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New Medical Marvels Mean More Work for Bioethicists

If life were simple, there would be no such thing as a bioethicist.

Bioethicists tackle extremely difficult moral issues in medical research and treatment. More often than not, right and wrong is not black and white.

That's why bioethicists are there to help patients, their families, and medical professional make life-and-death decisions -- decisions they'll have to live with for the rest of their lives.

The field of bioethics emerged less than 50 years ago. It tackles the implications of medical advances, and addresses the deepest moral concerns, fears and hopes of society.

Ronald Green has been involved in bioethics for more than 40 years, before the field really existed. He's a professor of ethics and also the director of the Dartmouth College Ethics Institute.

"It has certainly grown from nothing," says Green. "There are hundreds if not thousands of people doing bioethics now."

It was in the 1960s that Green started seriously thinking and writing about ethical issues surrounding the beginning of human life.

"I just began to write and think about it, and then the field of bioethics rose up around me, which actually dealt more with end of life rather than the beginning of life," says Green. End-of-life decisions remain a huge focus of bioethics.

Certain issues in bioethics become hot topics at a given time due to new technology, events in the news or other factors. Despite the often-heated debate on many questions, bioethicists do agree on many things.

"While there's disagreement around the edge of cutting-edge issues, there's consensus around the basic principles of ethical conduct in the medical setting," says Green. Consensus means that everyone agrees.

For example, Green says there is a lot of agreement on respecting patients, justice in the conduct of research and the importance of rules against harming people.

What's a specific issue on which there is consensus? "Almost no bioethicists would [say] that the scientific value of a research project should override the free and informed consent of the patients," say Green.

Over his more than 40 years in bioethics, Green has watched the field evolve. "It's become more professionalized," he says. "Now there are people who do just bioethics. They go to doctoral programs in bioethics."

Another change has been that medical doctors have increasingly moved into the field. Originally, bioethics was mostly the domain of philosophers and theologians such as Green. "A lot more physicians have moved into the field," says Green. "They have re-colonized. They felt that they were being pushed out by the philosophers and theologians in the '70s and '80s."

Green's position is that bioethicists should have more than just medical training. "I firmly believe in a firm grounding in philosophical and religious ethics," he says.

The American Society for Bioethics and Humanities (ASBH) has about 1,600 members. Most are from the United States, but some members are from Canada and overseas.

"I think that in the last couple of years bioethics has become more of a major topic," says Alison Saylor with the ASBH. "There has been more research and more articles."

Twice each year, the ASBH publishes a bioethics journal and it hosts an annual conference with about 1,000 attendees. The conference includes paper presentations, panel presentations, workshops and poster presentations.

The newness of bioethics as a profession is reflected in the fact that it was not until 1998 that a number of bioethics associations combined to form the ASBH.

"It's not a small profession, but it's definitely a close-knit profession," says Saylor. "A lot of them coming from different professions have worked together before, so there's a lot of camaraderie."

Bioethicists work in a variety of settings. "The major employment setting is educational institutions, and then clinical or private -- working for government or private hospitals," says Saylor.

Rebecca Bruni is a bioethicist. She has a bachelor's degree in psychology, a nursing degree, a PhD in bioethics and a post-doctoral fellowship in bioethics. Bruni is interested in end-of-life care and organizational ethics. She estimates that 90 percent of clinical ethicists are employed by a hospital, like she is. Most people in such positions have a health-care background.

Bruni conducts education sessions for hospital staff, students and the public on various ethical issues. She also does policy development and review.

"We're involved in developing, reviewing and implementing [ethics] policy in a health-care organization," says Bruni. "An example would be, usually a hospital will have a policy regarding withholding and withdrawing treatment, or discharging against medical advice, or pandemic flu planning.

"And then there's another piece of our job which is research ethics," she adds. "That usually involves sitting on a research ethics board. The board reviews studies [that are proposed] to be done in our facility, and we're usually on those boards to determine which studies are ethically sound."

