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1 The Beginnings of Bioethics

In the 1960s, Dan Callahan and I traveled around the world together. At that time, Dan was the editor of Commonweal, a national Catholic journal of religion and politics based in New York. I was at Yale University on a fellowship after having been suspended from the priesthood for writing an article advocating change in the Church’s teachings on birth control. Dan was doing research on public policies on abortion in different cultures. I was studying different public policies on birth control. Both of us were writing books on these topics. What I remember most about our time together was that he missed his wife and children, and that he kept wondering whether he could leave his job at Commonweal in order to start an institute for the study of ethical problems raised by contemporary medicine.

Issues of ethics in medicine were very much in the public consciousness after World War II (WWII). First, there were the shocking ethical failures of Nazi physicians, revealed at the Nuremberg trials. Following the war, the US government invested enormous amounts of money in medical research. The ethical issues embedded in all the different research projects were supposedly handled by an Episcopal priest ethicist, John Fletcher, who was an employee at the National Institutes of Health (NIH), but he had too little authority, and the research projects were more numerous than any one person could monitor effectively.

Fruits of the enormous government investment, in the form of new treatments and new technologies, were arriving in clinical practice in a constant stream. Every new development raised its own specific ethical problems. Older ethical issues associated with the beginning and the end of life, which went back to before the Second World War period, became more and more prominent. For example, Dr. John Rock developed the birth control pill, which raised ethical questions about its use and about legal controls on the sale of contraceptives.

Procreational issues like abortion and birth control were widely discussed in the media, in federal and state legislatures, and in the courts. The general trend was to remove legal restrictions. The debate was intense and legislators were looking for ethical insight. Doctors working in clinical medicine also needed help with ethical issues, once the post-war technologies arrived at the bedside. Many of the new technologies made it possible to extend a patient’s dying and created questions about medicine’s role process.

Finally, there were the more philosophical questions about the nature of the medical profession and the ends of medicine. By the 1960s, ethical problems existed everywhere in medicine, which called for serious study, direction for medical practitioners, and effective public policies.

Dan and I talked about these questions all during our travels together. About the proliferation of ethical problems created by contemporary scientific medicine, there was no doubt. The doubt was whether or not financial help could be found to establish an institute for the study of the ethical problems in medicine. Could he find enough grant money to start a medical ethics institute? This was the big question.

When we got back from this trip, he did two things. First, Dan finished his book on abortion, which had an important impact on Supreme Court judges when they made the Roe v. Wade decision. Second, he received the financial help he needed, left his position at Commonweal and started the Hastings Center. This was 1969. The establishment of this first medical ethics institute marked an important step toward the establishment of a new academic discipline that came to be called bioethics. The term bioethics is attributed to Van Rensselaer Potter in his book, Bioethics: Bridge to the Future (Potter 1971).

Today, the idea of medicine as separate from bioethics, in the sense of formal and systematic attention to ethical issues, is unimaginable. The new bioethics was much broader and more complex than traditional medical ethics. Once established, it spread quickly around the world, and today it is one of the defining disciplines of our age. No one could presume to understand the medieval culture without seriously studying theology, and in the future no one will be able to understand today’s medical culture without studying bioethics. The discipline of bioethics defines us because medicine and health for us today are what religion and salvation were for western people of the Middle Ages. Disease, illness, surgeries, experiments, aging, enhancements, genetics, etc., preoccupy us and identify us. Ethical questions are bound up with every aspect of contemporary medicine. Professional associations like the World Health Organization (WHO), Pan American Health Organization (PAHO), American Medical Association (AMA), and similar medical associations in every country have to be concerned about ethical standards for medical research and medical practice.

Ethics has been joined to Western medicine from its Hippocratic beginnings. In fact, the classical philosophical ethics of Aristotle was medically based in the sense of being based on nature, i.e., the same physiology and biology that defined medicine. This bond between medicine and ethics continues into contemporary scientific medicine. Contemporary scientific medicine is German medicine, which links medicine with laboratory science. By the end of the nineteenth and early twentieth centuries, professional medical associations and German government authorities had developed ethical rules for medical research and medical practice. Footnote 1

We know, however, how quickly and how thoroughly these ethical norms were ignored by Nazi physicians who substituted a belief in eugenics for the classical background commitment to love and care expressed in the Hippocratic code.

