Original Research

The historical and philosophical basis of bioethics

Anton A. van Niekerk

Received: 12 Mar. 2025; Accepted: 11 July 2025; Published: 26 Aug. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: The author provides highlights from the three millennia history of bioethics. Bioethics can, simultaneously, be regarded as both one of the oldest and one of the most recently developed of the disciplines of the current-day university. Four key moments in the rediscovery of bioethics in the 20th century are discussed.

Objectives: The objectives of the article are fourfold: (1) To describe the historical background of the discipline of bioethics. (2) To provide a systematic analysis of the nature of philosophy. (3) To demonstrate the philosophical basis of bioethics. (4) To argue for the specific nature of philosophical bioethics as an interdisciplinary enterprise.

Method: This article, in line with most research in philosophy, is a conceptual study that, by and large, utilises the method of conceptual analysis for answering conceptual questions.

Results: An important result is the analysis of the philosophical basis of bioethics. The second part of the article also yielded an extensive analysis of philosophy and the way in which it is presupposed by and feeds into bioethics.

Conclusion: The main conclusion is reached in response to the fact that some bioethicists argue that bioethics is such a radically interdisciplinary enterprise that philosophy is no longer required for its operations. The author ventures to argue that philosophy is not only necessary for doing bioethics but indeed provides the intellectual basis for the enterprise of bioethics.

Contribution: The analyses of the nature of philosophical questions and how they must be approached are, throughout, illustrated with examples from bioethics, which clearly shows the significance of and extent to which philosophical analysis influences the practice of bioethics. Thus the ‘philosophical basis of bioethics’ is, to the author’s best understanding, demonstrated.

Keywords: history; ethics; bioethics; concepts; ideas; analysis; interpretation; conceptual; questions.

Historical overview of key events in the history of biomedical ethics

Biomedical ethics¹ is, at the same time, one of the oldest as well as one of the most recently developed disciplines at the university. It is one of the oldest in the sense that it draws on a problem that was already prevalent in the intellectual and medical reflections of the Antique Greek Enlightenment (around about 300–500 BCE). In its present guise, however, it re-occurs – and now quite systematically – in the course (particularly the second half) of the 20th century.

The first instructions and directives concerning care for the sick occur on a stone tablet that forms part of a Code issued by the Babylonian king Hammurabi (1792–1750 BCE). The best known in the history of the Greek Enlightenment, however, is the document known as the ‘Hippocratic Oath’, purportedly formulated and utilised by Hippocrates, the father of Western medicine. One of the oldest customs in the education of medical practitioners in the West is the swearing of the ‘Hippocratic Oath’ by all novice physicians, even though the content of the oath has been characterised by some changes over the centuries.

The oath contains a number of prescriptions and prohibitions that are quite recognisable to this very day, such as the prohibitions on euthanasia, abortion and sexual relations with patients. Striking is the prohibition on ‘cutting for stone’ (presumably kidney stones), which in fact meant a prohibition of administering surgery by ordinary physicians. General medical practitioners were therefore not allowed to execute surgery; the latter was the exclusive terrain of the surgeons, who embodied a different profession (This idea is, in South Africa, symbolically still adhered to by the fact that doctors who have completed their studies are awarded two degrees rather than only one, namely Bachelor of Medicine, Bachelor of Surgery [MB ChB].).

Also prescribed by the Hippocratic Oath is doctor-patient confidentiality. Much emphasis is laid on the duty not to harm a patient, and much is made of the need to maintain good relations with colleagues and to take responsibility for the proper and appropriate training of new physicians.²

The oath thus represents the original authoritative text of the Hippocratic tradition of medicine, a tradition that held sway until the advent of modernity in the first half of the 17th century; some would argue that the Hippocratic tradition was authoritative until the end of the 19th century. What is clear is that although medicine was practised during these times, the benefits that it bestowed on sick people were – particularly in comparison to what happened in the course of the 20th century – quite limited. In fact, medicine in these times was often practised with the aid of ‘treatments’ that were sometimes, in fact, lethal, for example blood-letting.³

Apart from the Hippocratic tradition as conceived in ancient times, very little progress was made in terms of significant developments of ethical sensitivity until the advent of the 20th century. What has happened since, was no less than momentous. Constraints of space do not allow for that story to be related here in full. I shall merely refer to four momentous events that were, among others, key in the rebirth and re-development of bioethics ever since. These events are (in chronological order):

• the judgement in the Schloendorff v. Society of New York Hospital court case in 1914
• the development of penicillin as treatment for syphilis and its spin-off in the Tuskegee ‘research’ trial (1934–1969)
• the ‘medical experiments’ of Dr. Joseph Mengele in Auschwitz (1942–1945)
• the success of the ‘Scribner Shunt’ in 1960 and renal care since.

