Bioethics needs to rethink its agenda

BMJ 2004; 328 doi: (Published 15 January 2004) Cite this as: BMJ 2004;328:175
  1. Leigh Turner, assistant professor (leigh.turner{at}
  1. biomedical ethics unit, McGill University, Montreal

    What issues belong at the top of the agenda in bioethics? What important topics are commonly ignored? Does bioethics matter? As someone who writes about bioethics one of the lessons I have learnt is that the articles that typically attract the attention of editors and readers are the manuscripts addressing “sexy” topics. Ambitious researchers in bioethics know that if they want to obtain research funds and draw attention to their work they should focus on such topics as embryonic stem cell research, germ line gene therapy, and therapeutic and reproductive cloning. These topics practically sell themselves.

    Not long ago researchers examining ethical issues in medicine and health care had a different focus. In the 1980s and 1990s the study of ethical issues in palliative care generated hundreds of articles, as doctors, philosophers, and lawyers addressed such topics as the withdrawal of fluids and nutrition, advance directives, surrogate decision making, defining death, medical futility, and physician assisted suicide. Scholars continue to address these subjects, but now the topics lack the air of novelty they once had. Researchers looking for the next big thing are shifting toward the study of “neuroethics” and genetic “enhancement technologies” supposedly on the verge of propelling us into a “post-human future.” In contrast bioethicists rarely address urban poverty and inner city violence, even though poverty and violence raise important issues related to health. Although doctors, epidemiologists, and public health specialists treat firearm related violence, poverty, joblessness, and the breakdown of communities as important topics, such issues are largely off the radar screen of bioethicists. If clinicians recommend withdrawing treatment from a gunshot victim, and the family wants medical care to continue, then perhaps bioethicists become interested. However, bioethicists rarely engage the legal, economic, and social conditions underlying violence in poor communities.

    Bioethics risks becoming a source of entertainment

    Bioethicists commonly address ethical issues arising in wealthy developed countries. Discussions about priority setting and resource allocation typically occur within the context of a particular developed state. While analyses of globalisation and international inequity in access to basic goods such as food, clean water, and shelter are beginning to appear in bioethics scholarship, bioethicists have traditionally tended not to think at the transnational level of analysis or addressed issues relating to the developing world.

    Perhaps one reason bioethicists are reluctant to address global ethical issues related to health, illness, and poverty is that bioethicists are deeply embedded in a global economic system that depends on the continued existence of impoverished societies. While there are many ways for corporations to generate profits, one effective means is to shift factories and jobs to places where employers are relatively free of government regulations and where labourers work for a pittance. In North America factories and jobs in industry migrated from north to south. Now factories, workshops, and labour intensive jobs in Japan, the United States, and Western Europe move to China and India. Many jobs are shifting from developed nations to poorer countries with low hourly wages, few work-place benefits, minimal health and safety standards, and patchy environmental regulations. Many of the goods enjoyed by citizens of wealthy nations are available for consumption because of the continued existence of massive economic disparities between wealthy and poor nations.

    Most of us would prefer not to confront the incredible disparity between living as a professor or clinician in a smart apartment in Manhattan and eking out a living in one of China's rapidly industrialising districts or a shantytown in South Africa. Scholars such as Solomon Benatar and Paul Farmer have drawn attention to such matters, but many bioethicists continue to see these questions as macrosocial economic issues falling outside the proper scope of bioethics. And yet questions of health and illness—and ethical issues related to health systems, social institutions, and economic policies—are connected to global markets and financial institutions.

    Many of the questions that bioethicists address only make sense within the context of wealthy developed nations. Some of the favourite topics of bioethicists seem trivial compared with the important health issues facing people in the world's poor countries and in impoverished regions in rich countries. Greater consideration of global ethical issues related to health, illness, and suffering might generate a richer, more meaningful research agenda for bioethics. Otherwise bioethics risks becoming a source of entertainment and spectacle in wealthy societies whose inhabitants overlook the poverty and suffering found throughout most of the world.

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