Goals of Bioethics
By: Darryl R.J. Macer, Ph.D.
Bioethics could be defined as the study of ethical issues and decision making associated with the use of living organisms. I have defined bioethics as love of life (Macer, 1998), and inculcating a balanced love of life and love of learning is one of the goals of using moral games to teach bioethics. Bioethics includes both medical ethics and environmental ethics, and this book includes examples from both. Bioethics is learning how to balance different benefits, risks and duties. Concepts of bioethics can be seen in literature, art, music, culture, philosophy, and religion, throughout history. Every culture has developed bioethics, and in this book there is a range of teaching resources that can be used that are written from a cross-cultural perspective by a variety of authors.
In order to have a sustainable future, we need to promote bioethical maturity. We could call the bioethical maturity of a society the ability to balance the benefits and risks of applications of biological or medical technology. It is also reflected in the extent to which public views are incorporated into policy-making while respecting the duties of society to ensure individual’s informed choice. Awareness of concerns and risks should be maintained, and debated, for it may lessen the possibility of misuse of these technologies. Other important ideals of bioethics such as autonomy and justice need to be protected and included when balancing benefits and risks.
Bioethics is not about thinking that we can always find one correct solution to ethical problems. The moral games included here teach that a range of solutions is possible, although in the process it will show that there are some inappropriate solutions to moral dilemmas, such as to always believe you are right and others are always wrong. Ethical principles and issues need to be balanced. Many people already attempt to do so unconsciously. The balance varies more between two persons within any one culture than between any two. A mature society is one that has developed some of the social and behavioural tools to balance these bioethical principles, and apply them to new situations raised by technology.
Research has shown that there are a number of goals of bioethics education including:
a) Knowledge
- Development of trans-disciplinary content knowledge
- Understanding the advanced biological concepts
- Being able to integrate the use of scientific knowledge, facts and ethical principles and argumentation in discussing cases involving moral dilemmas;
- Understanding the breadth of questions that are posed by advanced science and technology
- Understanding cultural diversity and values
b) Skills (capacity building in skill acquiring should be multi-faceted or many sided, and the goals include)
- Balancing benefits and risks of Science and Technology
- Being able to undertake a risk/benefit analysis
- Developing critical thinking and decision making skills and reflective processes
- Developing creative thinking skills
- Developing foresight ability to evade possible risks of science and technology
- Developing skills for developing “informed choice”
- Developing required skills to detect bias in scientific method, interpretation and presentation of research results
c) Personal moral development
- Understanding better the diversity of views of different persons
- Increasing respect for all forms of life
- Eliciting a sense of moral obligation and values including honesty and responsibility
- Being able to take different viewpoints to issues including both biocentric and ecocentric worldviews rather than only anthropocentric perspectives.
- Increasing respect for different people and cultures, and their values
- Developing scientific attitudes, reflective processes, and an ability for holistic appraisal, while not ignoring the value for reductionist analysis.
- Developing knowledge about bias in the interpretation and presentation of research results, benefits and risks of technology and bioethical issues, and how to detect bias
- Exploring personal morals/values (values clarification) Conducting values analysis and value based utilization of our scarce natural resources
Many of these goals apply to ethics education and development of critical thinking in general. The games included in this book will help achieve some of the above goals, and the list is not-exclusive. I welcome feedback from users of the book to assess how these goals were met for each user.
Providing different types of teaching methods and models for different target groups such as lectures, seminars, workshops, drama, narrative, role plays, case presentation and analysis, essay composition, small group discussion, on-line discussion forums, newsletters, public open discussion, media commentary and critiques, all have important roles uses in accomplishing the above goals. Researchers and educators need to work together to research into appropriate teaching methods for different target groups, to assess the effectiveness and impact (both positive and negative) of ethics education. Generating sustainable ethics teaching and promotion programmes is a method in itself, required by education planners.
We do not need to achieve all goals to consider a class to be successful, and different teachers and schools put a different amount of emphasis on each goal. It is important at all these levels to evaluate whether our teaching is having any impact or not. Because investigating bioethical issues is complex, the educators need to consider what knowledge needs to be developed in order for students to make sense of moral issues, to be able to critically evaluate them and to possibly take action based on this knowledge (Conner, 2004). Persons at all levels do mix ideas in different ways.
The type of class that we are teaching will also affect the outcomes. For example if we are training medical students to become medical professionals the goal may be to create medical professionals with competence and compassion. Medical education aims to teach not only high skills in medical practice, but also to foster compassionate and sympathetic attitudes in future medical professionals. But there is a difference between these two goals (Nagaoka, 2008). Competence may be measured more or less objectively. For instance, a doctor’s ability to diagnose disease, to prescribe proper medication for that problem and so on can be measured by the outcomes. On the other hand, whether an act is seen as compassionate or not depends on the context. Compassion or kindness is an evaluative judgment, made by the other partner in the interaction, and therefore influenced by the nature of the interaction as well as the mental states of the other partner. One could teach compassionate attitudes by character building, or through cases. We can see that goals of knowledge, skills and personal moral development are inter-related, and different choices of questions, cases, examples and different games can be used in ethics education.