These events played a decisive role in transforming bioethics from a borderline component of the health care sciences and curriculum to a central aspect of those sciences at the advent of the 21st century.

Schloendorff v. Society of New York hospital court case in 1914

The judgement in the New York Court of Appeals case known as Schoendorff v. Society of New York Hospital (105 N.E. 92, 93 [NY 1914]) is acknowledged in most of the literature as the first historical instance where informed consent as a necessary and reputable standard requirement in the practice of medicine (surgery in particular) became a legal requirement, based on sound moral reasoning that became publicly acknowledged and accepted.

In this case, where the Society of New York Hospital was charged for not soliciting consent for surgery on a patient, the judge ruled as follows:

Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained.⁴

A practice (respect for the autonomy of patients and research subjects) was thereby legally required and morally entrenched that maintains its desirability and legality to this very day.

The Tuskegee syphilis trial

It would require a few more decades before the second pivotal marker for the development of bioethics in the 20th century came to pass. This was precipitated by the infamous Tuskegee drug trial. In the course of the early 1930s, it became clear that the newly developed and seemingly ground-breaking antibiotic drug penicillin yielded excellent results when used for the treatment of syphilis in human subjects. The drug was originally tested in two experimental groups, one receiving the actual drug and the ‘control group’ receiving a placebo. The research subjects were all incarcerated African Americans who had very little choice about their treatment and were not informed that some would only receive a placebo. The trial was set up in 1932 in Tuskegee in Alabama.

It soon was clear that the drug is successful for the treatment of syphilis, in which case the indicated ethical course of action was to immediately halt administering the placebo and to revert to treating all participants in the trial with the actual drug.

This, however, did not happen. The trial researchers were, for reasons only known to themselves, interested in establishing the ‘natural history’ of the disease in the control group that were treated with the placebo. A possible justificatory hypothesis for this unethical action was that the disease might also disappear in infected patients not receiving penicillin or receiving nothing at all. All of this occurred in a situation where there was a perfectly effective drug available for the plight of this lethal disease. To add insult to injury, the remaining ‘trial participants’ were never informed about events, and no consent was solicited from them.

The observation, by the researchers, of the ‘natural history’ of the infected patients in the ‘trial’ continued for the next three decades without any favourable results. Shortly after the re-election of Richard Nixon as President of the United States (US) in 1972, the whistle was blown on the nature and iniquities associated with the trial. The trial subjects’ treatment was immediately rectified. There was uproar in the entire country about the inhumane way in which this extremely vulnerable ‘trial participants’ were treated. It was revealed that the funding for the continuation of the trial over the past four decades was indeed provided by the US Government. The result was that Pres. Nixon was compelled to inform the nation on national television of these events and to offer a formal apology to both the victims and the country.

To this day, Tuskegee remains the worst example of unethical behaviour in the practice and research of medicine in the USA.

What became clearer than ever before was that it is morally compulsory to obtain informed consent from research subjects – consent based on full-fledged information about the relevant research trial. This consent, in turn, ought to be based on demonstrable respect for the autonomy of research subjects, also, and in particular, when they are part of vulnerable populations. This respect for the autonomy of patients and trial participants ought, in turn, to be based on sound moral dictates, such as became apparent in the work of moral philosophers such as Immanuel Kant (18th century) and John Stuart Mill (19th century). Kant formulates this principle in one of the versions of his renowned ‘categorical imperative’:

Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end. (Kant 1964:96)

Apart from what is discussed above, Tuskegee, as a pivotal example of unethical behaviour in the field of medicine and medical research, demonstrated the shifts that occurred in identifying and prioritising key principles of medical ethics. It is widely acknowledged that the four ‘principles of biomedical ethics’ are beneficence (do good to patients); non-maleficence (If you cannot do good, at least do no harm; primum non nocere); respect for autonomy (whereby is included the need for informed consent in treating adults and some children); and justice (also known as ‘distributive’ justice), a normative concept intended to promote fair and equitable treatment of individuals within populations.⁵

What is notable is that the first two of these four widely acclaimed and acknowledged principles were central and authoritative in the Hippocratic Oath and Tradition, but that the last two were totally absent in that tradition. The situation reverses itself in the 20th century. Now respect for autonomy and justice become the pivotal and most widely acclaimed principles although adherence to the other two remains undiminished, yet considerably more complicated to apply in the more complex contexts of modern and current-day medicine.

