Harvard’s Daniels outlines an agenda for 21st century bioethics

April 24 , 2006
Harvard’s Daniels outlines an agenda for 21st
century bioethics

BY Stacia Brown

Bioethics is going global—at least, if Norman Daniels has his way. Speaking to clinicians, ethicists, chaplains and students at the Health Care Ethics Consortium of Georgia’s (HCECG) annual conference, “Decision Making in an Age of Mistrust: Rethinking Autonomy and Justice,” Daniels introduced a new agenda for bioethics in his keynote lecture, “Population Health and Equity Here and Abroad: A Broader Bioethics Agenda.”

The Mary B. Saltonstall Professor of Population Ethics and Professor of Ethics and Population Health at the Harvard School of Public Health, Daniels argued that if bioethics wants to remain relevant, it has to step outside the clinic and into the work of justice.

Though bioethics is a young field—it emerged in the 1970s—it faces irrelevance if practitioners fail to press beyond the conventional parameters of their discipline, Daniels said. Traditionally, bioethics has concentrated on the patient/provider relationship (the “informed consent” arena) and the challenges of new technologies. While such foci remain useful, they need expansion, he said. Bioethics must confront the dilemmas or “tradeoffs” that are reshaping the landscapes of health on global and not just clinical levels.

Daniels identified three such dilemmas. First is the problem of equity in health among demographic subgroups, or the tradeoff between health care for the “worse off” versus the “better off.” These trade-offs require more than a distributive justice approach, Daniels argued. Many in the “worse off” category are there for reasons beyond the health care system. Solving their health care problems will not resolve the conditions that helped make those people sick in the first place. Systematic inequalities, especially racial and economic injustices, also demand attention.

“Universal health coverage will not solve all of a social system’s inequities,” Daniels said. If bioethics wants to improve the health of the poorest, he said it must expand beyond the clinic and advocate for social change.
A second global dilemma involves generational equity in health. “Aging societies are going to change our health systems and affect equity issues,” Daniels said.

The graying United States is one example, China another. By 2050, the number of persons over 65 in China will rise to 332 million. Aging societies mean competition over scarce resources, changes in care for the elderly, and worries about access to benefits.

Bioethics cannot afford to ignore this pending crisis, Daniels argued. It must create strategies for treating patients fairly at different stages of life—keeping in mind that all of us, if we’re fortunate, will pass through all these stages at some point. “Societal aging is the public health problem of the 21st century,” Daniels said.
A third global dilemma involves the problem of equity in health across national boundaries, or the tradeoff between aiding poor countries versus enhancing the health of those within one’s own borders. Nearly everyone agrees that poor countries need the health care help of wealthier nations, Daniels said, but too many assume that humanitarian charity is sufficient.

In a world where, by mere accident of birth, a child in Angola is 73 times more likely to die before age 5 than a child in Norway, he said, charity is not enough. Bioethics should consider ways in which an international commitment on the part of wealthy nations to “do no harm” might begin to address these inequities on the level of justice, not just charity, Daniels argued. At the very least, a commitment not to harm might force wealthy nations to “stop making health worse than it would otherwise be” for poor nations, he said. And it would force the United States and Britain to stop siphoning off health care workers from less developed nations, a practice that robs poorer countries of essential human resources.

“Bioethics is living in a more complicated world than that of the traditional doctor-patient relationship,” Daniels concluded.

The HCECG, of which Emory and its Center for Ethics are a part, is a consortium of health care providers and organizations throughout Georgia. The 12-year-old consortium hosts an annual conference, and this year’s event was held April 18–19 at the Sheraton Buckhead Hotel.

2006 Faculty Ethics Seminar
The 13th annual Faculty Ethics Seminar, sponsored by the Center for Ethics, will examine “The Ethically Engaged University.” Guest speakers include:

• Mary Cahill (vice president for investments)
• Marie Csete (anesthesiology and cell biology)
• Arri Eisen (Program in Science and Society)
• John Ford (vice president for Campus Life)
• Leslie Harris (history and African-American studies)
• Gary Hauk (vice president and deputy to the president)
• Michael Mandl (executive vice president for finance and administration)
• Karama Neal (FACES program)
• Kirk Ziegler (microbiology and immunology)

Seminar participants will discuss ethical engagement within the University; the ethical dimensions of the University’s financial infrastructure and investments; student issues (including the honor code, graduate recruitment, disability issues and the preparation of future scientists); Emory’s role in health care for poor Atlantans; and the University’s response to ethically controversial research, especially embryonic stem cells.

Faculty are invited to enroll in the 2006 seminar, which takes place May 17–May 22. For session times and location, see www.emory.edu/ETHICS and click on “The Ethically Engaged University.” Each participant will receive a modest stipend. For more information, contact John Banja, assistant director for health sciences and clinical ethics and associate professor of clinical ethics at 404-712-4804 or at jbanja@emory.edu.

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