Where I am, in the late 70s, I find myself being asked to do far more than I am able. I'm at the stage when everyone assumes that I don't have any real work, so it's OK to ask for things. Increasingly the things I'm asked to do are historical: What was it like back then? When did you start doing this or that? How did this or that get started? I guess I'm in the penultimate period. I'm still working every day, much harder than I would like, and upset by the fact that my memory is not working the way it should. With this public confession, I'll now start my penance, that is, to do a little personal history of my involvement with bioethics first here in the United States, then in Spain and Spanish-speaking nations of Latin America.

The story of my involvement with medical ethics goes back to the post-WWII period, when modern medicine became American medicine. Shortly after WWII, I (a seminarian) was sent to Rome to study theology at the Gregorian University. The Gregorian is a historical Jesuit Institution with students from all over the world. The official language of the university then was Latin. The professors were famous Jesuit academics from different countries who lectured to large classes in Latin. Examinations were usually oral and in the same language. My moral theology professor was Father Francis Hürth, S.J., who held many different degrees besides being a physician. He used medical cases to apply theological principles to concrete situations. What we students received in Rome at the Gregorian was a classical medieval style education, focused on theology, law, and medicine.

During the long summers, American students were not permitted to return home and instead traveled throughout Europe. The Roman educational experience therefore was enriched by months of hands-on contact with different cultures. My first visit to Spain was in the early 1950s.

After returning to the States and being ordained to the priesthood, I was assigned to teach at St. John's Seminary in Little Rock, Arkansas. First I taught Latin and gradually moved into philosophy and romance languages. In 1961, I enrolled in a Master's Program in Spanish at Middlebury College in Vermont. After a few courses on the campus in Vermont during the summer, the Master's Degree students moved to Spain and to the University of Madrid to complete the program. During this time, General Franco was in charge, and at the university I was constantly confronted with issues of Marxism and Fascism.

To get beyond theoretical Marxism, I decided to try to sneak into the Soviet Union in order to see how all the claims worked out in practice. I went to Austria and to the sector then under control of the Soviet Union. I made friends with a communist group that was planning a tour of the Soviet Union and convinced them to take me along. Americans were not allowed in the Soviet Union at that time, so my identity had to be hidden. We traveled extensively, and I had many exciting experiences that I began to write about upon my return. When U.S. government agents read some of my newspaper articles they sent a group of investigators to interview me. I shared many photos, taken wherever the KGB guides said photos were forbidden. From that time on, to my surprise, the agents kept track of me, where I was, and what I was doing.

One year after completing the Master's Degree in Spanish I returned to Spain to begin a doctoral program in philosophy at the University of Madrid. During this second stay in Spain I had two objectives: to receive a Ph.D. Degree in ethics (under the tutelage of Spain's most renowned ethicist, José Luis Aranguren) and, while doing so, to try to influence the Spanish hierarchy to change their attitudes on the topic of religious liberty. The second objective was planned under the direction of Father John Courtney Murray, S.J., a Jesuit theologian who was the chief advisor of the American bishops at the Second Vatican Council.

The Second Vatican Council met in four sessions from 1962 to 1965. One of the most important documents of the Council addressed the situation of the Catholic Church in the contemporary world. This document was designed to move the Church beyond the First Vatican Council's negative attitude toward the Enlightenment and its condemnation of modern cultural values.

The 18th century European Enlightenment had a distinctly anti-Catholic flavor. It stood for hard laboratory science as the only way of understanding. Enlightenment era thinkers tried to move society away from religion and into a new era of individual freedom and political democracy. Enlightenment political leaders were especially antagonistic toward the Catholic Church because of the power exercised by Church authorities over ordinary people in many European nations. Catholic hierarchs were publically threatened. They were stripped of public power and lost the Vatican States. Popes reacted to the Enlightenment with streams of criticisms and condemnations of all the Enlightenment stood for.

John Courtney Murray, in his many books and journal articles, argued theologically for an American political perspective, for universal human rights, and for the ideal of religious freedom. The Church, he argued, needed to change its teachings and policies on these issues. One of the counciliar documents expressed, explained, and justified these changes. This important document met with strong opposition at the Council from Spanish bishops who held to the view that “error had no rights,” and therefore they defended the denial of basic freedoms to non-Catholics. This perspective was strongly and obviously in place in Franco's Spain during these years.