The Nazi ‘medical experiments’

The third of the momentous events that were key in the rebirth and development of bioethics in the 20th century were the so-called ‘medical experiments’ conducted in the concentration camps by the Nazis during the Second World War. The worst of these atrocities were perpetrated in the most notorious of these camps, Auschwitz, situated near Krakow in current-day South Poland. In Auschwitz alone, 1.1 million Jews and other ‘undesirables’, namely gypsies and, in particular, disabled people, were exterminated in the period 1942–1945.

Here, many victims of the Nazis, particularly the disabled, were submitted to some of the most atrocious and cruellest ‘experiments’ conceivable (‘experiments’ being a cynical euphemism for naked cruelty, always conducted without the ‘patient’s’ consent). These included observations of how long people can survive in extreme temperatures, what the reaction was if they were only allowed to drink sea water, whether the colour of people’s eyes could be changed and many more.⁶

The most notorious of these ‘medical researchers’ was SS-Hauptsturmführer Josef Mengele, M.D., Ph.D.

In Auschwitz, he was researching the issues of twins and the physiology and pathology of dwarfism in close cooperation with the Kaiser Wilhelm Institute of Anthropology, Genetics, and Eugenics in Berlin-Dahlem. He was also interested in people with different coloured irises (heterochromia iridii) and in the aetiology and treatment of the gangrenous disease of the face known as noma faciei (cancrum oris, gangrenous stomatitis), a little understood disease endemic to the Roma and Sinti prisoners in Auschwitz.⁷

In the first phase of the experiments, pairs of twins and persons with inherited anomalies were put at the disposal of Dr. Mengele and subjected to all imaginable specialist medical examinations. They were also photographed, plaster casts were made of their jaws and teeth and they were toe- and fingerprinted. As soon as these examinations were finished, they were killed with lethal injections of phenol to the heart so that the next phase of the experimentation could begin.⁸

Auschwitz was liberated by Russian troops on 27 January 1945. The world was stunned when it gradually became clear what Mengele and others committed in the death camps. Apart from all the other atrocities perpetrated by the Nazi armies and, particularly the Schutzstaffel (SS), people henceforth had to deal with the knowledge that medical prowess, which developed with such persuasive strides in the course of the 20th century, could be put to such violent and cruel ‘use’. People for the first time now fully realised that health care practitioners and researchers are not necessarily moral angels; they could behave – and in fact have behaved – like almost the worst conceivable moral monsters. The development of bioethics was accordingly accelerated by the realisation that the practice of medicine is not always benign. It has to be watched and strenuously regulated in order to avoid a repeat of the Holocaust and the kind of medical treatment precipitated by that almost inconceivable ‘rupture in the tradition’.

The Scribner Shunt

The fourth of the momentous events that were key in the rebirth and development of bioethics in the 20th century was not in itself an instance of moral reprehensibility, but was nevertheless quite controversial in terms of the questions and reflections that it generated. I refer to what has generally become known as the ‘Scribner Shunt’, namely the first instance of successful end-stage renal dialysis, performed for the first time on 09 March 1960 by Dr Belding Scribner on his patient Clyde Shields at the University of Washington.

Dr Willem Kolff invented the dialysis technique in the 1940s, but it could only be applied for temporary relief of critical kidney failure. Patients with irreversible and complete failure inevitably died.

After a previous patient, Niel Ward, had died because his successful dialysis could not be repeated, Scribner hit on the idea of a permanent arteriovenous access – a tube that could be fixed into a vein and an artery so that the patient could be hooked up to and taken off the machine as often as necessary. What happened was that glass dialysis shunts were modified by making them from Teflon. This worked by keeping the circulatory access open after dialysis treatment. The kidney dialysis machine could be attached to the tube whenever necessary without damaging the veins or arteries.

