In early 2005, at the same Academy Awards ceremony in which Clint Eastwood's Million-Dollar Baby was named best film, a Spanish movie called Mar adentro (The Sea Inside) by the young director Alejandro Amenábar received the Oscar for best foreign film of 2004. Though worlds apart esthetically, both films explore the themes of paraplegia and lives deemed not worth living, a cinematic coincidence that speaks of the enduring importance of issues such as these.
Amenábar's movie is based on the true story of Ramón Sampedro, a ship mechanic left paraplegic in 1968 by a diving accident. Mr. Sampedro spent a good part of his 29 bedridden years asking Spanish courts to allow someone to help him commit suicide without facing criminal prosecution. Having exhausted all legal options, he finally orchestrated an intricate plan that culminated in a glass of cyanide and a straw within reach of his mouth. Mr. Sampedro took his life in January 1998 at the age of 55.
The Sea Inside provides a glimpse of bioethics in Spain today and of the historical and philosophical fonts that nurture it. The film echoes classic features of Spanish moral philosophy, starting with its Catholicism, while reflecting more recent waning of church authority over matters of individual conscience. It also reflects the growing U.S. influence on bioethical questions: Mr. Sampedro's desired suicide reflects the North notion of the body as private property, over which individuals can freely exercise their rights and dominion.
The analogy to the American context is not airtight. There is not a line in the movie dedicated to the cost of treatment (basically free for the patient) or who is paying for it (the state through the healthcare system). And in a distinctively Spanish deontological manner, the film's main supporting characters opt for duty rather than consequences as they struggle to react to Mr. Sampedro's request for aid in dying.
These contrasts are interesting, and have a deeper meaning for comparative bioethics. The Sea Inside shows the different hierarchies of values and agendas between American and Spanish bioethics. It also suggests that although U.S. bioethics has been incorporated into Spanish life, local traditions continue to be informed by an indigenous bioethics prevalent on the Iberian peninsula.
This is a bioethics tradition worthy of study and one that has already had a subtle if largely unappreciated influence on bioethics, particularly on American bioethics. As we will see, it has informed some of the thinking of leading American bioethicists over the past two decades. Appreciating the Spanish contribution to the field may allow international scholars to extract lessons from a tradition in which foundations and principles have preponderance over contextual problem solving. One lesson centers on the place of character and virtue in the ethics of the healing profession, together with themes of multiculturalism and human rights. Another concerns the role of solidarity and communitarianism, as opposed to individualism and choice, in guaranteeing access to healthcare. At the same time, this appreciation may illustrate some of the idiosyncrasies of bioethics discourse in the United States, such as valuing practical outcomes over adherence to general principles.
An analysis in comparative bioethics is more than an academic exercise. Delving into the Iberian influences present in American bioethics may contribute to understanding the underlying philosophical influences ingrained in the culture of the growing number of Spanish-speaking Americans, a topic that has been of interest to us both. Since the summer of 1990, when both of us met at The Hastings Center, a considerable part of our work has been dedicated to appreciating American bioethics from the perspective of different cultural traditions—and to advocating the notion that although there is much to be learned from American bioethics, this tradition has to be understood within its own context and enriched with contributions from other bioethical and philosophical schools.1
Fins JJ. PAHO's progress. Hastings Center Report 1993;23(2):2; Rodríguez del Pozo P. Commentary on How Confidential Is Confidential? In: Kushner TK, Thomasma D, eds. Ward Ethics: Dilemmas for Medical Students and Doctors in Training. Cambridge: Cambridge University Press; 2001:52–5.
Bioethics in Spain Today
Throughout the 20th century, medical humanities in Spain enjoyed solid academic development, which translated into an early corpus of bioethics. Although 1960 may be pinpointed as the birth of bioethics in Spain, the public life of bioethics began only with la transición (the transition) in November 1975, when the parliamentary monarchy of Juan Carlos I replaced the dictatorship of Francisco Franco, thus transforming the country almost overnight into a modern democracy.
Spaniards have witnessed a fast succession of bioethical legal transformations, both direct and indirect, since the mid-1970s. The 1978 Constitution, which recognized all basic human rights, unleashed a chain reaction regarding the rights of the sick. This resulted in the Charter of Patients Rights for the National Health Service. In 1985, abortion was decriminalized in some circumstances, and in vitro reproductive techniques were soon widely accepted. In 1986, the right to healthcare was guaranteed by law and access was universally provided by the National Health Service, which until then had served only workers and their families. In the late 1980s and early 1990s new laws were passed regarding human experimentation and clinical trials. These changes were accompanied by a flurry of academic activity.
