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3.2 No account of the history of bioethics would be complete without mention of a biologist, Van Rensselaer Potter, who is typically – and quite wrongly – credited with coining the term ‘bioethics’ in 1971 (Jonsen 2014, 332). Potter wrote: ‘I propose the term Bioethics in order to emphasize the two most important ingredients in achieving the wisdom that is so desperately needed: biological knowledge and human values’ (Potter 1971, 2). It turns out¹ that the author who actually deserves credit for coining the term is a German Protestant pastor, Fritz Jahr. In 1927 he published an article called ‘Bio‐Ethics: A Review of the Ethical Relationships of Humans to Animals and Plants.’ In that article Jahr aimed to establish bioethics as a discipline as well as a moral principle (Sass 2007). Unlike Potter, Jahr’s work was quickly forgotten during the turbulence of the Second World War. Fast forward from 1927 to 1987. Helga Kuhse and Peter Singer, the founding editors of the leading international journal Bioethics described their fledgling new enterprise in the first issue of the journal this way:

Bioethics will publish articles on the ethical issues raised by medicine and the biological sciences. … The prefix ‘bio’ in our title, then, is used in a narrow sense to refer to the biological sciences, and especially, but not exclusively, the medical and health sciences. It is not being used in the wide sense in which we talk of ‘the biosphere’ to mean all living things, or anything which affects the ecology of our planet. ‘Ethics’ is at least a well‐established term. We understand it to mean the study of what we ought to do, and by ‘ought’ in this context we mean not prudential ‘ought’ of self‐interest, or even group interest, but rather reference to reason or considerations which can be defended from a universal or impartial perspective.

(Kuhse and Singer 1987, iv)

3.3 We will follow in this volume the understanding of ‘bioethics’ that Helga Kuhse and Peter Singer outlined in their journal editorial. For the purposes of this book we understand bioethics as a field of study inquiring into ethical issues arising in the biomedical and health sciences as far as they affect humans.

3.4 It is a legitimate question to ask whether bioethics should also cover ethical issues in our treatment of non‐human animals. Some of the most influential bioethicists² have written about the moral standing of animals³, not least the just quoted Peter Singer himself, and the morality of using sentient animals for medical research purposes as well as the production of food. We will be touching on this issue, albeit briefly, in the next chapter (Chapter 4) as well as in the chapter covering issues in research ethics (Chapter 7). The morality of animal experimentation⁴ has been debated controversially for many decades. There are also issues at the interface between species, such as xenotransplantation. You might also wonder why we are seemingly unconcerned about our natural environment⁵. Isn’t the destruction of the Amazon rainforest, for instance, an ethical problem? Well, we are not, strictly speaking, unconcerned, however, what is true is that we will focus in this book on environmental issues only insofar as they affect human health and human well‐being. Environmental ethicists have taken on the task of addressing challenging environmental ethics questions⁶. We shall by and large stay clear of those in this book. Our main focus in the remaining chapters of this book will be – broadly – on challenging ethical questions that arise frequently at the beginning and end of our lives, questions that arise in the context of clinical research involving human participants, the ability of genetic research findings to dramatically change who we are, as well as ethical challenges posed by population and global health issues.

3.5 A lot and very little could be said about the history of bioethics. Historically it certainly grew out of medical ethics⁷. Traditionally medical ethicists were concerned about normative questions that arise in the health care professional patient relationship. Medical ethics covered many clinical ethics⁸ issues such as informed consent in the doctor‐patient relationship and professionalism in medicine, but also more contentious issues such as the morality of abortion or euthanasia. It is probably fair to say that varying histories of bioethics as an academic and professional discipline could be written, depending on what country you are looking at. For instance, bioethicist cum historian Robert Baker⁹ has written a superb volume on the history of medical ethics in the United States leading up to what he calls, quite appropriately, the ‘bioethics revolution’ (Baker 2013). It is well worth a read if you are interested in how medical ethics evolved over the centuries prior to the rise of bioethics. There are fascinating stories to be found, such as that about J. Marion Sims¹⁰, the founder of US American gynecology. He shot to fame during his time for the perfection of surgical procedures, but is much more notorious today for achieving this task by undertaking surgery on enslaved African women – without anesthetic or voluntary first person informed consent (Sartin 2004). This might remind you of the kind of ethical relativist questions that we mentioned in Chapter 1, specifically the second type: should J. Marion Sims be judged by the ethical standards of his times or by today’s standards? Well, thankfully this is not actually at issue in this instance. Reportedly one of his competitors, Edinburgh based James Simpson¹¹, noted in those same years, ‘I took occasion to make an extensive series of experiments … upon the relative qualities of different metallic threads … [on] a number of unfortunate pigs, which were always, of course, first indulged with a good dose of chloroform¹²’ (Sartin 2004, 505). He found it appropriate to use anesthetics even on the animals he used for his experimental surgery, very much unlike his colleague in the United States who thought nothing of abusing enslaved African women during his research. The ethical relativism question doesn’t arise then, because Sims’ work was already controversial and criticized by colleagues during his times.