Within a week. Scribner and his colleagues fabricated such a device from Teflon tubing. The shunt worked and Shields lived, with dialysis twice a week, for another 12 years.

This was an unprecedented and revolutionary breakthrough in the history of treatment of kidney failure. A disease – end-stage renal failure – that had up to that point persistently been lethal, has all of a sudden become treatable. Although patients had to spend a number of hours every week in the dialysis clinic, they were otherwise able to continue their lives in good cheer.

However, the possibility of benefiting from this revolutionary treatment also precipitated the need to face the question: Who should have access to these machines – machines that were particularly short supply and remain so until this day. The title of a book (Thielicke 1976) by the German ethicist Helmuth Thielicke, The doctor as judge of who shall live and who shall die, articulated a new responsibility on health care professionals that, earlier, was hardly regarded as a realistic moral challenge. This was indeed a stark reminder of the momentous power that has gradually entered the ranks of medical professionals. Doctors increasingly appeared to be people who possess god-like powers. Small wonder that, when an ethics committee was created in the Medical School of the University of Seattle to facilitate possibly fatal decisions by doctors generally and nephrologists in particular, the committee soon acquired the nick-name the ‘God-committee’. Small wonder also that faces were increasingly turned towards bioethics and bioethicists to assist in these highly problematic choices. The discipline was, albeit from a very different angle than in the first three cases, now launched as an integral part of the work and training of health care professionals.

The result was that a myriad of additional issues have been and are being studied and researched across the globe since the Second World War. Abortion (or reflection on the status of prenatal life), which only became controversial since the middle of the 19th century, is, since the 1970s, a key topic in the US that has generated starkly divisive debate in that country that allocates most resources to bioethics.

Euthanasia, which is currently preferably referred to as ‘physician assisted suicide’ or ‘assisted death’, has always been controversial since ancient times, but has grown in severe controversy since the Roe v. Wade dispute in the US in the 1970s. The latest development in this seemingly ongoing controversy is the decision in June 2025 by the British House of Commons to henceforth make legislative provision for such a procedure.

Genetics and the unforeseen medical interventions that flow from it as a science have generated a range of ethical issues since the 1990s. This includes the recent debate about the moral permissibility of human enhancement(s).

In conclusion of this section, it also has to be pointed out that bioethics has also, in recent years, shown its need and relevance in the sphere of public medicine. More recently, issues to do with global justice have also become the focus of much work. In a country such as South Africa, epidemiology – particularly ethical issues related to people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) – has grown in prominence.

It could therefore be argued persuasively that bioethics today ought to be operational at the micro level of individualist medicine, the meso level of institutional medicine and the macro level of global medicine.

Philosophy, morality and (biomedical) ethics

We have now, as the heading of this article indicates, fairly extensively dealt with key moments in the historical development of bioethics, particularly as it emerged in the course of the 20th century, namely in the aftermath of its predecessor operations in the tradition of Hippocratic medicine, which lasted since the Greek Enlightenment until roughly the end of the 19th century.

We now move onto exploring, no longer the history of biomedical ethics, but the intellectual basis of this discipline. In this respect, my cards are from the outset visibly on the table. I, like the bioethicists that I by and large admire, are people who acknowledge and promote the philosophical basis of biomedical ethics. To put differently, I wish in this article to show how bioethics, as a sub-discipline of ethics, is indeed also a sub-discipline of philosophy. An understanding of this train of thought will hopefully assist us in construing and explaining the ‘philosophical basis of biomedical ethics’.

To fully understand what this entails, I will embark upon an exercise, namely conceptual analysis, which is the intellectual activity that philosophers are best known for and which represents a key component of what philosophically inclined bioethicists do.

What is philosophy?

This is not an introduction to philosophy, but no more than a broad outline of what is conceptually meant when one talks about the ‘philosophical basis’ of bioethics. For many (of which I am part), it is almost self-evident that bioethics, as a sub-discipline of ethics, is, as such, also a sub-discipline of philosophy if, for no other reason, ethics itself also turns out to be a sub-discipline of philosophy. Let us therefore try to attain a little more conceptual clarity about these notions.

