health care ethics.

The four principles of health care ethics

For a medical practice to be called ethical, it should respect all four of these principles.

Autonomy

When making decisions about a health care procedure, the patient must have autonomy of thought, intention and action. The decision making process must therefore be free of coercion or pressure. For a patient to make an informed decision, she or he must be aware of all the risks and benefits of the procedure, as well as its chance of success.

Justice

The costs and benefits of new or experimental treatments should be shared fairly among all members of society. Procedures must follow the spirit of existing laws and be equitable to everyone involved. When thinking about justice, a health care worker weighs four things: the fair sharing of limited resources, competing needs, rights and duties, and any clash with existing law.

Beneficence

The procedure must be carried out to benefit the patient. This asks health care providers to build and keep their skills and knowledge, to update their training regularly, to consider the particular situation of each patient, and to aim for a real net benefit.

Nonmaleficence

This is the duty to avoid causing harm. The health care professional should not inflict any harm on the patient. Almost every treatment causes some harm, even if it is small, but the harm must never be out of proportion to the benefit of the treatment.

Issues related to bioethics in India

These four principles are not just theory. In India they meet law, religion and new technology in several live areas, and you can find related pieces in our Ethics notes.

Euthanasia

Euthanasia, or mercy killing, of terminally ill people has long been a contentious bioethical topic in India. Supporters of Physician Assisted Suicide argue that a person's right to autonomy gives them the right to a painless death.

Opponents argue that a doctor taking part in a person's death breaks the profession's core commitment to life and to dignity. India permits passive euthanasia but not active euthanasia.

In Hinduism, Atma-gatha, meaning the deliberate act of taking one's own life, was forbidden. Hindu tradition believes in the theory of karma, in which one's suffering in this life is a consequence of deeds in a previous birth, so ending life early is seen as a breach of the law of karma and dharma. Many Indian Muslims also oppose euthanasia, holding that no one has the right to die before the time appointed by God.

Stem cell research

Stem cell research has great potential for understanding the basic mechanisms of human development and for creating new treatments for disease. However, research using human stem cells raises significant ethical and political concerns. The promise of stem cells in treating degenerative, incurable and irreversible conditions such as diabetes, heart disease, spinal cord injury, Parkinson's and Alzheimer's has pushed them to the front of medical research. The debate around stem cell therapy involves social, economic, political, cultural and ethical questions, and worries about designer babies have made these concerns even sharper.

Prenatal diagnostics

A range of prenatal tests, along with the recent arrival of preconception and gene based technologies, has made it possible to detect the sex or other supposed abnormalities of a fetus. In some cases this has led women and their families to seek elective abortions, including sex selective ones. It is the human use of a technology that decides whether it is good or harmful. For example, technology made it possible to know the sex of a child, but for some people it became a tool for a very different aim, adding to female foeticide.

The remarkable advances in medical science and technology have had a huge impact on society. They have brought forward concerns that are changing the way we live and the values we hold. These difficulties push us to rethink our ideas of social and medical ethics, and our value systems.

Why bioethics still matters today

Bioethics is not only a chapter to revise. The same four principles, autonomy, justice, beneficence and nonmaleficence, are being argued over in real courtrooms, hospitals and government missions right now. Here are three live examples that connect directly to the topics above.

India made living wills easier: autonomy in action

The euthanasia debate became more concrete in January 2023. On 24 January 2023 a five judge Constitution Bench of the Supreme Court of India eased the rules for a living will, also called an advance medical directive. This is a written note in which a healthy person records that, if they ever become terminally ill and cannot speak for themselves, they do not want to be kept alive by machines. The earlier 2018 rules were so slow that almost nobody used them. The 2023 order removed the need for a magistrate to countersign the document and allowed a hospital medical board to take the decision, while keeping safeguards so the choice stays genuinely the patient's own. That is the principle of autonomy from the notes above, written straight into Indian law.

The first CRISPR cure was approved: stem cells, for real

The notes above describe both the promise and the worry around stem cell and gene based medicine. That future arrived on 8 December 2023, when the United States Food and Drug Administration approved Casgevy, the first ever medicine that uses CRISPR gene editing. It treats sickle cell disease, a painful inherited blood disorder. Doctors take a patient's own blood stem cells, edit one gene in the laboratory so the body switches fetal haemoglobin back on, and return the cells to the patient. There is no donor, and so far no lifelong medicine is needed. It shows the bright side of the very technology the notes warn about, and it sharpens the old question: if we can edit genes to cure a disease, where is the line before we start editing for looks or intelligence?

A national mission at a huge scale: justice and access

The principle of justice asks whether the costs and benefits of new medicine actually reach everyone. India is testing this at scale. On 1 July 2023 the government launched the National Sickle Cell Anaemia Elimination Mission, with the goal of ending sickle cell disease as a public health problem by 2047. The plan is to screen seven crore, that is seventy million, people aged 0 to 40 across 278 districts in 17 states, many of them tribal areas where the disease is common. Screening on this scale raises the exact consent and privacy questions the notes touch on: who is told the result, what choices a carrier couple then faces, and how a family is supported rather than pressured. You can follow more of these debates on our Learnacy Hub and in the Science and Technology notes.

Sources

1. Supreme Court Observer, Supreme Court Review 2023: Right to Life (on the 24 January 2023 living will order)
2. US Food and Drug Administration, FDA Approves First Gene Therapies to Treat Patients with Sickle Cell Disease, 8 December 2023
3. Prime Minister of India, PM launches National Sickle Cell Anaemia Elimination Mission, 1 July 2023

Key takeaways

• Bioethics examines ethical dilemmas in medicine and biology, covering issues like abortion, animal rights, and euthanasia using moral principles
• The four principles of healthcare ethics are autonomy (patient's right to decide), justice (fair distribution of costs/benefits), beneficence (acting to benefit the patient), and nonmaleficence (avoiding harm)
• India permits passive euthanasia but not active euthanasia, influenced by Hindu beliefs in karma and dharma and Islamic views that only God can appoint time of death
• Stem cell research offers potential for treating diseases but raises ethical concerns about designer babies and the misuse of prenatal diagnostics for sex-selective abortion
• Recent developments include India's 2023 Supreme Court ruling easing living will rules and the US FDA's 2023 approval of the first CRISPR cure

Test yourself

What are the four principles of health care ethics?

Autonomy, justice, beneficence, and nonmaleficence

What form of euthanasia does India permit?

India permits passive euthanasia but not active euthanasia

What did the January 2023 Supreme Court ruling change about living wills?

The 2023 order removed the need for a magistrate to countersign the document and allowed a hospital medical board to take the decision while keeping safeguards