The late Pedro Laín Entralgo, a historian, philosopher, and anthropologist of medicine, laid the groundwork for, and made the first contributions to, Spanish bioethics back in the 1960s and 1970s. But it was not until after 1975 that bioethics flourished in education and research, legislation, and institutions. With the confetti of King Juan Carlos' inaugural parade still on the ground, a physician and Jesuit priest named Francesc Abel founded the Instituto Borja de Bioética, near Barcelona, to pioneer the development and expansion of bioethics. Instituto Borja has been, and still is, a center for teaching and research as well as a forum for creative thinking on difficult issues. This has resulted in tension with the Church more than once, particularly given the Instituto's openly Catholic affiliation. As recently as April 2005, the Instituto advocated that in some cases active voluntary euthanasia should be decriminalized, which inevitably irritated Catalonian bishops. In the late 1980s, the late Javier Gafo, another Jesuit, founded a department of bioethics at the University of Comillas in Madrid, which has made a substantial editorial contribution to the development and spread of bioethics in Spain. Since 1984, the department has published more than 30 volumes containing the writings of leading Spanish bioethicists on all fundamental topics, from stem-cell research to euthanasia, from experimentation on humans to ecology.
Notwithstanding these earlier efforts, Diego Gracia, who succeeded Laín as the Chair of the Department of History of Medicine at Universidad Complutense in Madrid, has been, to a large extent, the chief architect of bioethics in Spain. His work Fundamentos de bioética,2
Gracia D. Fundamentos de bioética. Madrid: Eudema; 1989.
“Looking back at all that has happened in the last ten years,” Gracia wrote in 1987, “it is surprising how closely bioethics in Spain has followed in the footsteps of North America and Central Europe” (31).3
Gracia D. Spain: From the decree to the proposal. Hastings Center Report 1987;17(3):S29–31.
Council of Europe. Bioethics. Available at: http://www.coe.int/T/E/Legal_affairs/Legal_co-operation/Bioethics/. Accessed June 15, 2005.
Looking at its degree of development, bioethics in Spain today can be proud of what it has achieved in terms of production and dissemination of knowledge, not to mention prestige, influence, and international reach, particularly in Latin America. Over the past 15 years, however, the focus of attention has moved from social issues such as sanitary justice to problems closer to the individual domain, such as self-determination, reflecting North-American trends, albeit dated ones.
Spanish Philosophy and Bioethics
To understand these trends, we need to construct their philosophical roots. Spanish bioethics belongs to the tradition of what has been called Mediterranean ethics,5
Gracia D, Gracia T. Southern Europe. In: Post SG, ed. Encyclopedia of Bioethics. New York: Macmillan Reference; 2004:3,1602–9.
For empiricist Anglo-American ethics, moral laws must be drawn from experience, and they are contingent. Continental and Mediterranean rationalist ethics, instead, maintain that universal moral laws can be discovered through reason, overriding any contingent circumstance. Anglo-American ethics judges human action by looking at its tangible consequences. Continental and Mediterranean traditions apply abstract principles to that end. The former is an ethics of responsibility, the latter an ethics of virtue.6
Gracia D. The intellectual basis of bioethics in Southern European countries. Bioethics 1993;7(2–3):97–107; Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New York: Oxford University Press; 1993; MacIntyre A. After Virtue. Notre Dame: University of Notre Dame Press; 1981.
In the legal field, predictably enough, the Anglo-American judge imparts justice within a context by means of the jurisprudential common law. The Continental–Mediterranean judge imparts the law as it is written, without considering the fairness of the consequences.
The existence of a genuine Spanish philosophy has been controversial among scholars. Only recently have those scholars who maintain that there is a legitimate Spanish philosophy become a majority. It is no surprise that the quest for discovering a national philosophy in history and defining it conceptually has been a visceral priority among Spanish scholars. As part of the same quest, Spanish philosophers tend to express lo nuestro (our own belongings), or the spirit of the people in their philosophy. Perhaps these features help to explain the almost iconic status and influence of those historical authors identified as Spanish, a rather broadly defined category, and the perdurability of their teachings.
Spanish bioethics is, by philosophical tradition, rationalist and principialist, dominated by a stoic sense of virtue and concerned with social ethics. Despite finding inspiration from abroad, Spanish bioethics preserves its local nature. In the following pages we will explore the historical roots of these features.