My first claim about the nature of philosophy is to assert that philosophy refers to a conversation that was initiated during the Greek Enlightenment (more or less around 500–300 BCE) and that continues, in a variety of formations, to this very day. The conversation, in the format that has become a key tradition in Western thinking, was initiated by a thinker named Socrates, who became famous for engaging interlocutors of their own free will into dialectical interchanges or dialogues, the outcomes of which were, by and large, (although not universally) experienced as both unsettling, yet also enlightening – exceptionally so since it introduced and developed a style or manner of (public) reflection and interchange that was, up to that stage, unknown in the ancient predecessor(s) of the Greek Enlightenment. What was most notable was the break that these Socratic dialogues precipitated with the tenets of mythical thinking that was generally accepted at the time. Socratic reflection propagated independent reflection, theoretical understanding and rational justification and criticism instead of the uncritical acceptance of certain seemingly divine manifestations, as well as of the interwovenness of human understanding and action and, lastly, the inconceivability of a rational discourse about and critique of authoritative myths, legends and doctrines, as were prevalent in mythical thinking.

Science and its questions

Philosophy is currently best understood in terms of its similarities to and differences from the kind of discourse currently known as ‘scientific’ discourse. The main reason for this turns out to be the fundamentally different kinds of questions that are raised by the discourses of philosophy and science respectively.

Scientific questions fall into two broad categories, namely formal questions and empirical questions. Formal questions are those questions that can fully be answered by logical and mathematical argumentation and that do not require any external observations in order to answer questions. For example, the question whether the sum of 555 and 999 is 1554 can be answered by mathematical procedures and argumentation. Similarly, the question whether the number of degrees of a triangle is equal to two right angles is not a question that one answers by an actual ‘count’. The affirmative answer to this question is the outcome of logical, mathematical reasoning by means of which it is proven, not only that the answer in one instance happens to be two right angles but also that is necessarily the answer.

Formal questions mostly occur in logic and mathematics and do not concern us further in this article. The second typical category of scientific questions are empirical questions. These questions can only be answered by making empirical observations or sense perceptions of what actually is happening in the world. These are questions such as whether John is a good golfer, or which city has the most people, Cape Town or Durban. There is only one way of answering these questions, namely ‘look and see’. Most of the great discoveries of the sciences, particularly since the advent of the modern world around about 1600 to 1650, are the outcome of careful observations that compelled people to realise that things ‘are not always what seem to be’! Cf. in this respect the development of Darwin’s theory (1859) of the evolution of species by means of natural selection, or Eddison’s observations (in 1919) of light reaching an observer on a trajectory that makes it deviate from its course of movement close to the sun, thereby proving that gravity does influence the movement of light.

So far as regards the nature of scientific questions. Of pivotal importance is to note that the empirical questions of science – those most prevalent and productive – are in principle answerable by observable phenomena in the world ‘out there’. This constitutes a major difference from the questions of philosophy, to which we now turn.

Many people dwell in the belief that the questions of science are the only important questions, and that the disciplines these questions generate – the disciplines of the current-day factual sciences – yield the only reliable knowledge available. Without for one moment disparaging the remarkable insights, theories and technologies that the factual sciences have produced up to this day, it is also essential to realise that there is also another kind of question that is essential for attaining meaning and harmony in life, yet that cannot be answered by the assumptions and methods of the factual sciences.⁹ These are the philosophical questions, of which we must take careful note.

Conceptual questions in philosophy and (bio)ethics: Conceptual analysis

The most important thing to understand about philosophical questions in contradistinction to scientific questions, is their respective different focus. A philosophical question is not focused on ‘the world out there’ and is not answered by making (more) sense observations. Philosophical questions, other than scientific questions, are not focused on things in the world, but on our thinking about the world in which we live.

To put differently: when we engage in philosophy, we try out best to figure out what and how we are thinking. Philosophy is, literally, ‘thinking about thinking’, resp. ‘na-denke’ (as this very accurate word in the Afrikaans language aptly conveys this unusual claim). Philosophy is, put differently, ‘re-flection’, namely a meta-activity whereby we focus on both what and how we think.

Can one, in a sense, ‘second-guess one’s own thinking’, as philosophy seems to require? This may seem like a strange idea until we realise that thinking seems, on the one hand, to be something self-evident (even uncritical?) and, on the other hand, far from self-evident. Thinking does not just happen or occur without some measure of intellectual endeavour that moves the process in some direction.