In Nuremberg, after WWII, separate trials were conducted to address the crimes against humanity committed by so many physicians. The judges at Nuremberg formulated their own ethical code for medical research. Actually, this Nuremberg code was not all that different from the German government regulations so blatantly ignored by Nazi physicians. What facilitated the Nazi ethical violations was not the absence of ethical rules and regulations, but the absence of continued surveillance on the part of professional organizations, continued professional monitoring of medical activities, and continued emphasis on the ethical components of professional medicine. Withdrawal on the part of government and professional organizations from hands-on involvement with the ethical dimensions of medicine made possible the ethical violations which were condemned at Nuremberg. This is a lesson that cannot be forgotten without running the danger of having something similar happen all over again.

After WWII, the Nuremberg code was followed by ethical directives issued by the US government, the World Medical Association, the American Medical Association, and the Declaration of Helsinki. It was widely assumed that Nuremberg marked the end of ethical violations in medical research and medical practice. In the 1960s, there were many articles on medical research published in the United States, but great attention was not paid to the topic of ethics because it was assumed that the Nuremberg code and subsequent regulations had provided more than adequate direction for avoiding new ethical problems. Besides, the gross ethical violations committed by the Nazi physicians, people thought, could not happen in America.

Then in 1966, Henry K. Beecher, professor of anesthesia at Harvard University, dropped a bomb. In the New England Journal of Medicine, he published an article that detailed information about over 20 research projects that violated all the above-mentioned ethical standards (Beecher 1966). The similarity between these ethical failures in medicine and Nazi ethical failures was shocking. The ethical violations revealed by Dr. Beecher were done on the most vulnerable of patients, with government money, and presumably by good American physicians.

Rules and norms and codes had been in place for some time. One thing that was not in place was effective in-site monitoring of the research taking place everywhere. Many of the research subjects were patients who had gone to their doctors for help and were turned into research subjects without being informed or giving consent. The established ethical controls did not work, because doctors and researchers had so many personal incentives to pursue what they believed to be important scientific objectives. The classical ethical virtues of a good doctor, as well as the ethical rules of ancient and modern codes, were both simply ignored.

Dr. Henry Beecher’s revelations of ethical failures signaled the need for extensive reform in medical education and medical practice. This fomented a call for more supervision both by the government and by professional medical organizations. Dan Callahan’s idea of an institute for the study of ethical issues in medical research and clinical practice seemed a very appropriate next step.

2 The Role of the Pan-American Health Organization

The WHO had expressed its commitment to ethics in medicine in the preamble of its constitution. The PAHO had done the same thing much earlier and had established an ethics committee at the Washington office to examine all research projects taking place within its region. Dr. George Alleyne, who later became the director of PAHO, was the head of the institutional ethics committee at PAHO for many years. During his years as director (1995-2003), he continued to emphasize ethics within PAHO.

Dr. Carlile Macedo, during his tenure as director of PAHO (1983-1995), had recognized that the review of research projects at PAHO’s Washington office was not adequate to guarantee the required respect for human subjects. Under his administration, a conference on bioethics was organized in Latin America. Bioethics publications, originating from PAHO’s Washington office, were distributed in all Latin American countries. But even this was not enough. Latin Americans needed to be trained in the new discipline of bioethics and then organized into official Institutional Review Board committees in order to monitor research activities on site. This need required a giant new involvement with bioethics on the part of PAHO. Rather than have bioethics essentially as a Washington-based project, the decision was made to train bioethicists in every country in Latin America and the Caribbean in order to make sure that medical research and medical education and medical practice were all involved with the new discipline of bioethics.