What occupies most of a bioethicist's time? "Depending on who you talk to, you'll get a different answer," says Bruni. "Some bioethicists might spend 50 percent of their time doing academic research, and 50 percent doing clinical and organizational ethics. My job, however, is very much weighted heavily on frontline work and less so on research."

Bruni estimates that she spends just 10 percent of her time on academic research and writing articles.

"Ethics consultation would take up 50 percent of my time," says Bruni. "Essentially what I do is get involved in any kind of ethically charged situation and my role is to identify, analyze and help the stakeholder resolve the ethical issues and facilitate and support the decision-making process. It's not to come in and say, 'Here's the right answer.' It's to help them resolve the issues in an ethical manner."

That ethics consultation is done with patients, their families and medical staff. A bioethicist could assist with a decision whether to remove a feeding tube when there's uncertainty or disagreement, for example.

Bioethicists such as Bruni also get involved in organizational ethics consultation. This involves questions such as, "How do we divide resources fairly and justly in a pandemic?" "Who do we treat first and how do we justify it?"

Bruni says the bioethics field is "mobilizing" to determine who can call themselves a bioethicist. At the moment, "anybody can call themselves an ethicist, and I think we need to change that," she says.

"It's very confusing and complicated how you get into this job and what the training is," Bruni says. "We're in a state of flux.

"We are not a regulated health-care profession and there's debate in the field as to what constitutes a bioethicist," says Bruni. "I would call myself a health-care ethicist or clinical and organizational ethicist."

"So many of our members have so many credentials," says Saylor. "It's a very broad category. A lot of people are in their second career phase. We have a decent amount of MDs, a lot of PhDs. MPH (master's of public health) is another big one. Nursing is another one, law is a decently big one."

Bruni started out with an interest in health care, but didn't know she would become a bioethicist one day. "I always had an interest in pursing a career in health care mainly because I had the desire to do something that impacted people's lives, hopefully in a positive way," says Bruni.

Bruni didn't decide to go into bioethics until after she had earned her psychology degree. She had researched various career options and was shadowing a bioethicist when she realized this was the career she wanted.

"I instantly knew that this would be a good fit for the reason that you have the opportunity to help people in the most difficult time of their life, when they're vulnerable," says Bruni. "For example, [advising] a grown child making decisions for their elderly parents, to help them with a decision that could haunt them for the rest of their life if they don't have the right support."

The level of education required by bioethicists is constantly rising. "I think the field can agree that you absolutely need a master's or PhD in bioethics, and more and more we see job postings [with] master's required and PhD preferred," says Bruni. "I would say it's advisable to get a PhD because the bar is rising."

Bruni says that a clinically based fellowship, which gives you hands-on experience with clients, is also a good idea if you want to work in a health-care environment.

As with most careers, the more you learn, the more you earn. "I would say your earnings would correlate with your education," says Bruni.

New advances in technology and medicine will continue to create a demand for bioethicists to help people with difficult decisions.

"I think that medicine and technology changes so rapidly today, that we're in the place where we have new technologies and we haven't thought of how to deal with them," says Bruni. "The law and policy don't have time to catch up.

"The technology is growing so fast, new drugs are coming on the market everyday," says Bruni. "Resource allocation is a huge issue now, and people are looking to ethicists to determine how to allocate resources fairly." That means they are considering things like how to fairly provide medical treatments to everyone who needs them.

For those who do manage to find employment as a bioethicist, their education doesn't end the day they leave university.

"It's intellectually stimulating and dynamic, and no day is the same," says Bruni. "You're constantly learning. In a career like this, the day when you think you know it all is the day you should retire. It forces you to constantly rethink things."

Bruni believes that bioethicists will continue to be in demand, as they continually rethink some of the most challenging questions people can face.

"I think there are going to be continuing vexing and perplexing challenges," says Bruni. "People are living longer, they're going to live with more issues than we had even 10 years ago.

"Part of the origin of our field was with the human rights movement -- consumers and patients are becoming more aware, and I think there's going to be a drive to have ethicists at the table."


Medical Ethics Articles
A good collection from Santa Clara University

American Society for Bioethics and Humanities
Find out about current issues in the field

Bioethics Programs
A list of graduate programs

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