binary quantifier See PLURALITIVE LOGIC. bioethics, the subfield of ethics that concerns the ethical issues arising in medicine and from advances in biological science. One central area of bioethics is the ethical issues that arise in relations between health care professionals and patients. A second area focuses on broader issues of social justice in health care. A third area concerns the ethical issues raised by new biological knowledge or technology. In relations between health care professionals and patients, a fundamental issue is the appropriate role of each in decision making about patient care. More traditional views assigning principal decision-making authority to physicians have largely been replaced with ideals of shared decision making that assign a more active role to patients. Shared decision making is thought to reflect better the importance of patients’ self-determination in controlling their care. This increased role for patients is reflected in the ethical and legal doctrine of informed consent, which requires that health care not be rendered without the informed and voluntary consent of a competent patient. The requirement that consent be informed places a positive responsibility on health care professionals to provide their patients with the information they need to make informed decisions about care. The requirement that consent be voluntary requires that treatment not be forced, nor that patients’ decisions be coerced or manipulated. If patients lack the capacity to make competent health care decisions, e.g. young children or cognitively impaired adults, a surrogate, typically a parent in the case of children or a close family member in the case of adults, must decide for them. Surrogates’ decisions should follow the patient’s advance directive if one exists, be the decision the patient would have made in the circumstances if competent, or follow the patient’s best interests if the patient has never been competent or his or her wishes are not known. A major focus in bioethics generally, and treatment decision making in particular, is care at or near the end of life. It is now widely agreed that patients are entitled to decide about and to refuse, according to their own values, any lifesustaining treatment. They are also entitled to have desired treatments that may shorten their lives, such as high doses of pain medications necessary to relieve severe pain from cancer, although in practice pain treatment remains inadequate for many patients. Much more controversial is whether more active means to end life such as physician-assisted suicide and voluntary euthanasia are morally permissible in individual cases or justified as public policy; both remain illegal except in a very few jurisdictions.
Several other moral principles have been central to defining professional–patient relationships in health care. A principle of truth telling requires that professionals not lie to patients. Whereas in the past it was common, especially with patients with terminal cancers, not to inform patients fully about their diagnosis and prognosis, studies have shown that practice has changed substantially and that fully informing patients does not have the bad effects for patients that had been feared in the past. Principles of privacy and confidentiality require that information gathered in the professional–patient relationship not be disclosed to third parties without patients’ consent. Especially with highly personal information in mental health care, or information that may lead to discrimination, such as a diagnosis of AIDS, assurance of confidentiality is fundamental to the trust necessary to a wellfunctioning professional–patient relationship. Nevertheless, exceptions to confidentiality to prevent imminent and serious harm to others are well recognized ethically and legally.
More recently, work in bioethics has focused on justice in the allocation of health care. Whereas nearly all developed countries treat health care as a moral and legal right, and ensure it to all their citizens through some form of national health care system, in the United States about 15 percent of the population remains without any form of health insurance. This has fed debates about whether health care is a right or privilege, a public or individual responsibility. Most bioethicists have supported a right to health care because of health care’s fundamental impact on people’s well-being, opportunity, ability to plan their lives, and even lives themselves. Even if there is a moral right to health care, however, few defend an unlimited right to all beneficial health care, no matter how small the benefit and how high the cost. Consequently, it is necessary to prioritize or ration health care services to reflect limited budgets for health care, and both the standards and procedures for doing so are ethically controversial. Utilitarians and defenders of cost-effectiveness analysis in health policy support using limited resources to maximize aggregate health benefits for the population. Their critics argue that this ignores concerns about equity, concerns about how health care resources and health are distributed. For example, some have argued that equity requires giving priority to treating the worst-off or sickest, even at a sacrifice in aggregate health benefits; moreover, taking account in prioritization of differences in costs of different treatments can lead to ethically problematic results, such as giving higher priority to providing very small benefits to many persons than very large but individually more expensive benefits, including life-saving interventions, to a few persons, as the state of Oregon found in its initial widely publicized prioritization program. In the face of controversy over standards for rationing care, it is natural to rely on fair procedures to make rationing decisions. Other bioethics issues arise from dramatic advances in biological knowledge and technology. Perhaps the most prominent example is new knowledge of human genetics, propelled in substantial part by the worldwide Human Genome Project, which seeks to map the entire human genome. This project and related research will enable the prevention of genetically transmitted diseases, but already raises questions about which conditions to prevent in offspring and which should be accepted and lived with, particularly when the means of preventing the condition is by abortion of the fetus with the condition. Looking further into the future, new genetic knowledge and technology will likely enable us to enhance normal capacities, not just prevent or cure disease, and to manipulate the genes of future children, raising profoundly difficult questions about what kinds of persons to create and the degree to which deliberate human design should replace ‘nature’ in the creation of our offspring. A dramatic example of new abilities to create offspring, though now limited to the animal realm, was the cloning in Scotland in 1997 of a sheep from a single cell of an adult sheep; this event raised the very controversial future prospect of cloning human beings. Finally, new reproductive technologies, such as oocyte (egg) donation, and practices such as surrogate motherhood, raise deep issues about the meaning and nature of parenthood and families. See also DIGNITY, ETHICS, EUTHANASIA , INFORMED CONSENT. D.W.B.