II. SOUTHERN EUROPE

The term southern European countries includes all the occidental European countries in the Mediterranean area (Spain, France, Italy, Greece, Malta, and Cyprus), plus an Atlantic country closely related to them (Portugal). In addition to geographical and climatological affinities, these seven countries have for many centuries shared a common history centered on the Mediterranean Sea. Although they maintain local peculiarities and differences, the nations of southern Europe can be said to have a common identity.

This common identity is particularly evident in ethical issues (Gracia, 1993). Occidental ethics had its origin in the Mediterranean Greco-Latin culture, and since the days of the Greek philosophers, this ethics has centered on the concepts of virtue and vice. Only with the Enlightenment did a new ethical tradition, with right and duty as its main concepts, begin to take shape in central Europe. Since then the two approaches have widely been considered opposites, although they are in fact complementary. The ethics of virtue has persisted in those countries in which the Enlightenment had less influence, such as the Catholic or Orthodox southern European nations (Savignano), while the ethics of duty has prevailed in the Protestant central European and Anglo-Saxon countries (MacIntyre).

Today the occidental world harbors three palpably different ethical traditions, each with its own characteristics: the Anglo-Saxon, the central European, and the Mediterranean. Because modern bioethics is a product of the Anglo-American culture, Mediterranean countries have not attempted simply to import or "translate" bioethics but, rather, to re-create or remake the discipline according to their own cultural and ethical traditions (Gracia, 1990).

A "Latin Model" of Bioethics

If traditional Anglo-American philosophy is generally classified as empiricist, European philosophy has been more influenced by rationalism. Anglo-American ethics is generally more teleological and consequentialist, and European ethics more deontological. This explains why, for instance, the term autonomy has acquired a different meaning in the United States than in Europe. According to North American ethics, autonomy is the capacity to act intentionally, with understanding, and without controlling influences. On the other hand, European ethicists often interpret the principle of autonomy in a Kantian sense, as the capacity of human reason to impose absolute moral laws upon itself. The latter is a metaphysical assumption, while the former is only the lack of constraints. To European ethicists, acting autonomously means that the human reason is capable of freely establishing absolute and compulsory moral laws (freedom to). In the Anglo-American, on the contrary, freedom is understood only negatively, as the capacity to act without constraints (freedom from). The first is a maximal concept of autonomy, and the second a minimal one. These two meanings are so disparate that an autonomous person, according to the European point of view, may not act autonomously from the Anglo-American perspective because of constraints such as ignorance or coercion. Moreover, it is also possible to deny the capacity of reason to impose on itself absolute moral laws, and to accept the concept of autonomous choice as the absence of external constraints.

The rational foundation of ethics is closely linked to the discussion of whether the principle of autonomy is relative or absolute. In Europe, the Anglo-American propensity to base ethical analysis on several theories, such as utilitarianism and contractualism, and on a few principles, such as autonomy and beneficence, is usually considered insufficient or less adequate. Europeans generally search for more universal or transcendental ethical foundations. The meaning of the concept of transcendental differs in central and southern Europe. Central European ethics often attempts to reach the transcendental dimension through an intersubjective procedure, such as the universalization of personal interests. According to many Mediterranean ethicists, the transcendental universality of ethical norms is reached in a more objective way, based on metaphysical concepts like reality, human nature, or personhood (Russo). The latter is, of course, the most classical position in occidental philosophy. It is no coincidence that this classical concept of metaphysics was born on the Mediterranean coast.

Modern northern European ethics, based on the concepts of right and duty, has been the matrix of ethical minimalism (or the ethics of duty), while the traditional Mediterranean ethics, based on virtue, has tended more toward ethical maximalism (or the ethics of happiness). While minimalistic ethics looks for the basic rights and duties of every human being and society, maximalistic ethics is concerned with life projects and ideals of perfection and happiness (in Greek, eudaimonia). During the sixteenth century, Mediterranean countries adopted anti-Protestant, and therefore antimodern, attitudes; they considered certain aspects of modernity to be fundamentally hostile to their cultural traditions: their medieval political, ethical, and religious ideals. These attitudes may explain why many Mediterranean nations belatedly and with difficulty adopted the doctrines of human rights and parliamentary democracy, the greatest achievements of the Anglo-American world. This may also explain the relative weakness of democratic practices in these countries in comparison with other areas. This antimodern stance enables one to understand the history of southern Europe since the nineteenth century, particularly the potency of antidemocratic movements and authoritarianism during the first half of the twentieth century. And while western European countries definitively adopted democracy and liberal systems following World War II, some of the Mediterranean countries maintained a markedly different identity.