What led to the decision to amplify PAHO’s bioethics projects was an ethical failure that bore a heavy cost. Certain American pharmaceutical companies wanted to move trials required for drug approval outside of the United States. In poorer countries of Latin America it was easier to recruit subjects for drug testing. It was also easier to avoid the restrictions imposed by the US government and professional medical associations. When some of the drug testing caused severely damaging consequences for the (mostly female) subjects, even death in some instances, PAHO was blamed for the failures. This created a crisis within PAHO. One change that followed from the crisis was a decision to create ethical monitoring committees in each country in order to provide in-place and hands-on oversight of medical research with human subjects. I came on board at PAHO in order to help with this project.

It was a series of subversions of medical ethics by pharmaceutical firms in order to advance their own economic interests that created the need to bring bioethics to Latin America in a more aggressive way. After all that has been done since then, all the educational programs that have taken place, all the new courses in bioethics at the medical schools, etc., the threat that first brought bioethics to Latin America has not been eliminated. Much has been done, but much remains to be done. There will be a bond between my generation of bioethicists and the younger generation now doing this work. We will be bonded by the values that we share, as well as by the need to address the threat to professional medicine that is still with us.

I worked with the bioethics project at PAHO during the 1980s. In the early 1990s, I traveled throughout the region to identify persons willing to be trained to work in this field. I worked with PAHO offices in each country, visited government officials, university hospitals, and medical schools in order to inform interested persons of PAHO’s plan to promote bioethics. What I communicated in my contacts was the urgent need for an in-place functioning bioethics throughout the region in order to address both the ethical problems in clinical practice and the ethical problems in medical research. I also communicated my personal conviction that a Latin American bioethics would have to be developed in order to expand, enrich, and in some cases correct the North American and European perspectives. This project marked the beginning of bioethics in Latin America that was promoted and sponsored by the powerful medical organization (PAHO) responsible for the character and quality of medicine in the region.Footnote 2

One thing is sure; in the years ahead, bioethics is not going to decline in importance or recede from the front-line concerns of professional organizations like PAHO. It cannot do so because today there are even greater dangers to the medical profession than were posed by the earlier ethical failures. Different academic congresses and seminars on ethics in medical research have been held over the years and have demonstrated the continuing need for PAHO support and for other independently sponsored bioethics programs. The bioethics issues and the need for ongoing attention to bioethics now go far beyond the area of medical research. Today the very soul of the medical profession is in danger.

Henry Beecher is one of the giants of medical ethics. He pushed governments and health organizations and research associations to develop ethical rules and policies, especially in the area of informed consent. But he did more than that. In the book he wrote in the late 1960s, he made the point that, as important as objective ethical rules are in medicine, they will never be enough to bring about truly ethical medicine. In his final major work, he made the point that only able, informed, compassionate, and responsible medical professionals can ensure that medicine meets its ethical objectives (Beecher 1970). The Latin American bioethics project originating from PAHO aspired to create effective monitoring of research, and then to help create medical professionals who are committed to the high ethical ideals of professional medicine.Footnote 3

3 An Ongoing Bioethics Project

During my travels throughout Latin America, I visited with medical school faculties and with medical association officials in order to promote a Latin American bioethics. I found many physicians who were interested in the new discipline, and I found persons who were already doing what I was trying to promote. In Argentina, I knew of a program in medical humanities that had been in place for years under the direction of Dr. Jose Alberto Mainetti. Dr. Mainetti and I had been educated in medical ethics by the same Spanish intellectuals.Footnote 4

Jose Alberto provided important help for the design of a PAHO bioethics project throughout Latin America. With his ideas, and the ideas of staff members at the legal offices at PAHO, and with ideas provided by medical professionals in all the different countries, a Latin American Bioethics Project was put into place. It was based in Santiago, Chile. It represented a collaborative effort by PAHO, the University of Chile, and the Chilean Federal Government.

My personal academic background included Catholic theology studied at the Gregorian University in Rome, and philosophy and ethics studied at the University of Madrid. Later, I studied medicine and did a residency in psychiatry with Karl Menninger in Topeka, Kansas. Because of my theology background, I was familiar with Latin American theologians. During my travels, I visited with theologians who enjoyed international recognition and had a particular interest in social justice, including the issue of justice in health care. I also made contact with several important Catholic hierarchs (e.g., Cardinal Evaristo Arns). For me it was important to develop a social justice perspective in bioethics, which in the United States and Europe was at best only a marginal concern. The Catholic universities and medical schools I visited already had medical ethics components, which they were very disposed to enlarge. Within a few years, with the help of an already in-place medical ethics base, a new Latin American discipline of bioethics was established and immediately started its own development.