Philosophical Origins
Spanish bioethics has identifiable historical roots in the country's philosophical and cultural heritage. These roots stretch from the stoic legacy of Seneca to the Aristotelianism of physician–philosophers Averroes and Maimonides to the enlightened social teachings of Renaissance Vives to the philosophy of equality before the law and popular sovereignty of 16th-century scholastics Vitoria and Suárez. The novel Don Quixote in some senses wove together these varied strands of thought. The work of the Europeist Ortega y Gasset in the 1930s and the more obscure Zubiri in the 1950s further laid the theoretical groundwork. Gregorio Marañón, a neo-Enlightened physician and humanist, with his all-in-one-man multidisciplinary approach to medicinal science and humanities, laid the last layer of Spanish bioethics' bedrock. Marañón's death in 1960, thus, marks for us the birth of Spanish bioethics. In a nutshell, these are the philosophical origins of Spanish bioethics that we will discuss in this section.
Ancients and Medieval: Stoic Virtue and Aristotle's Arrival
Spanish philosophy, along with the ethics of virtue in the Iberian Peninsula, begins with Lucio Anneo Seneca (4 BC–AD 65). Seneca, a Córdoba-born Roman who belonged to the “new Stoics” (nova stoa), has entered posterity for his moral treatises, where morality equals virtue. This is Seneca's lasting legacy, not least because the notion of virtue is a major point of contact between Christianity and Stoicism. This nexus is also strong in medicine, where the Stoic doctrines were introduced by Galen7
Temkin O. Galenism: Rise and Decline of a Medical Philosophy. Ithaca, NY: Cornell University Press; 1974.
Unlike in the rest of Europe, the Middle Ages in Spain were an era of enlightened civilization, culture, and tolerance, following the settlement by the Arab Muslims in 711. The Arabs brought with them the most advanced medicine and science of the time, and reintroduced in Europe the medicine and philosophy of classical Greece. The integration of the other cultures was a vital aspect of Al-Andalusian progress. Intermarriage was common. The Jewish community “rose from the ashes of an abysmal existence under the Visigoths” (30) to the degree that a Jew was the Caliph's foreign minister.8
Menocal MR. The Ornament of the World (How Muslims, Jews and Christians Created a Culture of Tolerance in Medieval Spain). New York: Black Bay/Little, Brown and Co; 2002.
Laín Entralgo P. Historia de la medicina. Barcelona: Salvat; 1982.
Social Concerns and Human Rights: The Renaissance
For some authors, Al-Andalus represents an early Renaissance,10
See note 8, Menocal 2002.
Historian of philosophy José L. Abellán believes that the Spanish Renaissance is linked to the Counter-Reformation, and starts with the arrival of the Spanish in the Americas. In that framework, the Spanish Renaissance is a very fertile period intellectually, in which Erasmism, together with Juan Luis Vives and his preoccupation for the poor, and the Scholastics, with the School of Salamanca and its doctrines on ethics and political philosophy, provide examples of original Spanish thinking at the time whose influence continues today.11
Abellán García JL. Historia crítica del pensamiento español. Madrid: Espasa-Calpe; 1986.
Erasmism, after Desiderius Erasmus of Rotterdam (1466–1536), is a doctrine that embraces Saint Paul's notion of the Mystical Body of Christ and postulates brotherhood by nature and solidarity among all human beings. Thanks to Vives, these doctrines are transformed into a secular Spanish tradition of considering charity as a public concern.
Juan Luis Vives was born in Valencia in 1492 to a family of converted Jews who were nevertheless condemned to the bonfire by the Inquisition. Despite having spent most of his life as a refugee abroad, Vives is revered as a national author and his influence is vast.
If Erasmus demands that the wealthy mitigate the misfortune of the poor by practicing the virtue of charity, Vives transforms this private virtue into a public duty of charity that includes the poor and the sick. Vives' De subventione pauperum (On Assistance to the Poor) of 1526 states that the rich are mere administrators of their wealth, obliged to share their possessions with the poor.12
Vives JL. Del socorro de los pobres. In: Vives JL. Obras completas. Madrid: M. Aguilar; 1947:I,1355–411.
See note 12, Vives JL 1947:1389.