3.6 A few books about the beginnings of bioethics have been written (Jonsen 1998; Rothman 1991; Evans 2012). Not unexpectedly these accounts of the birth of bioethics were not written by philosophers but by professionals hailing from other disciplines. Most of these histories are fairly United States’ centric. Whether they are reflective of how bioethics came of age in other countries or cultural contexts is unclear as these histories still need to be written. Having acknowledged this, North‐American bioethics and its conceptual frameworks have proven to be very influential the world all over. We will stick in this chapter, for the purpose of sketching a brief history of bioethics, by and large to the United States. It is reasonable to assume – with variations – that similar phenomena led to the birth of bioethics in other relatively resource‐rich countries.

3.7 Bioethics as we know it today is in many ways a creation of the 1970s. Robert Baker writes that the political and cultural changes sweeping through the United States from the mid 1960s created the ideological ground for the birth of bioethics (Baker 2013: 275). Well, what exactly happened during those years? A number of things occurred nearly concurrently. Scandals in scientific research rocked the country. Henry K. Beecher¹³, a Harvard based medical doctor, published in 1966 an article in a top‐flight medical journal, the New England Journal of Medicine¹⁴, flagging fairly outrageous unethical research practices in some 22 or so medical studies, many of which were funded by United States’ government agencies (Beecher 1966). Beecher’s article led subsequently to a US government investigation and a whole slew of policies and regulations addressing ethical standards in biomedical research were introduced and eventually implemented. This wasn’t a uniquely United States’ problem. Two years earlier Maurice H. Pappworth¹⁵, an English physician, blew the whistle¹⁶ on scandalous research ethics failings in the United Kingdom (Harkness 2001, 366). You will hear more about these episodes in the history of bioethics in Chapter 7.

3.8 Both medical professionals as well as patients saw also the advent of revolutionary medical technologies, such as dialysis machines, ventilators and in‐vitro fertilization (IVF). IVF in particular gave rise to a whole host of controversial normative questions about ‘new ways of making babies’. Traditionally understood medical ethics was simply ill‐equipped to deal with these issues. Meanwhile various groups demanded specific liberties from oppressive medical practices for themselves. The psychiatrist Thomas Szasz¹⁷ fought from the 1960s to liberate people from what he considered to be an oppressive psychiatry (Schaler 2004). Gay activists demanded from the American Psychiatric Association that it remove homosexuality from its list of mental illnesses¹⁸. They denied that there ever was a scientific basis for the profession’s mental illness designation verdict of homosexuality (Bayer 1981). These activists succeeded in 1973. Equally, women also fought to gain control over their bodies from the medical profession and the law, campaigning to have abortion decriminalized. In 1973 in Roe v Wade the United States Supreme Court decriminalized abortion¹⁹. In 1988 the Supreme Court in neighboring Canada, in effect, declared laws limiting access to abortion unconstitutional (R v. Morgentaler, [1988] 1 S.C.R. 30²⁰).

3.9 In a very general sense, trust that the doctor or medical researcher knows best, as it were, was replaced with the idea that competent patients are entitled to make their own self‐regarding choices and to see those choices respected by health care professionals and clinical researchers. Today, in many jurisdictions, patients are legally entitled to decline even life‐preserving medical care, provided they are competent at the time of their decision‐making. Patients became more powerful, medical researchers and doctors’ generally saw their powers cut.

3.10 Since those relatively early days, bioethics has seen a whole range of specializations. Researchers in public health ethics²¹ address questions to do with moral issues arising in the context of health care delivery on population levels. They are concerned about problems as varied as the ethical treatment of multiple‐drug resistant tuberculosis patients²², or the ethical challenges posed by the large number of young people with minor traumatic brain injuries²³ caused by popular sporting activities. We will be taking a closer look at public health ethics in Chapter 13. At the other extreme is arguably the equally young field of neuroethics²⁴. It is concerned with the ethical implications of recent advances in neuroscientific research. Should we provide medication to patients with post‐traumatic stress disorder that would make them forget permanently²⁵ whatever traumatic events they experienced? Is it ethically acceptable for students to take memory or attention enhancing drugs²⁶? Neuroethics research overlaps to some extent with concerns driving transhumanists²⁷. They are hoping that eventually we would be able to ‘upgrade’ our flawed bodies by technological means, permitting us to be more intelligent, more moral, live much longer, love better, and generally transcend what biological evolution has so far permitted us to be. You will come across these sorts of questions in Chapter 8.