In 1994, I spoke at the inauguration ceremony for the Pan-American Bioethics Program in Santiago. Eduardo Frei, then president of Chile, attended, as well as the president of the University of Chile, the director of PAHO, and many other distinguished guests. Ten years later, in 2004, I gave an address at the University of Chile in which I tried to describe how far we had come in the development of bioethics, and how far we still had to go. The bioethics that many had worked so hard to get established in Latin America could decline in importance. Indeed, it could fail unless certain ongoing dangers were recognized. In that talk I tried to refer to important aspects of the medical profession that I think are under threat and that bioethics must address. In fact, they may be under more threat today than they were in 2004.

Violations of medical research standards by pharmaceutical firms had generated PAHO’s original bioethics campaign and my personal involvement with bioethics in Latin America. These have not been eliminated. Over the years, we found that there were physicians working in clinical medicine that had turned themselves into salesmen for certain drug companies and promoters for certain drugs. In the 1980s, there was a threat to the profession of medicine coming from drug companies, and it remains a threat after all that has been done during this first period of Latin American bioethics. A bond between first generation bioethicists like myself and those who are now carrying the bioethics banner is a common concern about the influence of an aggressively capitalistic pharmaceutical industry on the profession of medicine, the practice of medicine, and the personal ethics of physicians.

4 The Medical Profession

Let me tap into my seminary background and do a little Latin etymology. The term professional comes from the deponent verb, profiteor, profiteri, professus sum. It means to vow publicly, to make a public promise, to declare publicly a commitment. A professional is one who makes a public commitment to do good for others: to bene facere, to beneficence. The three historical professions in Western civilization are Law, Priesthood, and Medicine. By examining medical history, we can gain insight into the meaning of a profession and into its important ethical components. With this background preparation, we can then look at the contemporary situation of medicine and see the challenge facing the classical medical profession and the new discipline of bioethics.

A professional is one who makes a public promise to provide services that are considered crucial in a decent society. A professional is defined by the following characteristics:

  1. 1.

    Professions provide essential public services for the good of others.

  2. 2.

    To aspire to do professional public service is considered a vocation, a calling rather than just a job.

  3. 3.

    Prolonged specialized university training is a pre-requisite for entering a profession. The university-based education includes both theoretical understanding and practical training.

  4. 4.

    Control over entering a profession is through licensing; one must have a proper license to practice a profession.

  5. 5.

    License and admission boards are made up of members of the profession.

  6. 6.

    Laws having to do with a profession are ideally influenced by the profession.

  7. 7.

    Those who pay for professional services do not control or have authority over what is provided.

  8. 8.

    Professions enjoy autonomy in the provision of services.

  9. 9.

    Professions compose their own ethical codes and the ethical standards of practice.

  10. 10.

    Professions operate according to objective ethical rules and with subjective virtuous attitudes in practitioners.

All the characteristics of a profession deserve attention. Autonomy, high levels of education, the setting of its own ethical standards, all deserve special attention today. They are particularly constitutive of a profession, and today they are under serious threat. Society grants professional privileges in exchange for a professional’s university preparation and a publicly declared altruistic ethic, versus a superficial academic formation and a selfish or self-serving personal ethic. Society grants individual autonomy, public respect, and a decent remuneration in exchange for being a good person and doing what is best for others.

The autonomy traditionally granted by society to medical professionals today is threatened. There are increasing pressures from different sources to control what physicians do. More and more frequently, physicians are treated like employees rather than like independent professionals.

The autonomy, respect, and monetary benefits historically enjoyed by the medical professional were never total. Society grants these benefits to professionals, and society monitors the way professionals carry out their promises. Are they truly providing needed services to others, or are they serving other interests? This is a question continually asked by society.