This tax-financed public charity, throughout the centuries, provided relief to the needy and built the myriad of public hospitals that ultimately became the backbone of the contemporary Spanish National Health Service. Modern Spanish theory and practice of the welfare state take root in Vives' doctrines and are explicitly expressed in modern political thinking.14
Peces-Barba G. Humanismo y solidaridad social como valores de una sociedad avanzada. In: Lorenzo García R, ed. Las entidades no lucrativas de carácter social y humanitario. Madrid: La Ley; 1991:13–62.
The currents of humanism, Protestant Reformation, and the exploration and conquest of America left Spanish philosophers and theologians rather puzzled. In dealing with these issues, the Scholastics, represented by the School of Salamanca, dominate the Spanish Renaissance with their doctrines of human rights and popular sovereignty, founding notions of modernity.15
Peces-Barba G. Tránsito a la modernidad y derechos fundamentales. Madrid: Mezquita; 1982.
The conception of human rights as natural rights was explored by Francisco de Vitoria (1483–1546). For this author, if human beings are equal in nature, they should also be equal in rights. Some of these rights are fundamental rights that preexist the state and cannot be overruled even by law. Suárez, for his part, overturned the notion that sovereignty belongs to the monarch by grace of God. He maintained, instead, that sovereignty resides in the people, and it is the people who entrust it to the monarch.
These democratic lessons were first used to sustain the rights of native populations in the new territories and reject their forced religious conversion. They later provided intellectual support for the independence of the colonies throughout the Americas.
Don Quixote's Ethics of the Exerted Spirit: From Cervantes to Unamuno
Cervantes' Don Quixote, of 1605, rides on the philosophical coattails of Erasmus and Vives. Spirituality and charity are found throughout the adventures of the knight-errant, whose order “was instituted to defend maidens, to protect widows and to nourish the orphans and the needy,” being “God's ministers on earth and the arms by which his justice is done therein.”
Don Quixote's moral philosophy is that of the espíritu esforzado or exerted spirit, deeply rooted in Stoicism. In this conception, a virtuous man must demonstrate his attachment to principles and ideals by means of the courage and effort he dedicates to achieving them. But these efforts need not necessarily translate into practical results.
This strict principialism and noble disdain for the consequences continue to be imbibed by Spanish moral philosophy today. For Miguel de Unamuno and the Generation of 1898, the exerted spirit is the moral philosophy of Spain.
The Generation of 1898—a rather heterogeneous group of poets, intellectuals, and writers—helped Spain rediscover itself after the loss of Cuba, Puerto Rico, and the Philippines in that same year, a year that marked the end of the Spanish empire and the beginning of contemporary Spain. Unamuno, the dean of the University of Salamanca, is the main protagonist of this generation.
For Unamuno, Spanish philosophical thinking is the product of the culture, history, and sentiments of the land, a fruit that takes its juices from the soil underneath. The soil's chief nutrients in Spain are Stoicism, with its ethics of virtue, and Catholicism, with its concern for immortality and salvation of the soul. For Unamuno, the most genuine Catholic ethics is oriented toward the salvation of the soul more than the maintenance of society. This is why Catholicism produces virtuous heroes, whereas Protestantism produces sensible, wealthy, free societies, “though incapable of any grandiose action” (106).16
Unamumo M. Del sentimiento trágico de la vida. Madrid: Espasa-Calpe; 1976.
For Unamuno, Don Quixote is a complete system of philosophy that in the exerted spirit synthesizes Stoicism and Catholicism, the innermost constituents of the Spanish soul. In this sense, Unamuno did not produce an original philosophy, but rather translated into academic words prevalent Spanish sentiments. He structured a series of disperse thoughts and feelings into a philosophical body that, for the average educated Spaniard, is perhaps known and understood even without having read Unamuno.
Soon enough, though, the Generation of 1914 found Unamuno's quixotism too parochial.
European Flair and Medical Humanities: Ortega y Gasset and Marañón
World War I consternated Spanish intellectuals, who feared it would raze their enlightened Europe, at the same time it fueled their Europeism and gave them a name. The Generation of 1914 pushed philosophy to new heights, as it did other manifestations of culture and science. Pablo Picasso belongs to this generation, doing for visual arts what José Ortega y Gasset and Gregorio Marañón did for philosophy and medicine.
José Ortega y Gasset (1883–1955) was a thinker and a doer. His philosophical legacy is more a work in progress than a concluded system. However, the thread of his perspectivism evolves uninterrupted from his first work, Meditations on Quixote, of 1911. It was there that he coined his “I am myself plus my circumstance,”17
Ortega y Gasset J. Meditations on Quixote. Champaign IL: University of Illinois Press; 2000:45.