This becomes clearer when we realise that thinking does not simply mysteriously occur, but that it is itself an intellectual process that happens by means of categories or means or ‘instruments’ of thinking that facilitate the outcomes of the thinking process, namely ‘thoughts’. Thinking, to put it differently (and hopefully clearer), operates by means of (for a lack of a better word) ‘thought structures’ or ‘thought categories’ by means of which we think.

In order to refrain from unnecessary complexity, I will settle for two kinds of these ‘thought structures’ that can be identified and analysed, as well as the questions that they provoke. These are, firstly, concepts and, secondly, ideas. We think by means of these thought structures. Concepts are the thought categories by means of which we identify and categorise things that we encounter in the world, whereas ideas are the categories by means of which we interpret things in our field of experience. This statement requires a little more clarification.

First of all, two general remarks about concepts and ideas. Concepts as thought structures enable us to order and structure our field of experience. This is because concepts have the remarkable capability of functioning as general classifications. It is because we master and use the general concept of ‘tree’ that every such entity need not be separately identified. ‘Tree’ as concept, namely thought structure, can be applied to a host of entities in our field of experience. It is because concepts are generally formulated that order and structure is bestowed on our field of experience – something that has not yet happened with illiterate infants. Our ability to distinguish trees from buildings or from computers, namely, is the outcome of our ability to formulate general concepts that place phenomena in these respective categories. That, in turn, is fundamentally what enables us to know the world.

To better understand the difference between science and philosophy, it is best to understand the different questions that they ask. Philosophical questions are the outcome of our focus, not on things in the world but on thought structures such as concepts. These are not any concepts; philosophy does not ask about the nature of trees or buildings or wheelbarrows. Philosophers ask conceptual questions: questions about concepts. Philosophy is provoked by a wide range of concepts, of which the meaning is unclear or whose meaning is increasingly challenged or is growing more obscure, compared to what used to be the case. These are particularly abstract concepts like ‘person’, ‘truth’, ‘right’, ‘democracy’ or even ‘university’. In each case, the conceptual question asked about each of these concepts is the question about the rules for the legitimate use of the concept. I cannot simply replace the concept of ‘book’ with the concept of ‘orange’, just as I cannot simply replace the concept of ‘truth’ with the concept of ‘feeling’. Concepts can only be legitimately applied to our field of experience if the rules for their application are adhered to. A central task of philosophy is to explicate these rules.

Ethics (and bioethics) are fully engaged with conceptual questions that are, in fact, philosophical questions. To use just one example, note the question: Is abortion murder? – a question that has been extensively debated in bioethics. This is a conceptual question that can only be satisfactorily answered if we (better!) understand the rules for the legitimate use of the concept ‘murder’.

What is particularly interesting about this question, is that participants in a debate about this question, can be in full agreement about all observable facts that could be established relevant to the question: that life starts at conception, that the embryo has to attach to the woman’s uterus in order to develop, that the foetus is not viable before around about 22 weeks and so on. Yet, in spite of a general consensus on these empirically ascertainable facts, certain health care workers, when consulted about this question, will insist that abortion is murder, while others will insist that it is not. This occurs because the question: Is abortion murder? is not factual but philosophical. It is a question about the rules for the legitimate use of the notion ‘murder’. To solicit an answer requires a conscious and deliberate act of philosophical reflection and analysis.

A host of ethical and, particularly, bioethical questions have the nature of conceptual questions; for example, Is assisted death permissible? What is the nature of legitimate informed consent? May we enhance humans by means of genetic manipulation? Is it in order to terminate congenitally disabled newborns or to allow or leave them to die? May authorities declare coronavirus disease 2019 (COVID-19) vaccines compulsory for a whole country and so on.

These questions are not answerable by recourse to factual research (although such research can throw significant light on morally problematic issues such as HIV and AIDS). These are fully fledged philosophical questions. This indicates clearly the ‘philosophical basis of bioethics’.

Questions of meaning in philosophy and (bio)ethics: Interpretation

This brings us back to the second kind of philosophical question referred to earlier and the way in which it feeds into the philosophical basis of bioethics, namely questions of meaning. These questions are questions about the second kind of thought structure or instrument that we distinguished, namely ideas.