Monitoring of professions at the most concrete level, i.e., at the level in closest contact with actual medical practice, is not done by government officials. Governments do not have police just to watch over the behavior of medical professionals. Ethical monitoring is done by fellow professionals, medical associations, and professional medical organizations. The AMA oversees medical research and medical practices inside the United States. Internationally, World Medical Associations are responsible for maintaining ethical standards in medical research and clinical practice. Medical associations are the first line of ethics monitoring agents. If they do not perform this essential ethical monitoring and do not make sure an altruistic ethic is maintained in medicine, we have a situation similar to what took place in Germany during the 1930s.

Without maintaining a strong commitment to traditional ethical standards and contemporary bioethical principles, medicine loses its professional character and physicians slide toward employee status. The quickest way to undermine medicine as a profession is to ignore or downplay bioethics and professional ethical obligations. Every ethical failure in medical research or clinical practice invites outside control, and with enough outside control the profession of medicine is gone.

Without a strong and evolving discipline of bioethics and continuing involvement with bioethics on the part of professional medical associations, the future of the profession of medicine is dim. The involvement of professional associations must be substantial; perhaps the proper word is aggressive. The national and international professional associations cannot fulfill their ethical responsibilities by window-dressing-type programs in bioethics, any more than medical schools can fulfill their ethical responsibilities toward medical students by having them recite the Hippocratic Oath at graduation. A serious responsibility requires a serious commitment.

There is overwhelming evidence that the privileges so defining of a profession today are threatened. More and more physicians in the United States., Europe, and Latin America are workers in a health care industry. Obedience to orders from administrators of health care businesses or government officials, rather than autonomy, increasingly defines day-to-day medical practice.

The biggest threat today to a medical profession, however, comes from the pharmaceutical industry. Pharmaceutical firms are increasingly in control of more and more aspects of medical education and medical practice. This is true both in state-run and free-market health care systems. Bioethics came to Latin America because of concern about unethical treatment of medical research subjects. Bioethics today has to continue to be concerned with the pharmaceutical industry’s influence on both medical research and medical practice. This is true in Latin America, the United States, and wherever contemporary scientific medicine is practiced.

5 The Pharmaceutical Industry’s Influence

The pharmaceutical industry continues to increase its control over medical research. Its influence is enormous for determining which new drugs receive attention and which drugs are approved. Now, once a drug is on the market, the pharmaceutical industry moves to educate physicians. Education that historically and by definition is university-based and under control of the profession is gradually being moved by giant pharmas from academic settings to business settings.

Continuing medical education is necessary to retain professional medical competence. A certain number of hours of continuing education are required to retain a medical license. Meetings authorized to provide the continuing education credits for physicians are increasingly organized by pharmaceutical firms. They do the advertising for continuing education conferences. They pay the speakers and choose the topics to be addressed. Many of the speakers are employees of pharma firms, but even those who are not know who contracts them to speak and who pays them. For what once was independent and university-based, the continuing medical education system is now strongly influenced if not controlled by the pharmaceutical industry.

Day-to-day education about drug therapy takes place in doctors’ offices and is provided by pharmaceutical salespersons. The salespersons (many of whom are attractive women) are trained to sell, i.e., to convince physicians to use their company’s medication rather than other competitive products. Selling could be based on objective scientific communication, but that is not what is taking place. The sales representatives are schooled in ways to manipulate physicians rather than ways to provide objective scientific information. Salespersons are taught how to convince rather than how to educate. Most salespersons lack the educational background to be teachers of biological science. Physicians get free drug samples to pass out to their patients, but they do not get updated objective education about medications.

Even the approval system for medications is strongly influenced by the pharma industry, and consequently most of the new drugs approved are not new therapies. Rather, they are most often imitations of already available drugs (Angell 2004). This means that the system put into place to provide physicians with ongoing education about medications has actually been turned into a stage where actors compete to sell products. For good reason, salespersons bring gifts to physicians and invite them and their families to dinners and other types of entertainment. Salespersons who refuse to be manipulators and insist on being honest about the information they communicate first are warned, then downgraded, and finally they are fired.Footnote 5

Sometimes, manipulation of physicians becomes even more direct. In Latin American countries, I found that some physicians were directly paid to use certain medications. In some instances I found that medical “research” was being paid for to show positive data and get new publicity for already-approved medications. Patients were often turned into “research subjects” without their informed consent. The most basic professional ethical principles of beneficence and truthfulness and respect were being violated for economic gain. Some physicians and some pharmaceutical companies cooperated to undermine the foundations of the medical profession. The subversion of ethics by large pharmas, which in the 1980s required PAHO to be involved with the promotion of bioethics, turned out to be much more extensive than originally thought.