He also created a style that was artistically rich, filled with images, examples, and metaphors. He would trespass the limits of literary genres whenever clarity required, mixing styles and tones that go from grave to jovial and choosing words carefully so as to suggest more than define.
Through editorial projects and civic foundations, Ortega transcended the academic realm to become the proponent of a major spiritual restoration in Spain. His Revista de Occidente, a magazine founded in 1923, was aimed at reinvigorating the languishing cultural life of the interwar years. His energetically pursued civic foundations boosted the influence of his thinking in the Hispanic world. One of his close partners in these political endeavors was Dr. Gregorio Marañón.
The Generation of 1914's Marañón is one of the fathers of endocrinology and an intellectually opulent humanist whose significant contributions to sciences and arts earned him simultaneous seats on all five Spanish Royal Academies (Medicine, Sciences, History, Language, and the Arts).18
Kyle RA, Shampo MA. Gregorio Marañón. JAMA 1982;247(22):3088.
Keller GD. The Significance and Impact of Gregorio Marañón. New York: Bilingual Press; 1977.
Marañón inaugurated a new scholarly paradigm where topics must be exhausted from all angles and disciplines to be comprehended. After Marañón, the more specialized the knowledge, the more enriched by other fields and not evidently connected disciplines it has to be.
As a man of his generation, Marañón tirelessly tried to bring Europe into Spain, doing for medicine what Ortega did for philosophy. But he remained close to his roots. He enjoyed wide popularity in Spain, and his funeral in March 1960 was attended by hundreds of thousands of Madrileños. In contrast, Xavier Zubiri (1898–1983), the most recent influence on leading Spanish medical humanists, never had the same reach.
A Radical Innovator: Zubiri
Xavier Zubiri's philosophy is impenetrable, only clear to those who have decided to become “zubirians”—or so goes conventional wisdom. Nevertheless, the doctrines of this rarely published former priest tint contemporary Spanish bioethics through their influence on Pedro Laín Entralgo and Diego Gracia. Zubiri developed a philosophical system that includes a theory of knowledge, a cosmology, a philosophical anthropology, and a metaphysics. He also provided the materials for a foundation of ethics. All Zubirian doctrines are radically innovative.
Zubiri's theory of knowledge detaches itself from the millennial tradition of separating intelligence and sense, a division he regards as merely didactic, and postulates instead the inseparability of the sensible and intellectual facets of human knowledge, which is carried out by what he termed “sentient intelligence.” His cosmology introduces the notion of cosmos as dynamism. His anthropology looks beyond the traditional opposition between dualism (man is soul and matter) and monism (man is only matter). Zubiri's metaphysics somewhat challenges Aristotle's concept of substance, unfolding it into substantivity and structure. These groundbreaking theories, together with Zubiri's phenomenology, are among the bases of Laín Entralgo's works, particularly in his medical anthropology. Gracia builds his foundation of ethics on Zubiri's doctrines.
Spanish Bioethics: Its Authors and Contents
Laín Entralgo
Pedro Laín Entralgo, professor of history of medicine in Madrid, was a physician and thinker philosophically linked to Ortega and, more particularly, to Zubiri, of whom he was a fraternal disciple. A psychiatrist educated in Vienna in the 1930s and a member of the Spanish Royal Academies of Medicine, Language, and History, Laín's legacy encompasses the history of medicine, philosophy, and medical anthropology. Like William Osler,20
Osler W. The Old Humanities and the New Science. Boston: Houghton Mifflin; 1920.
There are a few main themes in Laín's philosophical works, each one dominating a stage of his career and each one also connected to the contingent reality of the moment, and none of them alien to the central problems of philosophy of medicine. Those themes are faith, hope, friendship, and the human body, and represent Laín's anthropology, according to which the human being is a credens, sperans, amans, and corporale animal. “We are our beliefs, our hopes and our preferences” (267).21
Laín Entralgo P. La espera y la esperanza. Madrid: Alianza; 1984.
Doctor and Patient is perhaps one of Laín's most influential works in the field of medical ethics. In it, he argues that the doctor–patient relationship is a social phenomenon whose essence is friendship, albeit a rather asymmetric friendship where both parts, echoing Aristotle, are not equal. Unlike the patient, the doctor has power, knowledge, and health. This, Laín maintains, makes it a quasi-dyadic relationship, one of different but equal sides. From the very nature of this relationship, Laín sketches the moral principles that should govern it. The morality of the virtuous doctor, Laín maintains, is commanded by the principle of maximum technical competence, work well done, and the authenticity of good.