Ideas are also thought structures (by means of which we think), but are markedly different from concepts, and they operate in different kinds of questions. Ideas are thought structures that we also utilise to bestow order on our field of experience, although not to identify and categorise entities (as concepts do) but to interpret our field of experience. This simply means that ideas function to establish the relevant value, importance or relevance of the contents of our field of experience.

Human existence is not simply a matter of the registration and relative categorisation of the things that we experience. Human existence is very much also a matter of interpretation, namely of establishing what is of more or less importance or relevance in that which we encounter in our existence. That is why value judgements play a key role in the raising, discussion and conclusions of questions of meaning – those questions that deal with and are focused on ideas.

Maybe an example might be useful in this regard. The famous British statesman of the 20th century, Sir Winston Churchill, has allegedly once declared that ‘democracy is arguably the worst form of government ever conceived in history, except for all the others which have been tried thus far’.

This is an excellent and, I propose, profound example of an idea. Firstly, it contains a value judgement. It does not simply claim something to be the case, but it asserts the relative value of the entity (in this case, democracy). The latter activity, provoked by the question of meaning – is known as interpretation. Ideas interpret our field of experience.

For example, note the idea formulated in the statement ‘Picasso’s Guernica provides a better depiction of the experience of violence and fragmentation than does Van Gogh’s painting of the artist with a self-inflicted, amputated ear’. Note again: this is an interpretation based on some idea of aesthetic value.

Note secondly that, although ideas may (have) been extremely powerful and influential in history, they are always at the same time contested; people continue to argue about their accuracy and only very seldom is a kind of consensus achieved – a consensus that, in principle, can always be challenged.

Ideas function not only in people’s individual lives but also and in particular in their social lives and actions. We, as humans, do not only act as individuals; we often act collectively, namely together with one another. Those collective actions are always directed by certain ideas. Sometimes, indeed, ideas become so entrenched in society that members of that society no longer realise that a key idea underlies their collective action. When this happens, we talk of institutions and claim that a certain idea has become institutionalised. This is behind Churchill’s claim referred to earlier. Other examples of institutions are schools, the rule of law, an independent judiciary, hospitalised health care, banking and universities. Each one of these contributes to the institutionalisation of an idea.

For example, the university is the institutionalisation of the idea that the scientific knowledge is the best kind of knowledge, and that young people who have gone to university are the best educated and have the best chance of a successful career and of contributing to the welfare of society. These are very strong and widely accepted ideas, yet they can be and consistently are contested.

It can happen that ideas, whether in private or in collective contexts, become so strongly contested that they are gradually replaced by other ideas. The German philosopher of the late 18th and early 19th centuries, Georg Wilhelm Friedrich Hegel, illuminated this phenomenon with the image of the ‘owls of Minerva that fly out at dusk’ (Hegel 1952:13). This suggests an image of the philosophers (‘owls of Minerva’, namely reflecting philosophers) ‘flying out’ (without any guarantee of success), ‘at dusk’, namely the time of day when ordinary life reflects back upon itself as a result of experiencing the seemingly self-evident ideas and idea-based phenomena in the world as no longer self-evident. The image also suggests that the light of our hitherto accepted concepts and ideas that used to illuminate the phenomena (concrete and abstract) we earlier made sense of is fading or receding and that the search for some alternative(s) is due. That is the kind of thing that happens when we philosophise.

Questions of meaning are in the process developed and answered anew by means of ideas as renewed thought structures. A significant number of such new ideas are then formulated, seldom overnight, but gradually over time. This entails the activity of philosophy and of ethics and bioethics. Examples of such new ideas that have been developed in the course of the philsophico-ethical tradition of the West include:

• The idea that knowledge derives its influence and status from power (particularly technologically mediated power) and not from the assumption that we know the world in order to ourselves gain in virtue. What happened in modernity was or is an unprecedented acquisition of power (particularly over nature and many parts of the social world) as coming to expression in the new technologies of our time.¹⁰
• The idea that women are the equals of men (except for their reproductive function and capability) and rightly ought to play an equal role in society.
• The idea that social relations are not a sub-category of natural relations and can therefore be changed if people so wish and are allowed to act accordingly.
• The idea that royalty are not created with ‘divine rights’ and therefore do not have a right to absolute power (as was, e.g., propagated by the ‘Sun King’, Louis XIV in the late 17th century).
• The idea that skin colour is irrelevant for determining people’s value and rights as human beings.