All these elements help clarify why southern European countries have tried to elaborate a "Latin" model of bioethics (Leone). While the Anglo-American model is structured around the four classical principles of autonomy, nonmaleficence, beneficence, and justice, Salvino Leone, following Elio Sgreccia, bases the so-called Latin model on the four principles of the fundamental value of life; liberty and responsibility; totality (or therapeutic wholeness); and social subsidiarity (the idea that smaller units are always preferred to larger ones when it comes to addressing social problems) (Sgreccia; Palazzani). This search for distinctiveness also led Mediterranean ethicists to seek to establish their own terminology. The French expression éthique biomédicale, "meaning the desire to promote a new style of questioning in the field of biomedical sciences, both theoretical and educational" (Moulin, p. 280), has been adopted as an alternative term to the Anglo-American bioethics not only in French but also in other Mediterranean languages, such as Italian (Spinsanti, 1987) and Spanish. The reason for this terminological change is that for many authors, the word bioethics seems overly biologistic and suggests that ethical behavior is biologically determined. The alternative expression biomedical ethics was coined to avoid this danger. It situates the term ethics as the noun, with biology and medicine in secondary adjectival position. Of course, the term bioethics is also frequently used in Mediterranean countries, just as North American literature occasionally uses the expression biomedical ethics (Beauchamp and Childress).

The Ethics of Virtue and the Doctor–Patient Relationship

Mediterranean countries have created a realistic and personalist model of biomedical ethics, based on the classical Aristotelian-Scholastic philosophy and complemented with more modern European philosophical traditions such as phenomenology, axiology, and hermeneutics (Viafora, 1990). In this model, the idea of virtue acquires much more significance than in any other occidental tradition, a fact that has important consequences in the medical field. For example, trustworthiness is considered more crucial than the right to information (Dalla-Vorgia et al., 1992). Patients in southern European nations are generally less concerned with receiving detailed information or having their autonomy respected than with finding a doctor in whom they can place their full confidence (Gordon; Spinsanti, 1992; Fletcher; Loewy).

One virtue is particularly important in establishing a satisfactory doctor–patient relationship: friendship. The Spanish physician and humanist Pedro Laín Entralgo has written extensively on this topic, especially in his book The Doctor–Patient Relationship (Laín Entralgo, 1983 [1969]). This relationship must be based on what Laín Entralgo calls "medical friendship," composed of benevolence, beneficence, and confidence. His studies have had a substantial but not exclusive impact in Mediterranean and Latin American medicine; as a result, the idea of friendship as the cornerstone of the relationship between doctor and patient has gradually acquired importance in bioethics. The influence of his studies is also visible in North American bioethical literature (Siegler, 1979, 1981; Pellegrino and Thomasma; U.S. President's Commission; Cassell; Drane).

Friendship includes trust and confidence, which is why we talk about intimate friends; friendship is the ambit of trust. The three theological virtues (faith, hope, and love) are common between friends. The core of this relation is hope, understood as trust: we trust friends, we have faith in them, and we trust them because we love them. Friendship is more than ethics; it is almost a religion. Charity, or agape, is considered the most important virtue in the Judeo-Christian tradition. But, according to Laín Entralgo, agape can be considered perfect only when benevolence and beneficence, its main components, join friendship's trust and confidence (Laín Entralgo, 1985 [1972]). The result is, as Edmund Pellegrino and Warren T. Reich, two U.S. authors influenced by Laín Entralgo, have written, "com-passion," the act of putting oneself in the place of another in order to understand his or her experiences (Pellegrino, 1986, 1988, 1989; Reich, 1989, 1991). Compassion is not pity but, rather, the human relationship based on devotion, constancy, personal respect, and responsibility. As Reich says, it is the relation with the other, based on love, benevolence, comprehension, and friendship. Mediterranean bioethics has emphasized the study of the friendship aspect of the physician–patient relation, and the Spanish contribution has been important (Gracia, 1989).

Ethics and Law

The relationship between ethics and law is peculiar in the Mediterranean. In its origins, Roman law was substantially influenced by Stoicism, a school of thought that assimilated law and morality. Stoics considered nature the source of both law and morality; natural law could be known rationally, and thus formulated deontologically and axiomatically into a legal code. Because law expresses what is morally correct, ethics and law converged. Ethical goodness, the intention with which an act is performed, only added to the legal rightness of the act and to the virtue of the person involved.