The principle of maximum technical competence means the doctor “starts being moral only after achieving the technical sufficiency permitted by his personal endowments together with the didactic and instrumental possibilities of his world.” The principle of work well done simply states that all knowledge may be superfluous if it is not used to achieve the perfection of each and every task. “The physician's moral,” says Laín, “consists of doing in the best possible way what technically has to be done. The perfection of one's own work is not only an intellectual, technical or aesthetic deed, but—essentially—a moral duty” (452).22
Laín Entralgo P. La relación médico-enfermo. Madrid: Alianza; 1983:452.
Laín's principle of the authenticity of good introduced patient self-determination and autonomy in the early 1960s, decades before those terms had entered the medical vocabulary. This is possibly the most influential of all three of Laín's principles. The principle of the authenticity of the good states that “the good of the patient has to be authentic, which demands the doctor abide by a double—and not always harmonious—set of commands; on the one hand the patient's intimate beliefs of what is the good and the perfection of man; on the other hand, the doctor's own beliefs about what good and perfection are.”23
See note 22, Laín Entralgo 1983: 453.
Laín's anthropologic phase started with a series of reflections on health and disease in his book The State of Illness—A Sketch of a Chapter on a Potential Medical Anthropology (1968). He worked feverishly on his theory of the body, on a systematic medical anthropology, and on the body–soul problem.
Gracia
Diego Gracia, at the time a recent graduate of Salamanca, went to Madrid to specialize in psychiatry and to work on his doctoral thesis with Laín. A book by Laín that he read in high school is what awakened in Gracia his will to access humanities through the door of medicine. Via Laín, Gracia met Zubiri. For many years, Laín and Zubiri were Gracia's mentors, which is reflected throughout his works.
Gracia introduced contemporary bioethics in Spain. Going beyond simply translating American bioethics, Gracia transformed bioethical concepts and institutions into a set of Mediterranean categories and institutions, and worked to build its philosophical foundations. Nevertheless, he kept intact the practical spirit of American bioethics. If not for Gracia's transformation, American bioethics perhaps would have remained alien to the Spanish context, an intellectual curiosity with few practical repercussions.
Gracia's works have produced critical contributions to the philosophical foundations of Spanish bioethics, its principles and procedures. Gracia, like Vives, is concerned with the social costs and benefits of medicine and healthcare systems.24
Gracia D. What constitutes a just health services system and how should scarce resources be allocated? Bulletin of the Pan American Health Organization 1990;24(4):550–65; Gracia D. Spain: new problems, new books. The Hastings Center Report 1988;18(4):S29–30.
Gracia's foundations of bioethics are well rooted in the Mediterranean and continental European traditions of nonconsequentialist Kantian formal principialism. However, like Zubiri, his principialism is rooted in values and not goods, which separates the Spanish tradition from the Kantian legacy. In this framework, even if Gracia in some ways adheres to the four principles of Georgetown—nonmaleficence, beneficence, autonomy, and justice—for him only nonmaleficence is a material principle (i.e., a prohibition). The rest are more procedural checklist than strictu sensu principles.
Gracia's procedural ethics draws on Aristotelian deliberation. If certainty in medicine is impossible, recommendations are never assured, but merely “reasonable.” And this reasonability is achieved through the deliberative process. However, even if deliberation is—according to Gracia—necessary for any ethical decision-making process, from principialism to pragmatism, it is also a method in itself. And it is not an inductive process moving from practice to principles, as is often the case in American clinical ethics. On the contrary, in Gracia's framework, deliberation first determines the values at stake. Second, it analyzes possible courses of action according to their ability to realize the identified values, to finally look at the likely consequences.25
Gracia D. Ethical case deliberation and decision making. Medicine, Health Care, and Philosophy 2003;6(3):227–33.
In the following section we attempt to identify the influence of Spanish bioethics on American scholars.
Spanish Echoes in American Bioethics
Spanish echoes in American bioethics run from Edmund Pellegrino and David Thomasma's use of Laín's phenomenological approach to medicine26
Pellegrino ED. Humanism and the Physician. Knoxville: University of Tennessee Press; 1979; Pellegrino ED, Thomasma DC. For the Patient's Good. New York: Oxford University Press; 1988.