A most recent reflection of the corruptive influence of large pharmaceutical companies on the ethical core of the medical profession is a fine paid by Pfizer for ethical violations. This pharmaceutical giant agreed to pay 2.3 billion to settle criminal and civil allegations of illegal marketing of a painkiller, Bextra (now withdrawn). 2.3 billion is the largest fine in history. The federal government’s responsibility to protect patients from the dangers of inappropriate drug use was undermined by Pfizer’s promotion of drugs for unapproved use. Patients were seriously damaged by company promotion tactics to doctors. This was Pfizer’s forth fine for illegal marketing since 2002. The company not only engaged in criminal activities but did so over and over again. The illegal marketing of Bextra was engaged in while the company was paying other fines and promising to reform its practices. Pfizer’s general counsel said once again that the company had reformed. From 2002 to 2009, company executives planned and carried out illegal marketing schemes. The illegal marketing of Bextra followed similarly harmful marketing practices for an epilepsy drug, Neurontin. The fine for this illegal activity was 430 million. Sales representatives were trained to miseducate the doctors whom they visited. The miseducation was supported by gifts to the doctors, meals, invitations to resorts, money for attending meetings and other illegal incentives. For protection, patients are now advised to ask doctors who are prescribing medications, whether the drug is F.D.A approved for their condition. The next likely government move will be to begin prosecution of doctors doing the off-label prescribing.

One remedy for healing a continuing education system controlled by pharmaceutical companies would be to insist that physicians focus on mainline medical literature and on education coming from the major medical journals. But even the area of professional education has not been immune from pharmaceutical industry influence.

Pharmaceutical firms employ persons just to write articles on their drugs. Then they pay academic physicians to “author” the articles and send them to journals for publication. Some “authors” re-do the material, others may slightly alter a text, and some just send the company article for publication. The percentage of articles in medical journals that are “manufactured” differs in different journals, but the fact that professional literature in some instances is being manufactured testifies to a manipulation even of the science of medicine. Pharmaceutical companies pay to manufacture articles, to influence the content of educational programs, and finally to have their salespersons teach doctors how to practice medicine using their products.

The issue of equity and justice in access to health care is one that needs special attention in Latin American bioethics. Current drug prices place health care beyond the reach of millions of poor people. One explanation for the ever-increasing cost of prescription medications came from an unusual source: Dr. Peter Rost, a former vice president of marketing at Pfizer. Footnote 6 Interviewed by a television ­journalist, Dr. Rost talked about the fact that drug companies are the cause of the continuing inflation of drug prices. People need the drugs. They will sacrifice any other purchase, even food, to pay for medications. Therefore, the strategy of the companies is to keep jacking up prices. Most recently, major pharmaceutical firms have adopted a strategy of charging thousands of dollars for a single dose of critically needed medications. In many cases, the pill is not even a new drug, but rather a new version of an older drug, usually for something serious like cancer. The pharmaceutical industries are taking advantage of patients in desperate situations and then charging thousands of dollars for a small particle of hope. If patients are desperate to hold on to life, not only will they exhaust savings on a helpful drug, but also these patients are not likely to initiate suits, thereby saving the drug company even more money. Abraxane is a “last hope” drug for patients with advanced breast cancer which costs $4,200 a dose. The drug company expects to make one billion dollars a year in annual sales.

The new drugs and many more like them exemplify a medicine only for the rich. The pharma industry is creating a contemporary medicine that ignores not just poor patients, but the very essence of the medical profession, which is a commitment to providing help to all patients in need. These new pills, focused on rich patients, not only take advantage of the desperate, but also undermine medical insurance programs and government health care systems. Governments cannot afford the cost of these medicines; neither can employers who provide health insurance for their workers.