Christian thinkers adopted this relationship between ethics and law without substantial changes, and it has been a latent presence both in canon law and in the moral theology of the Roman Catholic church. Thus, in Catholic nations such as those of southern Europe, law and morality are difficult to distinguish conceptually.

One of the problematic outgrowths of this tradition is legalism, the tendency to believe that every human act can be legally prefigured, that laws precede facts, making it possible to regulate beforehand every real or possible situation. Thus, in these countries court rulings are considered nothing more than the concrete application of statutory law. This law is prior to individual rulings, quite the opposite of the Anglo-Saxon common-law system. The traditions also diverge in that the Roman model is largely centralized and state-oriented and places less importance on social dynamics. The prevalence of state over society explains why Mediterranean countries have fostered more authoritarian and less democratic political practices than Anglo-Saxon ones.

Health Systems

That the state must, in southern European countries, take responsibility for what in other countries is considered the realm of private enterprise, illuminates another distinctive characteristic of Mediterranean bioethics: its overwhelming concern with healthcare justice. In fact, the health systems of these countries are mainly state-run. Justice plays the decisive role in European biomedical ethics that autonomy plays in North American bioethics (Thomasma).

France, Italy, Greece, Portugal, and Spain have similar national health insurance systems. Their common origins date back to the German Krankenkassen (patients' fund) system, designed by Otto von Bismarck in the final decades of the nineteenth century as a means of assuring medical assistance for workers. In distinction to the socialist European countries, where all the population was covered by an insurance system financed by public funds, Mediterranean countries, following the German model, began insuring only workers, and financing the system with the economic support of both workers and employers. Coverage was later extended by public funding, and today nearly the entire population of each country is protected. This process of generalization of the health insurance system took place during the zenith years of the welfare state, between the end of World War II and the economic crisis of 1973. In the mid-1970s, health insurance as well as the entire social security system, and perhaps the welfare state itself, experienced a crisis, mainly because of the costs explosion that made it impossible to satisfy the population's health expectations. To find solutions for this complex problem, most countries set up reform commissions aimed at proposing measures to make health insurance viable in the future.

In Spain, compulsory health insurance for all workers was enacted in 1942 and implemented in 1943. Over the next three decades, coverage was gradually extended. In 1986 it became a national health system very similar to those in Britain and Italy, covering the healthcare of most of the country's population (Gracia, 1987). This satisfied one of the people's greatest wishes but at the same time gave birth to a new problem, which became more and more acute as time went by: the scarcity of economic resources and the subsequent need to limit free health services. In order to analyze and evaluate the needs of the national health system, in 1990 the Spanish parliament set up a commission, known as the Comisión Abril Martorell. The commission's main report, published in July 1991, asserted the importance of the national health system in maintaining the level of health and well-being in Spain, and proposed certain amendments to increase efficiency without altering the basic system. One such modification would require every user of healthcare services to pay a percentage of the total cost, in an attempt to make everyone shoulder the burden of the constant increases in health expenses.

Patients' Rights

The way patients' rights were established marks another differentiating factor of Mediterranean countries. In the United States these rights, particularly the right to informed consent, took shape in the field of common law, while in Mediterranean countries their entry was directly through statutory laws and codes (Council of Europe, 1976; Gracia, 1989). In these countries, protecting patients' rights is a duty of the state more than the duty of individuals. In Spain, patients' rights were first established legally in Article 10 of the Health Law of 1986, and then socially.

In all Mediterranean countries the respect for patients' autonomy and their right to make decisions about their own bodies has grown remarkably in the last decades (Cattorini and Reichlin). This has produced profound changes in the role of healthcare professionals, as well as more litigation against physicians and other healthcare workers. The old juridical terms professional incompetence and negligence that referred to faulty medical procedures have come to be overshadowed by new complaints about health workers' lack of skill or their negligence in giving information, or about battery, for handling the patient's body without consent.

The patients' rights movement of the 1970s provoked wide-ranging legislative changes (Council of Europe, 1976). For example, the large antipsychiatry movement in 1978, led in the Mediterranean area by Italy, prompted some countries to modify laws on the compulsory restraint of the mentally ill by passing new legislation more respectful of these patients' human rights and providing greater protection against possible abuse by family members or health professionals. In 1997, the Council of Europe introduced the "Convention on Human Rights and Medicine"; the fifth article of this document states that "an intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time" (Council of Europe, 1997) The convention has been signed by all the Mediterranean countries, and has influenced national legislation about the rights of patients and informed consent.