Pellegrino was struck by the analytical richness of Laín's theory of medicine. Medicine in this framework is not an entity but a social phenomenon where the physician plays a variety of roles:
Pedro Laín Entralgo has written most perceptively about the history of the patient–physician relationship in terms of the physician's motives under four general headings: (1) physician as a technical helper; (2) physician as a seeker of knowledge; (3) physician as functionary of an institution; and (4) physician as seeker of profit…. One of these roles, the role of healer, is primary; the other are subsidiary. (8)27
Pellegrino ED. The Moral Foundations of the Patient–Physician Relationship: The Essence of Medical Ethics. In: Pellegrino ED, ed. Military Medical Ethics. Washington, DC: Office of the Surgeon General at TMM Publications; 2003:3–22.
Pellegrino, drawing on Laín, brought into the American context the notion that physicians frequently play simultaneously conflicting, sometimes difficult to conciliate, roles. These views, now part of mainstream American bioethics, have contributed to the understanding of the conflicting roles of doctors in the clinical field and in research.28
Pellegrino ED. Medical morality and medical economics. The Hastings Center Report 1978;8(4):8–11; Pellegrino ED. Patient and physician autonomy: Conflicting rights and obligations in the physician–patient relationship. The Journal of Contemporary Health Law and Policy 1994;10:47–68. Barie PS, Bacchetta MD, Fins JJ, Eachempati SR. Research in the Intensive Care Unit: Ethical and Methodological Issues. In: Souba W, Wilmore D. Surgical Research. San Diego, CA: Academic Press; 2001:137–154.
Pellegrino, oftentimes with Thomasma, introduced the model of friendship to understand the doctor–patient relationship, a paradigm he also borrowed from Laín. This model, on which other authors elaborated, helps illustrate the paternalism (love, care, authority) and antipaternalism (equality, respect, rights, comradeship) inseparably knit into the doctor–patient relationship.29
Childress JF, Siegler M. Metaphors and models of doctor–patient relationships: Their implications for autonomy. Theoretical Medicine 1984;5(1):17–30; Fried Ch. Medical Experimentation. Amsterdam and New York: North-Holland/American Elsevier; 1974; Thomasma DC, Kissell JL, eds. The Health Care Professional as Friend and Healer—Building on the Work of Edmund D. Pellegrino. Washington, DC: Georgetown University Press; 2000.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions: A Report on the Ethical and Legal Implications of Informed Consent in the Patient–Practitioner Relationship. Washington, DC: U.S. Government Printing Office; 1982.
Siegler M. Searching for moral certainty in medicine: A proposal for a new model of the doctor–patient encounter. Bulletin of the New York Academy of Medicine 1981;57(1):56–69; Siegler M. The nature and limits of clinical medicine. In: Cassel E, Siegler M, eds. Changing Values in Medicine. New York: University Publications of America; 1979.
Pellegrino considers the concept of virtue the foundation of ethics. This notion, the author states, had its heyday in the classic world, with Aristotle and the Stoics, until well into the Middle Ages, with Aquinas. It was gradually buried in modern times under positivist and analytical philosophical systems, but was resuscitated at the end of the past century.32
Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New York: Oxford University Press; 1993; Pellegrino ED. Toward a virtue-based normative ethics for the health professions. Kennedy Institute of Ethics Journal 1995;5(3):253–77.
Pellegrino ED. Every sick person is my brother or sister. Dolentium Hominum 1988;3:65–70.
Whereas Pellegrino made use of some of the Spanish scholars' ideas and methods, James Drane, on the contrary, did not just borrow ideas from Spain. Drane, a bioethicist educated in Italy and Spain, set himself the goal of bringing “back to the attention of my American colleagues the ideas and orientations of my Spanish friends” (x)34
Drane J. Becoming a Good Doctor—The Place of Virtue and Character in Medical Ethics. Kansas City, KS: Sheed & Ward; 1988.
Drane was fascinated by the atmosphere of erudite comradeship found in Spanish tertulias, regular café meetings of a small group of intellectuals around a couple of scholarly heavyweights, to share cultivated conversation, interminable rounds of coffee, and endless cigarettes. Drane, who as a young priest in the 1960s was suspended for having argued that the Church should change its stance on birth control,35
Drane J. PAHO y bioética. ¿Una relación accidental o un compromiso profundo? In: Lolas Stepke F, ed. Diálogo y cooperación en salud. Diez años de bioética en la OPS. Santiago de Chile: Organización Panamericana de la Salud; 2004:15–22.