Each of these new ideas on the basis of which the meaning or sense of our lives in the world has been dramatically changed and enhanced in the course of history is a response to a question of meaning.

Many of the most influential ideas in the history of medicine and bioethics thus have a philosophical basis. This includes ideas like:

• Patients ought to, if they are competent, provide informed consent for medical treatment or intervention of whatever nature, including research on human subjects.
• Healthcare is a necessary need because it protects and promotes that which is species-typical in all of us. It therefore ought to be provided free of cost, if possible, or to be distributed to all in society, if possible.
• The task and responsibility of medicine is not the prolongation of life or the promotion of health, but the relief of suffering.
• Vulnerable populations require special care in the administration of health care, as well as benefit protection in order to ensure that communities that participate in biomedical research are not excluded from the benefits of their voluntary participation in research.

Each of these ideas has been the outcome of the owls of Minerva flying out at dusk, namely responding to questions of meaning by developing and introducing, often over long periods, new ideas with which our field of experience became extended and renewed. This indeed shows the philosophical basis of bioethics.

Conclusion

The purpose of this article, as indicated in the title, was twofold. Firstly, the author provided, in broad brush strokes, highlights from the three millennia history of bioethics. From this overview, it is apparent that bioethics can, simultaneously, be regarded as both one of the oldest and one of the most recently developed of the disciplines of the current-day university. Attention was paid to aspects of the original Hippocratic tradition of health care. Thereafter came the bulk of the first part of the article, namely a discussion of four key moments in the re-discovery and poignant development of bioethics in the 20th century. These four pivotal events in this ‘re-birth’ are:

• the judgement in the Schloendorff v. Society of New York Hospital court case (1914)
• the Tuskegee syphilis trial (1934–1970)
• the Nazi ‘medical experiments’ (1942–1945)
• the Scribner Shunt (1960).

It was, in particular, argued how these four events (tragic as they mostly were) facilitated the key significance of the bioethical principles of informed consent and doctor-patient confidentiality, as well as justice in the face of scarce resources, in the 20th century. Although the other two well-known principles (beneficence and non-maleficence) continued to assert authority and were dominant in the Hippocratic tradition, the first-mentioned principles that were unknown in the Hippocratic tradition replaced the Hippocratic principles in prominence in the course of the 20th century.¹¹

This historical analysis was followed, in the second part of the article, by a now no longer a historical analysis but indeed by an analysis of the philosophical basis of bioethics. This was particularly done in response to the fact that some bioethicists argue that bioethics is such a radically interdisciplinary enterprise that philosophy is no longer required for its operations. The author respectfully disagrees and ventures to argue, in this second part of the article, that philosophy is not only necessary for doing bioethics but indeed provides the intellectual basis for the enterprise of bioethics.

This, of course, is not in any way meant to deny the interdisciplinary nature of bioethics. The entire argument in this article is based on an acknowledgement of the way that many disciplines impinge on the bioethical enterprise. It merely re-affirms the widely accepted claim that real and effective interdisciplinary work can only come to fruition on the basis of cooperating disciplines, each drawing and deriving from solidly grounded intellectual disciplines.

Secondly, the article is then devoted to an extensive analysis of philosophy and the way in which it is presupposed by and feeds into bioethics. Much is made of the difference between philosophy and the sciences, particularly in terms of the different kinds of questions that each deals with, the fact that philosophy is not focused on (‘things’ in) the world but on the structures or categories by means of which we think (i.e. philosophy as ‘thinking about thinking’), as well as a closer analysis of these thinking categories, namely concepts and ideas and the functions or operations of these structures: identification, categorisation and classification (in the case of concepts) and interpretation (in the case of ideas).

These analyses are, throughout, illustrated with examples from bioethics that clearly show the extent to which and significance of philosophical analysis for the practice of bioethics. Thus, the ‘philosophical basis of bioethics’ is, to the author’s best understanding, demonstrated.

Acknowledgements

The author, A.A.v.N., serves as an editorial board member of the Journal of Interdisciplinary Ethical Research. A.A.v.N. has no other competing interests to declare.

A.A.v.N. is the sole author of this research article.

This article followed all ethical standards for research without direct contact with human or animal subjects.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views and opinions expressed in this article are those of the author and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The author is responsible for this article’s results, findings and content.

References