One little event that occurred during my stay will help readers understand the political and religious climate in Spain at this time. An evangelical American tourist stopped to have his shoes polished in downtown Madrid and used the opportunity to try to convert the older man who was shining his shoes. After listening to the pleas for conversion to Protestantism, the old man thought for a minute and then said, “No, I don't believe in the Catholic Church, which is the one true Church; how can I believe what you say. His disbelief was not uncommon. One of Fr. Murray's points was that, where the Catholic Church was the official religion and enjoyed privileged status, widespread unbelief was created but repressed. All religions would be better off in a social climate of political freedom and mutual respect.

My task, worked out with Fr. Murray at Georgetown University, was to write a doctoral thesis in Spanish on these issues and, while in the country, to address the Spanish bishops personally with the arguments for change in official Church teachings. My professor and mentor at the university shared Father Murray's perspective. He approved my writing a dissertation of this topic and my efforts to interact with the Spanish bishops. My dissertation was entitled The Foundations of Tolerance.

I spoke to many bishops and on one occasion addressed the whole Spanish hierarchy on this topic. They listened, but my arguments were met with a deafening silence. One bishop, after the lecture and on the way to the dining room, whispered in my ear very privately that he agreed with me. When the final document came up for a vote at the Council, the Spanish bishops voted no. My project was not successful, but the final vote on this document at the end of the Council was 1,954 in favor, 249 against. This vote and the new Church teachings were one of the high points of the Council. It was a success for the American bishops who advocated for the changes and a tribute to their chief advisor and theological expert, Fr. Murray, whose ideas and arguments the document reflected.

I was in Madrid during the Council period. My work during this period enriched my relationship with the Spanish people and with the Spanish culture. My professor brought me with him to meetings held weekly with some of Spain's most recognized intellectuals, including Pedro Laín Entralgo.Footnote ¹Don Pedro was Spain's most respected physician intellectual and the best known medical humanist in all of Western culture. His dozens of books connected today's scientific medicine with classical and contemporary philosophy and theology. I attended many of Laín's lectures, which helped me to appreciate ethical issues embedded in contemporary medical practice before there was a discipline called bioethics.

During my stay in Spain, I had considerable experience with the secular political system of General Franco. My professor, José Luis Aranguren, was a prominent critic of Franco and his regime. Consequently, in our classes there were always government observers. We knew that we were being watched. Shortly after I left Spain, my professor was stripped of his personally held academic chair and had to leave the country. Franco's Spain was not a friendly environment for what he and I were doing.

Besides my doctoral work at the University during the second stay in Spain, I provided help to a Catholic priest in the Basque region who publicly opposed Franco and was organizing free labor unions for poor young Basque men outside Franco's system. I made several trips to the Basque region for this purpose. On the night before my thesis defense, I received a call from the U.S. embassy telling me that the Franco government had me under observation and I was about to be arrested. I had to leave the country immediately, they said. So, I packed up that night and, after my defense, escaped. During the years back home, I was involved with ethical issues of race and religion in Little Rock, but these years were peaceful by comparison, until the biggest upset of my life.

In 1967 I was working at Yale after having been expelled from the priesthood and removed from my position as Professor of Philosophy and Romance Languages at St. John's Seminary in Little Rock. What caused this disruption in my life was a series of articles that I had written, arguing for change in traditional Catholic teachings on birth control. The ethics of fertility control had to do with medicine and medical procedures: tubal ligation in women, oral contraceptives (the pill), subdermal implants, progestin injections, intrauterine devices (IUDs), condoms, diaphragms, cervical caps, spermicides, and so forth. The birth control issue also had to do with changed cultural situations and, I thought, with the inevitable evolution of moral thinking on concrete moral issues.

Some theologians came to my defense following the expulsion. I initiated a legal suit in the Ecclesiastical Court System to challenge my dismissal. I lost at the diocesan level, the archdiocesan level, and finally in Rome. Some of the judges in Rome, however, thought that ecclesiastical procedures had been violated, and they offered me lay status and a dispensation from my clerical vows. I accepted. The case received national attention in the media (e.g., Life magazine).

While at Yale I was busy writing about medical ethics at the beginning of life. I was also writing a book on Authority and Institution in the Catholic Church. Dan Callahan was involved with the issue of abortion and public policy. He wanted to do a study of the way abortion was handled in different cultures and how the experience of abortion in these cultures might contribute to public policies in the United States. Dan received a grant to do his study and invited me to go along. He was studying abortion policies; I was studying birth control policies. We traveled around the world. One of the last places we intended to visit was Czechoslovakia and, just before we arrived there, the Soviets invaded. Dan missed his wife and kids, so he decided to go home. I decided to stay, finally got into Prague, where I got into trouble for traveling with reporters in order to observe the Soviet military. Then, I left and finished up the project in Spain.

