1. Second-stage bioethics

    Several years ago I attended the Council of Europe's International Bioethics Conference, and was able to have discussions with some of the participants. There I met an American bioethicist whose name I had sometimes seen in bioethics journals and books. I told him that I was thinking about the possibility of a holistic and integrated approach to the study of life, including as an essential part, bioethics.
    After listening to me, he immediately replied that holistic approaches are impossible in this field, and advised me to concentrate on a single topic in medical ethics. I was shocked at his response because I had thought bioethics was an intellectual movement attempting to unite every discipline in order to solve contemporary problems of life and the environment.
    The word "bioethics" was first coined by Professor V.R. Potter in 1970 (1, 2). He meant by this word an "interdisciplinary ethics" which cuts across natural sciences and the humanities. Potter's bioethics was closer to today's environmental ethics than to medical ethics.
    During the 1970s and 80s, however, the word "bioethics" began to be used as the name of a discipline dealing with contemporary ethical issues in medical care such as abortion, euthanasia, the doctor-patient relationship, and so on. The Encyclopedia of Bioethics was published in 1978, and a number of textbooks appeared in the 1980s. We might say bioethics as applied ethics in the field of medical care was established as a discipline in the early 1980s in the United States. Many graduate students began to be trained as specialist, bioethicists, and were expected to solve bioethical problems in hospitals by applying "bioethical principles" to actual cases.
    Professor Edmund Pellegrino, a well-known bioethicist, writes in a recent article as follows (3). Before the mid-1960s medical ethics had been discussed in the context of the Hippocratic tradition. In the mid-60s the paradigm of traditional medical ethics collapsed, and a new type of medical ethics, contemporary bioethics, emerged. This developed into principle-based medical ethics in the 1970s and the early 80s. A good example of this was Beauchamp and Childress's Principles of Biomedical Ethics (4). They chose four principles, namely, nonmaleficence, beneficence, autonomy, and justice, and sought to resolve actual bioethical problems by systematically applying these principles to each case.
    Then came the period of antiprinciplism. Principle-based medical ethics began to be criticized "from outside the philosophical community (3, p.1160)." Such critics argued, for example, that principles are too abstract; that they ignore psychological factors; that they disregard a person's character, life story, cultural background, and gender. Some alternative theories, including virtue-based theories and the ethics of caring, are now coming onto the scene. Pellegrino himself proposes "clinical bioethics" in place of principle-based bioethics, but at the same time, he urges us to be alert to the possibility that future bioethics may lead to barren relativism and nihilism because of the lack of a dominant bioethical theory based on universalism.
    Pellegrino's analysis is very interesting. If he is right, we are now standing at the threshold of a second-stage bioethics. And this second-stage bioethics, should I believe be developed from international and cross-cultural perspectives.

2. Bioethics for sound public policy

    Here I would like to go back to my initial question: "What is bioethics?" and I want to further ask, "what should bioethics become in the 21st century?" I believe future bioethics should leave behind today's principle-based, male-centred, medicine-oriented, American bioethics, and become an international, cross-cultural, more feminist, more environmentally oriented study of life, science and society (5, 6). The main questions we are faced with today are how to view life in this age of science and technology, and how rightly to manage a society which has been vexed by [293/294] contemporary medical, technological, and environmental problems. Our goal is, hence, not to stick to bioethics as principle-based applied ethics, but to widen our vision to include medical, technological, psychological, and global environmental problems in the topics we are to research, and try to get at the essentials of the interrelated problems of our age. Of course, "medical bioethics" (7) is going to remain an essential part of this effort.
    Thus, second-stage international bioethics will have two aspects. One will be bioethics for making sound public policy, the other bioethics as an integrated study of life, science and society.
    Let us first take a look at bioethics for making sound public policy. This includes the process of making health care policy for domestic and worldwide health problems such as AIDS, transplantation, and care for the aged. It also includes everyday clinical ethics in the hospital, and our activities in creating mutual support networks for the weak and the disabled (Cf. 8).
    Four important points should be noted here.
    First, this process must be cross-cultural and international. We have to respect every ethnic group or community's value system and worldview when deciding health policies which may profoundly affect their societies. However, a set of difficult problems immediately arises. For example, what should we do were the introduction of "informed consent" into a community to destroy the traditional value system and customs there? We are going to be confronted with the difficult problem of deciding what ideas in bioethics we should view as universal and what values and customs in a given tradition we should leave as they are (9).
    Second, we must pay special attention to the variations in values and customs among different classes, genders, races, and religions. In this sense, I think recent feminist approaches to bioethics are noteworthy (10).
    Third, we cannot ignore psychological factors influencing both clients and physicians when making medical decisions in the clinical setting. First-stage bioethics has concentrated on the logical analysis of moral rules, and made light of the psychological aspects of human nature. This is wrong. People's conduct is often deeply influenced by personal psychological relationships, not by moral rules and sermons.
    Fourth, we will have to create international networks which effectively guide those aspects of science and technology which affect our life and health. For example, research on the early human embryo is forbidden in Germany, but possible in other countries. Surrogate motherhood is possible in the U.S. but not in Japan. This might be a problem. We are again faced with the problem of universality versus local diversity.