Additional consequences of this new respect for patients' rights are the strict regulation of biomedical experimentation and the creation of institutional review boards to monitor every clinical trial and research project protocol, analyzing not only technical and methodological but also ethical aspects. On November 24, 1986, the Council of the European Community approved a directive on the protection of the animals used in research and other scientific projects (European Union). Every country of the European Community adopted its own legislation in the following years, and by the end of the twentieth century, research with animals was strictly controlled (Illera).

In an attempt to promote organ transplants while avoiding any kind of commerce and abuse in the donation process, all Mediterranean countries have introduced legislative criteria for brain death and have elaborated laws regulating transplants. The legal regulation of medical care to the dying has encountered greater obstacles, and has provoked heated debates over euthanasia (Gracia, 1987, 1988; Lefevre; Dracopolou and Doxiadis; Bompiani).

Issues related to the origin of life, especially abortion and new techniques for human reproduction, have been the subject of the most intense debates. Mediterranean countries have adopted conservative positions in these debates. In these nations the U.S. Supreme Court decision Roe v. Wade (1973), based on the right to privacy and restricting the right of states to legislate on abortion in terms of viability and trimesters, is not easily understood. In Mediterranean countries, abortion is held to be a public rather than a private issue and therefore a matter of justice and not of autonomy, since the life of a human being is believed to be at stake. Hence, in these countries, laws governing the interruption of pregnancy are based on exceptional circumstances or indications rather than on periods of time or terms of pregnancy. These laws allow abortion in three exceptional indications: great danger to the mother's health or life; important defects of the fetus; and rape. Only a few countries, such as Italy and Cyprus, have included a fourth indication: socioeconomic incapacity, valid during the first trimester of gestation. The Veil Act (1975) in France established that any pregnant woman can undergo an abortion during the first ten weeks of pregnancy if gestation is a source of anguish (détresse) for her, an indication that, in practice, is analogous to a law of terms (a period of time in which abortion is permitted without any indication). Since 1986 Greece has had a law of terms: Abortion is permitted in the first twelve weeks of pregnancy. After this period, gestation can be interrupted only with an ethical (nineteen weeks), eugenic (twenty-four weeks), or therapeutic indication (Glendon).

The problems presented by new techniques of human reproduction are so various and complex that every southern European country has established a specific commission for their study. The Comisión Palacios of Spain and the Commissione Santosuosso of Italy are examples. Both bodies have elaborated reports for legislative enactment, which has been achieved in both countries (Gracia, 1988; Fagot-Largeault; Mori; Walters; Bompiani). More important, these commissions highlighted the need for national committees on bioethics, which were firmly established in the Mediterranean area by the end of the century. This same process has taken place in Europe as a whole, where the Council of Europe in 1983 established the Ad Hoc Committee on Ethical and Legal Problems Related to Genetic Engineering, which a few years later became the Ad Hoc Committee of Experts on Bioethics and was later called the Steering Committee of Bioethics.

National Committees of Bioethics

National committees of bioethics have been set up because of the increasing complexity of biomedical research and to avoid dangerous research like that which made possible the construction of nuclear weapons during the 1940s and 1950s and the experiments carried out in Nazi concentration camps. The main aim of these committees is to help those involved in biomedical research by offering prudent criteria for conduct. On February 23, 1983, French President François Mitterrand created the first national bioethics commission in a European country, the Comité Consultatif National d'Éthique pour les Sciences de la Vie et de la Santé (CCNE). Its purpose is mainly to elaborate recommendations on ethical problems stemming from scientific research in biology, medicine, and other health professions (Isambert, 1989). It deals not with healthcare problems but with ethical questions raised by biomedical research. The CCNE is composed of thirty-six members plus a chairman who is appointed by the president of the republic. The departments of Education, Research, Industry, Health, Justice, Family, and Communication appoint sixteen members with proven competence and interest in ethical issues. Fifteen posts are filled by researchers and representatives of universities and the National Institutes of Health and Research. Five members, named by the president of the republic, are drawn from the "spiritual and philosophical" fields. Committee members are divided into working teams to prepare reports and recommendations. The documents so far produced have dealt with the use of fetal and embryonic tissues for diagnostic, therapeutic, or research purposes; techniques of artificial procreation; prenatal and perinatal diagnosis; the use of the abortion-causing drug RU-486; and the noncommercialization of the human body, among other topics. Every year, the committee organizes meetings of study and debate called the Journées Annuelles d'Éthique, in order to release the year's work to the public.