Years after his first Spanish experience, Drane wrote his Becoming a Good Doctor, subtitled The Place of Virtue and Character in Medical Ethics, where he pours into the American bioethical vase the contents of the Spanish ethical Quixotic traditions. Drane finds a fundamental problem with American medical ethics; this is, that in it “ethics becomes a decision-making methodology that is conscious or unconscious imitation of the law,” where “a judgment is rendered by applying the precedent to the facts” and “facts plus standards produce specific, concrete judgments.” This, for Drane, impoverishes ethics, which is reduced to technical knowledge, paralleling the “Sophists who also construed ethics in terms of rules and technical knowledge.” This is why, Drane points out, American bioethics is centered “in the creation of concrete action guides” instead of being concerned with character. Modern medical ethics needs both ethical models playing off each other: “The Protestant model [that] centers around duties and rights and formal standards of right and wrong.” and “The other [which] centers on character, virtue and styles of being a good person.”36
See note 34, Drane 1988:134–6.
Drane J. Clinical Bioethics. Kansas City, KS: Seheed & Ward; 1994.
In Drane's proposals, each area of ethical problems in medical fields should be ruled by a specific virtue. Diagnosis and prognosis, by benevolence; communication, by truthfulness; decisionmaking, by respect; feelings, by friendliness; access, by justice.
Concluding Remarks
Spanish moral philosophy has a long history and strong personality. The expression of ancient and modern philosophical traditions, it is also a popular philosophy, connected to the spirit of a society that appreciates its cultural heritage, where Séneca is affectionately called “the great Andalusian,” where current Socialist Party leaders find inspiration in Vives and Vitoria on matters of solidarity and human rights, and where the adages of Don Quixote—a best-seller even today—color many a conversation. Unamuno and his ethics of the exerted spirit are the culmination of these traditions.
Spanish contemporary bioethics was built on this bedrock, with Ortega and Zubiri providing a refined philosophical apparatus, and Marañón showing how to integrate medicine, philosophy, and humanistic disciplines. Despite these new philosophical and methodological currents, the basic loyalty to the ethics of virtue, character, and principle remain intact.
Laín, then, offers principles that condense what a doctor's virtues must be. His principle of “authenticity of the good,” which today might be read as a call for patient autonomy, in fact states that the virtuous doctor must be humble and magnanimous. Gracia's efforts to build the foundations of bioethics can be seen, to a large extent, as an attempt to complete what from his philosophical tradition may seem lacking in American bioethics. Drawing on the philosophical legacy, Gracia redefines the four classic principles as nonprinciples (except for nonmaleficence)—in the Kantian sense—that constitute a straightforward checklist.
Spanish bioethical traditions, with their immense historical heritage and their newly developed doctrines, have had clear impact on American bioethicists such as Pellegrino, Drane, Siegler, and others. One of us (J.J. Fins), a proponent of utilizing the American pragmatist tradition in bioethics under the rubric of clinical pragmatism, has nonetheless borrowed strong notions of virtue ethics from the Spanish masters.38
Fins JJ, Bacchetta MD, Miller FG. Clinical pragmatism: A method of moral problem solving. Kennedy Institute of Ethics Journal 1997;7(2):129–45.
Novoa Jurado AJ, Molina Duran F, Luna Maldonado A. Reconstrucción del pensamiento médico: Fundamentos del pragmatismo clínico. Medicina Clinica (Barc). 20048;123(9):345–51.
At the same time, Spain has much to contribute to American bioethics for the benefit of doctors and patients. As Pellegrino and Drane have proposed, virtue and character should be fostered among young physicians. Friendship between doctor and patient, with its dignifying and therapeutic properties, should take the place of the contractual, impersonal model. Social solidarity could provide some hope to the millions of Americans who are left out of any health coverage.
Understanding Spanish bioethics may also be a way to better serve a large portion of the American population. As Unamuno said, Spanish philosophy is the expression of the history, culture, and feelings of a people. We would extend that definition to Spanish bioethics, and note that the roots are not limited to the Iberian Peninsula, but rather extend to much of the Spanish-speaking world. A nuanced understanding of this heritage can help shape, in the United States, an ethics that is resonant with the growing number of Spanish-speaking Americans. Bioethical and philosophical competence make cultural competence all the richer.