Evaluation options
Crucial to the development of bioethics education is a method of evaluation that allows for improvement of materials to better meet the needs of students in different countries. There are different methods of evaluation including development of specific evaluation forms for student and teacher responses to questions, and a range of ways to analyze the content of student discourse, essays and reports.
One important goal of teaching about bioethical issues is to get students to critically evaluate the issues and most of these moral games can be used to allow opportunities for students to go beyond agreement to consider carefully the issues, if sufficient time is given. One of the difficult questions in bioethics education is how to evaluate the usefulness of the materials provided, beyond mere student or teacher satisfaction. One concept to use is whether students demonstrate “bioethical maturity” in some way. “Bioethical maturity assumes a certain level of recognition of weighing up the different arguments that can be used to discuss an issue, the different ethical frameworks that can be used, and comparisons and balancing of the benefits and risks of the dilemmas”. There are several indicators of “Personal moral development” that can be used (Maekawa and Macer, 2005). These include whether students can understand and express both sides of view. Mature persons should be able to express more than one side of an argument or a question being mentioned, even though they may have their own opinion. The personal point of view (e.g., an “I think” statement) can be developed into reflective discourse so that it is mixed with other people’s points of views being stated, regardless of whether they concur.
Integration of scientific facts is also important in moral reasoning. A concrete and/or detailed scientific fact is more intellectually demanding than a broad statement of common sense. We could expect persons to be able to cite scientific evidence, as well as quantitative facts and statistics. We would expect students can also provide reliable sources for their information and be able to detect and acknowledge the bias in information they use. A commonly used source of material in many schools is newspaper articles. Teachers would sometimes take two opposing articles and have the students discuss.
Environment and biocentric ideas can be promoted. A statement made mentioning concerns for the environment or ecological concerns, or for example the care or treatment of animals may be raised as a concern. Generally people tend to reason and write from an anthropocentric viewpoint, but as they develop bioethical views they will be able to view issues from different perspectives.
A utilitarian view is judging an act as being morally acceptable based on the opinion that the benefits of the action to one group or individual will outweigh the risks or harm produced affecting a larger population. It can balance interests of society versus those of individuals, and it is not limited to human beings.
A keyword denoting an ethical principle or connotation of one regardless of whether being directly stated or not would indicate understanding of how to apply theory into moral decision making. This could include the term “rights”, or specific bioethics principles and keywords such as benefit and risk assessment, informed consent, enhancement, public welfare, autonomy, justice, equality of life, animal welfare, etc.
An idea is a distinct message unit, statement or concept. Ideas can come from many sources, others or themselves. Analysis of the number of ideas, key words and concepts can be used to measure the diversity of thinking. Changes in the frequency of keywords and concepts used by persons over time need to be measured against several variables, including internal factors connected to the class such as the wording of the statements discussed, the nature of the materials used, the comments given by the teacher, and the comments made during the groups and class. Examination of the progress of moral development can be aided by detailed discourse analysis of oral discussion or written reports.
There is a consensus among many Western scholars that the balancing of four main bioethical principles, which are autonomy, justice, beneficence and non-maleficence, is central to making better decisions (Beauchamp and Childress, 1994). Autonomy means “self-rule”, and includes ideas such as respect for privacy and respect for personal choice. Justice is to respect the autonomy of others, and to treat persons equally. Beneficence is to try to do good, and non-maleficence is to avoid harm. When solving or trying to reach a consensus about bioethical problems, these four main principles can be a good guide in balancing which ideas should be mostly weighed. One measure of bioethics education could then be whether students are able to use these principles in decision-making. Currently the use of principles as expressed in the UNESCO Universal Declaration on Bioethics and Human Rights (2005) is being used to develop a core curriculum to teach bioethics based on inclusion of the consensus view of bioethics as included in that Declaration.
No matter how we learn, reaching a good moral decision is often difficult. The best decision may not be the same if made in different times and situations. One approach that is common in education is to teach learners to break down ethical dilemmas into manageable problems, for example, the separation of action, consequence and motives connected to a moral decision. This separation can be used to teach different bioethical theories. No matter what bioethical theory one uses, moral games can be used to allow students to develop their application of theory into practice, comparing different ways of thinking in the exercises.
Kohlberg’s (1969) theory of moral development holds that moral reasoning, which he thought to be the basis for ethical behavior, has developmental stages. He claimed that these are universal, however there is now a consensus that they are not because of different cultural norms and customs. Kohlberg’s six stages were grouped into three levels: pre-conventional, conventional, and post-conventional. He claimed it is not possible to regress backwards in stages nor to ‘jump’ stages; each stage provides new perspective and is considered “more comprehensive, differentiated, and integrated than its predecessors.” One criticism of Kohlberg’s theory is that it emphasizes justice to the exclusion of other values. As a consequence of this, it may not adequately address the arguments of people who value other moral aspects of actions more highly. His theory was the result of empirical research using only male participants (aged 10, 13, and 16 in Chicago in the 1960s). Carol Gilligan argued that Kohlberg’s theory therefore did not adequately describe the concerns of women. She developed an alternative theory of moral reasoning that is based on the value of care. Among studies of ethics there is a tendency in some studies to find females have higher regard for ethics theories (Ford and Richardson, 1994). Other psychologists have challenged the assumption that moral action is primarily reached by formal reasoning (Crain, 1985). People often make moral judgments without weighing concerns such as fairness, law, human rights and abstract ethical values. If this is true, the arguments that Kohlberg and other rationalist psychologists have analyzed are often no more than post hoc rationalizations of intuitive decisions. Macer (1998) argued that bioethics is love of life, but that the decision making process that combines both emotion and rationality is based on moral principles.
