Notwithstanding popular perception that bioethics or health ethics was a 20th Century development based largely on Western philosophy, concern for and social responses to ethical issues have been extant for millennia. Documentation of ethical principles dates to the Code of Hammurabi—circa 2500 BC—which included provisions concerning the importance of ethical considerations to clinical practice and recognized the physician’s dual responsibility to the patient and to society. The Pharonic principle of Maat addressed the principle of ethical balance and compassionate care for the poor and sick. Hindu philosophy holds sacred the transcendent character of human life, expressed through the principles of sanctity and quality of life and the duty to preserve and guard individual and communal health. In Judaism, Tikun olam is the Judaic imperative to repair the world, reflecting the divine values of justice (tzedek) and compassion (hesed). Christianity values charity toward individuals and members of society generally and the sanctity of human life. In Islam, one of the hadiths (sayings of the Prophet Mohammad) made treatment mandatory or obligatory when a treatment was definitely available and if withholding treatment would be harmful. If one is unsure of any benefit from a treatment and any harm is feared, then it is discouraged according to Islamic principles. (Jillson, 2011)

Knowing that there are common values across spiritual beliefs is critical for an understanding of the developing conceptual frameworks of health ethics that are being applied to health issues as diverse as resource allocation, clinical practice, engagement of vulnerable populations in medical research, donor investment in health, and related development policies and programs.  The development of the contemporary ethics movement, which initially focused on medical research, is considered to have initiated with the Nuremberg Code (1949), which stated that the voluntary informed consent of the human subject is absolutely essential. (US GPO, 1949) This was followed by the Declaration of Helsinki by the World Medical Association, which stated that the well-being of the participant should take precedence over the interests of science and society. (World Medical Association, 1964) This declaration is updated every few years to take into consideration new medical technologies and research methods, as well as other factors. The most recent revision—the sixth— was approved in 2008.The Belmont Report, prepared under the aegis of the US President’s Commission for the Protection of Human Subjects, was issued in 1979. (Beauchamp and Childress, 2001) This document, and indeed much of the discourse related to bioethics in the past 40 years, was based primarily on the principalism approach developed at Georgetown University in Washington, D.C. This approach posits four basic principles: autonomy, beneficence, non-maleficence, and justice. These principles are considered universal; that is, they were believed to transcend geographic, cultural, economic, and political boundaries. (Beauchamp and Childress, 1979) They have also influenced the clinical care of patients, including adolescents; the conduct of research involving human subjects at the national, regional, and international levels; and the training of clinicians and researchers.

Over the past decade, there has been a flourishing of philosophical, social, and other discourse regarding health ethics; much of this discourse has been based in new concepts of and approaches to health research, development, and public health. It has, importantly, not been dominated by North American or European thinkers—although many, including notably Dr. Paul Farmer, Dr. Nancy Kass, Dr. Alex London, Dr. Peter Singer, and others, have made invaluable contributions to the discourse.  Rather, the discourse has benefited from a rich diversity of scholars and others who have explored health ethics from a wide range of perspectives. New concepts of health ethics principles and frameworks have been proposed by bioethicists from the Democratic Republic of the Congo and South Africa, philosophers from Cameroon and India, public health physicians from Egypt, and biomedical researchers from Argentina and Venezuela. Among the conceptual frameworks that have been posited—and that have been the basis for recent discourse regarding health ethics—are the Human Development Approach to International Research (London, 2005), which makes explicit the linkages between medical research and the social determinants of health and global justice; the Fair Benefits Approach (El Setouhy, et al, 2004), which also focuses on medical research; Ethics from Below (Farmer, P and Gastineau Campos, N, 2004), which addresses health ethics more broadly and suggests contextualizing ethical dilemmas broadly in the social sciences, rather than focusing only on moral philosophy; a Participatory Framework for Health Ethics (Singer and Benatar 2001); and the African Meta-physical Worldview (Tangwa, 1996).

Awareness of these new concepts of health ethics is essential for all those engaged in ensuring that individuals and populations broadly benefit from the health rights to which they are entitled through the multiple international accords that have been promulgated since 1948. Rather than focusing somewhat narrowly on medical research—as vital as that field is, and as important are assurances that all, including adolescents, benefit equally from it—many of the new approaches consider public health, access to individual health care and to related services, and the broad socioeconomic context of health. Moreover, as they reflect a wide diversity of cultures and religions, they are not embedded only in Judeo-Christian principles, but in a broader range of spiritual and philosophical belief systems. Although Principalism has served for more than half a century to endeavor to ensure protection of human subjects of research— and, to a lesser extent, equitable access to health care— consideration of religious, cultural, and other values and norms beyond those prominent in the West has enriched the discourse and enabled a broader understanding of both health ethics generally and their implication for adolescent health. Applying the Global Health Ethics Framework of Benatar, Daar, and Singer, for example, requires considering not only philosophical paradigms, but also allowing “the extension of human rights beyond civil and political rights to include social, economic and cultural rights and their close integration with reciprocal responsibilities.” (Benatar, Daar and Singer, 2003) Thus, an individual’s rights would be considered in the context of interpersonal ethics (including freedom of choice), public health ethics (including equity and access to care), and environmental rights, which pertain to all members of society. However, these individual rights are also balanced with collective rights of his or her society, the global community, and individual and collective responsibilities.

Notably, although not explicitly mentioned in the Universal Declaration on Bioethics and Human Rights, adopted in October 2005 by acclamation at the 33rd session of the General Conference of UNESCO (UNESCO, 2005), the influence of broader considerations of health ethics is apparent in the Declaration and the documents that have been produced subsequently by the UNESCO Office on Bioethics and Human Rights. Importantly, the Declaration linked human rights and ethics related to health broadly speaking; that is, beyond research to include health services, resource allocation, and complex issues related to genomics and organ transplant.

Addressing these and other comparable complex issues requires a broad and deep understanding of health ethics on the part of the clinician, researcher, and all those who are involved in making necessary ethical decisions, or contributing to the discussion regarding such decisions.   The emerging, diverse concepts of health ethics both contribute to a deeper understanding of health issues related to adolescents and can serve as a framework for planning and evaluating national, regional, and international health strategies at the global, regional, national and local levels. Consideration of the socioeconomic and political context in which each individual lives; the education, health, and social infrastructure with which he or she interacts; and the religious and cultural norms that pervade that society, are increasingly part of the intellectual fabric of these new global health ethics frameworks.

 

Works Cited

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Benatar SR, Daar AS, Singer PA. (2003) Global health ethics: the rationale for mutual caring. International Affairs. 2003;79(1):107-138

Farmer P, Campos N. Rethinking medical ethics: a view from below. Dev World Bioeth. 2004;4(1):17-41

London AJ. Justice and the human development approach to international research. Hastings Cent Rep. 2005;35:24-37

Singer PA, Benatar SR. Beyond Helsinki: a vision for global health ethics. BMJ. 2001;322:748-788

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Trials of war criminals before the Nuremberg military tribunals under Control Council Law, Volume 2, Number 10. Washington, DC: US Government Printing Office (reprint); 1949: 181-182

United Nations Educational, Scientific and Cultural Organization. Universal Declaration on Bioethics and Human Rights. 2005. United Nations Educational, Scientific and Cultural Organization. Universal Declaration on Bioethics and Human Rights Web site. Available at: http://unesdoc.unesco.org/images/0014/001461/14618e.pdf. Accessed March 7, 2011

United Nations (2000) General Comment No. 14, The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights).  Geneva:  United Nations Committee on Economic, Social and Cultural Rights