3. Bioethics as an integrated study

    Now let us turn to bioethics as an integrated study of life, science, and society. Since I published the book Invitation to the Study of Life in 1988 (5), what I have argued is that while contemporary bioethics is a paradigm with a very narrow outlook, we really need to create a truly integrated study of life which views our life from every angle to grasp the fundamental relationships among life, science, and society.
    In order to attain this goal, we must first create research networks made up of researchers from a variety of disciplines such as bioethics, cultural anthropology, religion studies, sociology, ecology, feminism, etc., and grapple with contemporary problems concerning life from as many different angles as possible. For example, today's problems concerning in vitro fertilization must be examined not only from ethical, but also from religious, sociological, anthropological, feminist, and even ecological perspectives. The essence of today's complicated problems concerning life cannot possibly be reached through a single discipline, such as medical ethics.
    Second, reexamination of fundamental notions and ideas will be needed. For example, in the discussion of bioethics the concept of "life" or "death" is rarely examined, even when the debate itself concerns human death. It seems to me that the questions, "what is life?,""what is the meaning of our life?," and "what happens after I die?" have been a kind of taboo in bioethics. But I think a study of life without these questions is meaningless, hence I must say most discussions of today's medical ethics concerning human life and death are basically hollow. Since 1989, I have investigated images of life among contemporary Japanese (6). In this seminar we have seen brought rich data on images and concepts of life from around the world. The future study of life must be constructed on the basis of this kind of research. [294/295]
    Third, we should research these bioethical issues together with other related social problems, for example, care for the terminally-ill and the aged. I don't know why, but we cannot find these topics in collections of papers on bioethics or textbooks. This is a mystery. We must also research medical problems and environmental problems together in the same context because both sets of problems have been raised by the intrusion of modern science and technology into the realm of life inside and outside of the human body. I think Professor Potter was right when he said that a real bioethics must include both "medical bioethics" and "ecological bioethics" (7). We need to be attentive to ecological studies and environmental ethics as well as medical ethics.
    I've stressed the importance of integrated research on life. However, gathering related disciplines together and simply combining the information acquired would lead us to total chaos. In order to avoid this, we must have a method of integrating a variety of ideas, information, and ways of thinking. I don't think we have had such a method in the past. Hence, we must create a method of integration in the process of making a second-stage bioethics with the help of researchers from different disciplines around the world. Then, I hope, the discipline of bioethics will be restructured into an integrated study of life, and will be able to help create sound public policy based on international perspectives in the 21st century.

References

1. Potter,V.R.,(1970) Bioethics: The Science of Survival. Persp. Biol. Med. 14(1): 127-153.
2. Potter,V.R.,Bioethics, Bridge to the Future (Englewood Cliffs:Prentice-Hall, 1971).
3. Pellegrino,E.D., (1993) The Metamorphosis of Medical Ethics: A 30-Year Retrospective. JAMA 259:1158-1163.
4. Beauchamp,T.L. & Childress, J.F., Principles of Biomedical Ethics. (New York: Oxford Press, 1979).
5. Morioka,M., Seimei Gaku eno Shotai (An Invitation to the Study of Life) (Tokyo: Keiso Shobo, 1988).
6. Morioka,M., (1991) The Concept of Inochi: A Philosophical Perspective on the Study of Life. Japan Review 2: 83-115. Also reprinted in Global Bioethics (in Press).
7. Potter, V.R.,Global Bioethics: Building on the Leopold Legacy (East Lansing:Michigan State University Press, 1988).
8. Morioka, M. (ed.), Akabayashi, A., Saito, Y., Sato M., & Tsuchiya,T., Sasaeai no Ningengaku (Philosophy of Interdependence). (Tokyo: Hozokan, 1993).
9. Akabayashi, A. & Morioka, M., (1991) Ethical Issues raised by Medical Use of Brain-Dead Bodies in the 1990s," Bio Law vol.II-48: S531-538.
10. Holmes, H.B. & Purdy, L.M., Feminist Perspectives in Medical Ethics (Bloomington and Indianapolis:Indiana University Press, 1992).