One of the common goals of school education is that students can produce a good argument (Toulmin et al. 1984). An argument consists of integrating the following:
A conclusion or claim – assertions or conclusions about an event or theory Facts – data that is used as evidence to support the assertion Warrants – the statement that explains the link between the data and the claims
Backing – underlying assumptions which are often not made explicit Rebuttals – statements that contradict the data, warrant or backing of an argument
To create an argument a person needs to state their claim, then support it with facts (data) that are arranged logically. For each fact, they should give the evidence for the fact (warrant), and for each warrant, state the quality of its validity (backing). Then for each warrant and its backing, people should think of an opposing point of view (rebuttal). They then consider further possible warrants and backing for the rebuttals. At the end then they review, having argued the rebuttals, examining whether they need to qualify their original claim.
The mental mapping project, or human behaviourome project1 identified different classes of ideas, and attempted to explain the linkages between ideas in the construction of moral choices by different persons (Macer, 2002a). The Ideas, Evidence and Argument in Science Education (IDEAS) project of Osborne et al. in the UK2, has as its goal the assistance of teachers in developing their skills to teach about ideas, evidence and argument in science. The materials they wish to develop include worksheets and video clips to enable teachers to teach children to develop and evidence scientific argument. The IDEAS project suggests that the following criteria can be used in evaluating students’ arguments: Is there a claim? Does the argument have data to support the claim? Does the argument link the data to the claim? Are there further justifications to support the case? Is there any anticipation of a counter argument and how it could be opposed? Ratcliffe and Grace (2003) gave examples of knowledge, understanding and skills that students studying ethical issues in science acquire and that can be used to design assessment questions.
They listed several different levels of knowledge:
Conceptual knowledge: Learners can demonstrate understanding of: underpinning science concepts and the nature of scientific endeavour; probability and risk; the scope of the issue – personal, local, national, global, political and societal context; and environmental sustainability.
Procedural knowledge: Learners can engage successfully in: processes of opinion forming/decision making using a partial and possibly biased information base; cost-benefit analysis; evidence evaluation including media reporting; and ethical reasoning.
Attitudes and beliefs: Learners can: clarify personal and societal values and ideas of responsibility; and recognize how values and beliefs are brought to bear, alongside other factors, in considering socio-scientific issues.
As with the questions that Kohlberg used for the linkage of student arguments to moral stages of development, and with the goals of bioethics education in the Bioethics Education Action Plan discussed above, there are a number of ways that could be developed into evaluation tools for assessment of bioethics education.
Evaluation must be done ethically. It is very important to examine the direction of bioethics education and how this might enable people to question scientific endeavours and use of technology, and what impact their moral decisions will have on them as individuals and upon their societies. The skills that are required to do this involve the ability to identify existing ideas and beliefs, listen to others, be aware of multiple perspectives, find out relevant information and communicate the findings to others. These skills cannot be ‘given’ to students through a didactic approach to teaching, where the teacher imparts the knowledge in a one way stream. Instead, students need to experience situations that will allow them to develop these skills through interacting with the teacher and with each other. The methods outlined in this book allow sharing of cases and experience in a range of cultures as well.
When bioethics is applied to professional behaviour, such as in medical ethics, methods to evaluate have included the way students conduct a patient examination. In Buffalo University Bioethics program3 (Singer et al., 1993), they applied the technology of the objective structured clinical examination (OSCE) (Cohen et al., 1991) using standardized patients to the evaluation of bioethics. Methods to evaluate the ethical abilities of students, trainees, and practicing professions that have been used include multiple-choice and true/false questions (Howe and Jones, 1984), case write-ups (Siegler et al, 1982; Doyal et al., 1987; Hebert et al., 1990), audio-taped interviews with standardized patients (Miles et al., 1990), and instruments based on Kohlberg’s cognitive moral development theory (Self et al., 1989).
The reliability and validity of these methods have seldom been examined. Auvinen et al. (2004) applied the use of Kohlberg’s stages of moral development to assess ethics teaching in nursing students in Finland, and they found significantly higher ethical maturity when nurses actually had to deal with ethical dilemmas in their practical training in clinics. Pre and post questionnaire surveys about specific topics relating to the content of the lecture or teaching intervention can be useful to measure change. A mix of qualitative and quantitative methodology can help in the monitoring of bioethical maturity.