The French commission's work has stimulated bioethics studies in the Mediterranean area, much as the National and President's Commissions have done in the United States. Of the two possible methodologies identified by the Belgian philosopher of medicine Jean-François Malherbe—that of the lowest common denominator (the search for a formula everybody agrees with, even if it is ambiguous and makes room for very different interpretations) and that of the highest common denominator (requiring much more work, reflection, and dialogue)—the Comité Consultatif National opted for the second. This decision had an evident impact on the text of a report the committee issued, "Biomedical Research and Respect for the Human Being" (CCNE). French bioethics is coming to be, as Malherbe noted, "an active center of public morality in the life of people" (Malherbe, p. 227). The French ethics of the highest common denominator is similar to some of the most creative ideas from Jürgen Habermas and Karl O. Apels's "ethics of communication," which is based on the idea that in the context of a pluralistic society, ethics will flourish only if it takes into account the interests of every person actually or virtually involved in the conflict. The French committee has integrated German dialogic ethics with French personalism, widespread among French philosophers of the last century, and firmly established in certain Catholic (Maurice Nédoncelle), Protestant (Paul Ricoeur), and Jewish (Emmanuel Lévinas) phenomenological thinkers. According to Lucien Séve, these ideas have proved fundamental for the elaboration of a working procedure based on rational consensus and not on a merely strategic consensus.

The French committee has had great success, and hence this model has spread throughout Europe, including the Mediterranean countries. Malta instituted its Health Ethics Consultative Committee in 1989 (Le Bris). In March 1990 the Italian government approved the creation of the Comitato Nazionale per la Bioetica, directly responsible to the prime minister. The body is composed of forty members and, like the French group, is aimed at controlling research involving human beings. It has published documents on gene therapy, definition of human death, ethics of the use of seminal fluid for diagnostic purposes, biotechnological security, bioethical learning in the clinical setting, healthcare and terminally ill patients, organ donation, and ethics committees.

Portugal, following the French pattern, established the National Ethical Council for Life Sciences in June 1990 (Martinho da Silva). The body started functioning January 1, 1991, and in its three first years published three reports: on organ donation and transplantation (1991), on the use of human corpses in research and teaching (1991), and on new reproductive technologies (1993).

In 1984 Spain created a special committee known as the Comité Palacios to study problems related to new techniques of assisted reproduction (artificial insemination, in vitro fertilization, and so forth). In July 1992 the Department of Health published a legal order creating a health advisory committee whose main goal was assessing and informing the secretary of the department on scientific, ethical, professional, and social questions. This committee deals not only with problems of biomedical research but also with those raised by healthcare. This innovative feature distinguishes it from others in the region.

In southern Europe, institutional ethics committees were rare until the 1990s, in part due to the prevalence of socialized medicine and in part because Mediterraneans are not completely conscious of patients' rights. In Spain, for instance, such committees only became standard in hospitals late in the 1990s, following the General Health Law of 1986 that specifically mandates the protection of patients' rights.

Goals and Challenges for the Future

In the last decade of the twentieth century, new problems emerged; two of the most important were population ethics and ecology. Ecology is of increasing importance in all Mediterranean countries, and is beginning to be not only an ethical and intellectual issue but also a political force (Gafo; Poli and Timmerman). Latin European countries are neighbors of the underdeveloped nations situated on the southern Mediterranean coast, and they therefore understand very well that only a sustainable development can correct the unsustainable development of the First World and the underdevelopment of the Third World. Ecology in these countries will be not only an ethical compromise but also a political project, prompted by the left-wing parties. With the death of the Marxist ideology, ecology assumes the place once held by economic theory.

Due to the increasing importance of bioethics in the life of these countries, research and teaching are growing quickly. The teaching of bioethics has been introduced not only in schools directly related to healthcare, such as medicine, pharmacy, and biology, but also in theology, philosophy, and humanities (Comitato Nazionale per la Bioetica; Gracia, 1992). Literature is being published, and universities are supporting new research centers (Viafora, 1993). All of the research centers have been integrated into the European Association of Centers of Medical Ethics. Since 1990 the Milazzo Group has published International Journal of Bioethics.

diego gracia

teresa gracia (1995)

revised by authors

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