During our travels Dan talked constantly about the possibility of starting an institute for the study of ethical problems in medicine. He knew about the number of ethical problems linked to new medical technologies and to ongoing medical research. He knew that these would continue to increase. These problems needed to be addressed in a solidly academic and rigorously systematic way so that responsible public policies could be created by legislators. After making a case for this type of institute to several foundations, he received a grant and started The Hastings Center, at Hastings-on-Hudson in New York. He also started a small journal called The Hastings Center Report. At the Center, he brought together the best scholars from different fields to study particular ethical problems in medicine and made available the ethical insights developed by these scholars to politicians responsible for public policies, as well as to the broader community.

Shortly after establishment of The Hastings Center (1969), The Kennedy Institute of Ethics was established at Georgetown University (1971) by André Hellegers. Originally, The Kennedy Institute was named The Kennedy Institute for the Study of Human Reproduction and Bioethics. Hellegers also had argued for change in the Catholic Church's teachings on birth control. The Hastings project brought together specialized scholars to provide ethical direction for public policies in the area of healthcare. The Kennedy Institute developed courses and degree programs in the new discipline, which had been named bioethics by Van Rensselaer Potter in 1971.

Bioethics was defined as the systematic study of moral conduct in life sciences and medicine. In the early days of bioethics, persons like myself with backgrounds in philosophy and theology had to gain access to some form of medical education. Physicians in turn had to study ethics. During the 1970s I took courses at Georgetown University Medical School and then did a residency at the Menninger School of Psychiatry. My theological training in Rome provided a good background for working in the new discipline of bioethics.

In this early period of bioethics the majority of the problems had to do with the beginning and end of life: abortion and contraception, death and dying. There was an ethics committee formed in the early 1960s in Seattle, Washington, that tried to establish ethical policies for distributing a scarce medical technology (dialysis) to dying patients, but the criteria designed by the committee to select patients for dialysis were severely criticized.

Because health (salus) in U.S. culture is what salvation (salvus) was in medieval times, medical practice received both substantial economic support from government and extensive attention in the media. Bioethics pulled together under one discipline the ethical issues associated with medical research and mainline medical practice. What for centuries was referred to as medical ethics, was now included within the broader discipline of bioethics. Bioethics quickly spread from the United States to Europe, then to the whole world. Assigning the beginning of bioethics to particular events like the establishment of The Hastings Center and The Kennedy Institute admittedly is somewhat problematic. Distinguishing first steps from preliminary and background influences is difficult, but these research and teaching centers were certainly related to the beginning of bioethics, which now is a worldwide and ever expanding discipline.

In my many visits to Madrid during the 1970s and 1980s, I had spoken often to Dr. Diego Gracìa about U.S. bioethics. I still remember our first meeting in his office and the immediate interest he showed in what I recounted about the new discipline of bioethics and how quickly it was spreading. He immediately wanted to introduce the discipline into the curriculum at his medical school. He started by teaching courses in death and dying and then, in 1985, began teaching a course in bioethics to medical students. I participated in this first step toward establishment of bioethics in Spain by sharing with Diego some of the teaching.

In 1987, I arranged for him to come to the United States. He stayed with his wife and family in Edinboro, Pennsylvania. He spent time at The Hastings Center and The Kennedy Institute, and then he and I traveled around the United States looking at how bioethics was being handled in different academic contexts. The visits also provided Diego with personal contact with the most prominent and productive North American bioethicists. When he returned home he started a Master's Degree program at the Complutense University in Madrid, the first in Spain. This program is still vibrant and about to celebrate its 20th birthday.

Diego and I have always been friends and have worked together to develop first a Spanish and then a Latin American bioethics.

Bioethics entered Latin America in a formal and legal way through the Pan American Health Organization (PAHO) in the late 1980s and early 1990s. Individuals like José Alberto Mainetti in Argentina had laid some background intellectual foundations for the discipline by holding conferences on medical humanities and medical ethics and by writing journal articles that made references to bioethics as it was developing in the United States and in Europe.Footnote ² Dr. Mainetti also had been a student of Laín and was strongly identified with humanities in medicine. Other individuals involved in the early period of Latin American bioethics were Alfonso Llano, S.J., Roberto Llanos, and Manuel Velasco-Suárez.