Cancer drugs worldwide soon are expected to cost 55 billion dollars a year. Who can pay such a cost? Pharmaceutical companies threaten poor patients, the image of physicians, and the whole medical profession. Social justice in health care, historically a focus of Latin American theologians, today is one of the most important issues in bioethics. Bioethics is concerned with many different aspects of contemporary medicine, but the pharmaceutical industry’s behavior is one aspect that cannot be ignored. Its ethical misconduct launched the bioethics program in Latin America, and its threatening behaviors are still a cause of concern.

Justice and equity concerns in contemporary medicine certainly affect Latin American patients and professional medical practice in Latin America. It is an aspect of contemporary medicine that Latin American thinkers with deeply rooted interests in social justice must address. As important as these developments are for bioethics, they are not given anywhere near the attention which they deserve.

Why did Dr. Rost make his shocking revelations about how drug companies operate? “Everyday, Americans die,” he said, “because they cannot pay for life-saving medications.” The same is true of patients in Latin America. His reasons were a reflection of his professional consciousness. In his case, the traditional professional medical ethics, and the basic bioethics principle of doing good for patients, kicked in. This basic ethical principle of beneficence does not play a role in the conduct of most pharmaceutical companies. More and more of the most vulnerable patients are being abandoned. Is there any wonder that the large pharmas spend billions of dollars on ads that try to offset their bad public image? The ads emphasize the ethical values that should be promoted but are so often ignored that many ordinary people with infirmities are furious.

It was money that drove medicine and medical practitioners in ancient Greece. The Hippocratic healers not only developed a scientific approach to medical treatment but also developed a truly professional ethics committed to doing what was beneficial to the patient and avoiding whatever might be harmful. The Hippocratics distinguished themselves by their science and by their ethics. They separated themselves from those healers who were driven to manipulate the sick for money. Roughly 2500 years later we can see the same division in today’s medical world. It creates a demand for the development of a distinctly Latin American bioethics, focused on social justice.

6 Conclusion

Who can make sure that bioethics remains vital throughout Latin America? Who can protect the integrity of medical professionals and the solidity of medical science? Who can protect the subjects of research and keep medicine focused on those most in need? Who can help physicians to keep their public promises? Who can make sure that medical education and medical research retain their integrity? Unless professional medical associations advocate for solid medical science and safe ethical research and patient-centered medical practice and social justice in health care systems, a noble medical profession will be in serious danger. There are serious challenges ahead for the discipline of bioethics in Latin America.

The discipline of bioethics was sent to Latin America in response to large pharma violations of basic bioethical standards. Patients (mostly female) were turned into research subjects and some of them died. Pan American Health Organization leaders accepted responsibility for the violations and in response organized a program designed to bring the discipline of bioethics to every nation in Latin America and the Caribbean. With sound leadership, good effects were made to come from bad acts. The spread of bioethics throughout Latin America is not a good that can now simply be left in place. Bioethics must continue to be taught and applied at every level of contemporary medicine. The bioethics project initiated by PAHO continues. The reasons that brought bioethics to Latin America have not disappeared. They plead for continued development of the discipline.

Dan Callahan did not invent bioethics, and Henry Beecher did not invent research ethics. They did not impose an outside set of concerns upon medicine. Both of these men recognized the ethical issues embedded in contemporary medicine, and they took action to address them. Imagine the number of persons who had contact with the same realities but did not see, or saw and chose not to act. And imagine the social and personal damage this may have caused.

At some point, persons who had an opportunity to be involved in the emergence of bioethics in Latin America have to step aside and pass on the work to others. If I played a role at the beginning, I am grateful to those who gave me this opportunity. Those of us working in bioethics during different periods are all related. We share certain experiences. We aspire to similar goals. We participate in a unique community of bioethics that stretches around the world.

I hope that there is life after our short stay here on this planet. I hope, too, that those of us who worked together in medicine and ethics will get to enjoy the presence of God, who communicated in creation the foundations of a universal ethics and in revelation the importance of compassion for those who are ill.