The Birth of a Field

The term bioethics was coined by oncologist and biochemist Van Rensselaer Potter in 1971, in his book Bioethics: Bridge to the Future. For Potter, bioethics was a synthetic discipline bridging the biological sciences and human values — a “bridge” capable of guiding humanity in the face of risks that technological progress posed to the survival of the species and the ecosystem. Potter conceived bioethics broadly, in an almost environmental sense, encompassing the relationship between human beings and the entire biosphere.

Concurrently, André Hellegers, a Dutch-born gynecologist working in the United States, founded the Kennedy Institute of Ethics at Georgetown University in 1971. There, bioethics took a more strictly medical-clinical direction, focused on problems arising in hospital practice and research involving human subjects. This tension between a “global” bioethics (in Potter’s sense) and a “clinical” bioethics remains a constitutive feature of the field.

The historical context is decisive: the Nuremberg Trials (1945–1946) exposed Nazi medical atrocities, leading to the Nuremberg Code (1947), the first international document to require voluntary consent from research subjects. Later scandals — the Thalidomide case (1957–1961) and especially the Tuskegee study (1932–1972) — made the creation of more robust regulatory frameworks urgently necessary.

The Tuskegee Study and the Belmont Report

The Tuskegee study, conducted by the United States Public Health Service from 1932 to 1972, followed 399 Black men with syphilis in Alabama without providing them adequate treatment — even after penicillin became the standard treatment in the 1940s. The stated objective was to observe the natural progression of the disease. Participants were never informed of their diagnosis or the actual objectives of the study.

Public revelation of the scandal in 1972 provoked national outrage and led to the study’s immediate termination. In response, the U.S. Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, whose work produced the Belmont Report (1979). The document established three fundamental principles for research with human beings: respect for persons (autonomy), beneficence, and justice — the direct basis for what Beauchamp and Childress would systematize in the same year.

Beauchamp and Childress’s Four Principles

In 1979, Tom Beauchamp and James Childress published Principles of Biomedical Ethics, a work that would become the definitive reference text of clinical bioethics. The authors propose four prima facie principles — that is, principles carrying initial normative force that may be overridden by other principles when they conflict:

1. Autonomy

The principle of autonomy requires respecting the patient’s capacity to make informed decisions about their own health. An autonomous patient is one who acts intentionally, with understanding, and without controlling external influences that determine their action.

In clinical practice, autonomy is expressed through informed consent: patients must receive clear and comprehensible information about their diagnosis, treatment options, risks, and benefits, and must freely consent before any intervention. Autonomy also entails the right to refuse treatment, even when that refusal carries risks to life.

2. Non-maleficence

The principle of non-maleficence — primum non nocere (“first, do no harm”) — requires healthcare professionals to avoid inflicting harm on patients. It is distinct from beneficence: not causing harm is a negative obligation (abstention), while benefiting is a positive obligation (action).

The distinction matters because negative obligations generally carry stronger prima facie force: it is more grave to actively cause harm than to fail to provide a benefit.

3. Beneficence

The principle of beneficence requires healthcare professionals to act in the patient’s best interest — not merely avoiding harm, but actively promoting well-being. It includes preventing and removing harms, as well as balancing risks and benefits.

The tension between autonomy and beneficence is one of the central axes of medical ethics: what the physician considers to be the patient’s best interest (paternalistic beneficence) may differ from what the patient themselves desires.

4. Justice

The principle of justice requires the equitable distribution of the benefits and burdens of the healthcare system. It involves questions of allocating scarce resources (transplant organs, ICU beds, high-cost medications), universal access to healthcare, and non-discrimination.

Engelhardt and Moral Pluralism

H. Tristram Engelhardt Jr., in The Foundations of Bioethics (1986; 2nd ed. 1996), begins from an observation: we live in a morally plural society where reasonable people deeply disagree about fundamental ethical questions. In a secular and post-metaphysical society, moral consensus cannot be derived from a single set of premises.

For Engelhardt, the only viable foundation for bioethics in a secular and pluralist world is the principle of permission: interventions on persons are legitimate only if consented to by them. This minimal principle does not resolve disagreements — it merely frames them. Engelhardt distinguishes “moral strangers” — people who do not share the same fundamental values — from “moral friends” — those who inhabit the same moral community.

Classic Dilemmas

Euthanasia

Euthanasia (from the Greek eu + thanatos, “good death”) denotes the practice of ending a person’s life to relieve their suffering. The fundamental distinctions are:

  • Active vs. passive: actively causing death vs. withdrawing treatment that prolongs it
  • Voluntary vs. non-voluntary vs. involuntary: with consent, without capacity to consent, against the person’s will

Peter Singer, in Practical Ethics (1979), argues from a utilitarian perspective that voluntary euthanasia can be morally justifiable when the person rationally desires it and their suffering is severe and irremediable. Ronald Dworkin, in Life’s Dominion (1993), addresses the sanctity of life and argues that respecting individual autonomy includes recognizing a person’s right to determine the conditions of their own death.

The Karen Quinlan case (1975–1976) was a landmark in U.S. medical law and ethics: the family of a young woman in a persistent vegetative state won, after a court battle, the right to disconnect her mechanical ventilator. Quinlan survived disconnected for more than nine years, but the case established the legal precedent for the right to withdraw treatment.

Abortion

The philosophical debate over abortion centers on the moral status of the fetus. Judith Jarvis Thomson, in “A Defense of Abortion” (Philosophy & Public Affairs, 1971), makes a strategic concession to the opposing argument: even granting that the fetus is a person from conception, the right to life does not entail the right to use another person’s body — her famous unconscious violinist thought experiment remains one of the most discussed in analytic philosophy.

Don Marquis, in “Why Abortion Is Immoral” (Journal of Philosophy, 1989), argues that killing a fetus is wrong for the same reason that killing an adult is wrong: it deprives the victim of “a future like ours” — the totality of experiences, activities, projects, and pleasures that would constitute their life.

Human Research and Genetic Editing

Research with human subjects requires informed consent, proportionality between risks and benefits, and special protections for vulnerable populations. The development of CRISPR-Cas9 gene editing — a technology enabling the modification of DNA sequences with unprecedented precision — raised new ethical questions. The case of scientist He Jiankui, who in 2018 announced the birth of gene-edited babies, was widely condemned by the scientific community: the absence of clear medical necessity, unknown long-term risks, and lack of international ethical consensus made the intervention ethically indefensible in the current state of knowledge.

Justice in Healthcare

Norman Daniels, in Just Health: Meeting Health Needs Fairly (2008), applies John Rawls’s theory to the distribution of healthcare resources. Health is a condition for “fair equality of opportunity” — a Rawlsian principle — which is why society has a special obligation to ensure access to healthcare.

The COVID-19 pandemic (2020–2022) made justice dilemmas in healthcare dramatically concrete: allocation of ventilators, vaccine prioritization, global inequality in access to medications, and the role of social determinants in the unequal distribution of mortality.

Concluding Remarks

Bioethics is an intrinsically interdisciplinary field — it articulates medicine, philosophy, law, sociology, and political science. Beauchamp and Childress’s four principles provide a practical and widely adopted framework, but they do not by themselves resolve the deepest conflicts, which emerge from the irreducible moral pluralism of contemporary societies. The enduring challenge of bioethics is to create spaces for public deliberation where these conflicts can be negotiated with rigor, mutual respect, and attention to real consequences for human and non-human lives.

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