PAHO became involved with bioethics after having been blamed for ethical violations of research subjects in Latin America. Large pharmaceutical firms moved certain research projects to Latin America in order to avoid the monitoring and moral limits required in the United States. Some research subjects in Latin American nations were seriously injured in the trials, and PAHO was blamed for not providing them with adequate protection. What followed were lawsuits and fines and finally the effort by PAHO to keep such violations from happening again. Out of the legal office at PAHO, under the direction of Herman Fuenzalida, conferences on bioethics were organized in the late 1980s and bioethics publications were distributed in the region. The conferences were conducted mainly by U.S. bioethicists, and the publications were mainly translations of North American authors. These first moves were important but inadequate.

A Latin American bioethics is what was needed: a bioethics based in Latin American nations and expressing a Latin American perspective. I was contacted by PAHO and asked to work with this project. To initiate the project, the director of PAHO sent me on a trip throughout the region in order to communicate information about bioethics and to identify persons in the different nations who were willing to be trained in and to work in the discipline. One objective was to form ethics committees in each nation to oversee research being conducted there (IRBs) and eventually to develop national standards by which research projects would be judged. A different but related objective was to encourage the development of bioethics courses in medical schools and clinical ethics committees in hospitals.

In 1990 I took a sabbatical leave from Edinboro University to become the first resident bioethicist at PAHO and to promote the PAHO bioethics project throughout the region.Footnote ³ During visits to each country, I met with ministers of health, medical association directors, professors of ethics, university hospital staff members, and professionals who had written on medical ethics and related topics. I worked out of the legal office at PAHO in Washington, D.C., and continued my travels to Latin America during the 1990s.

The end result of these efforts was an agreement forged by PAHO, the University of Chile, and the Chilean Government to establish and to fund a Regional Bioethics Program from which ongoing bioethics projects would be conducted. The president of Chile, Eduardo Frei Ruiz-Tagle, attended the inaugural event along with PAHO directors from all Latin American nations. Carlyle Guerra de Macedo, the director of PAHO, and I spoke to those assembled. The first director of this Programa Regional was Dr. Julio Montt, the former Chilean Minister of Health. The next director was the former provost of the University of Chile, Dr. Fernando Lolas, M.D., Ph.D. He is the author of many books and many articles.Footnote ⁴ The Programa now is called The Unidad.

A great deal of the medical research carried out in Latin American nations was funded from outside, most often by international drug companies. They conducted their trials with persons who signed consent forms but, because of the paternalistic character of the doctor–patient relationships in Latin American countries, the research subjects were rarely free and informed participants. The ethics of the research usually was dependent upon the good will of the investigator. In many instances, the “research” was a repetition of research already completed in the United States and carried out by doctors paid by the pharmas. The objective was to get publicity for products and to boost sales.

Every nation in Latin America during the 1980s and 1990s had high-tech hospitals where contemporary scientific medicine was practiced. Ethics, however, did not play the same role at these hospitals that it did in the United States and Europe. Contemporary high-tech medicine in Latin America was usually practiced in more socialistic medical systems. Socialized medicine attempted to provide treatment access to broad populations, but it provided little opportunity to establish ongoing and personal relationships between doctors and patients. The focus was on delivery of medical treatment, and little attention was given, either on the part of doctors or patients, to communication of information, free consent, or moral dimensions of the doctor–patient relationship.

Following the great success with his program in Spain, in 1996, Dr. Gracia agreed to conduct a Master's Degree program, sponsored by the PAHO Programa, in Latin America. Three classes have already finished their Master's Degree. Dr. Gracia's students now teach bioethics in different countries and work with ethics committees both for research monitoring and problem solving in clinical settings. His Master's Degree program has enriched bioethics projects throughout Latin America.

To continue to develop this perspective and to increase its influence in the region, a bioethics institute has been established at Edinboro University of Pennsylvania, which will provide financial support and room and board at Edinboro University for Spanish and Latin American students and scholars to do research in bioethics.Footnote ⁵

Bioethics in Latin America is not yet as extensively developed as in the United States, but progress is ongoing. As more degree programs are established at different universities, more bioethics conferences are organized, more research institutes are started, more scholarships become available, and more journals are established, development of the discipline will continue. The form that bioethics takes in Latin America will be influenced by different cultural backgrounds in the different nations. Latin American bioethics will be influenced by U.S. and European thinkers, but it will also have its unique characteristics. It will continue the Greco-Roman intellectual tradition, a Catholic theological tradition, and a greater emphasis on social concerns. As its emphases and perspectives become better known in Europe and the United States, it will contribute to bioethics worldwide.