Speaker A
Well, Mr. President of the Royal Academy of Medicine of the Balearic Islands, excellent authorities, academic companions, ladies and gentlemen.
Dr. Diego Gracia Guillén reviews 50 years of bioethics, tracing its origins, scientific revolutions, and ethical challenges in medicine and genetics.
Key Takeaways
- Bioethics emerged in the 1970s as a response to new scientific and medical challenges.
- Scientific revolutions in physics and genetics profoundly influenced ethical considerations in medicine.
- Ethical frameworks evolved from rigid principles to more nuanced value-based approaches.
- Informed consent is a cornerstone of modern medical ethics, emphasizing patient autonomy.
- Technological advances continue to transform medical practice and ethical decision-making.
What the video covers
- The lecture commemorates 50 years since the emergence of bioethics as a discipline.
- Dr. Gracia discusses the scientific revolutions of the 20th century, including physics and genetics.
- He explains the discovery of genetic information encoded in nucleic acids and the development of molecular biology.
- The talk covers the ethical implications of scientific advances such as nuclear energy and genetic engineering.
- Historical context is provided on the development of bioethics from practical conflicts to theoretical frameworks.
- The role of the National Commission in the US in shaping bioethics is highlighted.
- Dr. Gracia reflects on the evolution from the four principles of bioethics to a broader language of values.
- The importance of informed consent and patient autonomy in medical ethics is emphasized.
- He touches on the impact of technology, such as computers, on evidence-based medicine and clinical research.
- The lecture also addresses sustainability and global development as ethical concerns linked to science and medicine.
Chapters
- 00:00Introduction and origins of bioethics
- 05:1120th century scientific revolutions in physics
- 10:04Genetics and the discovery of the gene
- 14:55Genetic code and molecular biology advances
- 19:45Ethical implications of scientific discoveries
- 23:07Political and philosophical reflections on science
- 32:56Development of bioethics as a discipline
- 39:36Evolution from principles to values in bioethics
- 49:32Informed consent and patient autonomy
- 57:40Impact of technology on medicine and ethics
Full Transcript — Download SRT & Markdown
Speaker A
I have to start, as is evident, thanking not only my friend Francesc Bullosa for the affectionate words he has just said, but also Joan Mar, who together with him are making my short stay on the island a real
Speaker A
pleasure, a continuous pleasure. And thank you all for coming here this afternoon. I will try in a relatively short time, I hope in three quarters of an hour, to see if I can transmit to you the panorama of what is happening in medical science
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in the last half century, the expectations of the future, and the reason why, at the height of 1970, it was necessary for a new discipline to appear, that a new term was coined, because until then that term did not exist, which is bioethics.
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A while ago I remembered what happened to me in a Madrid broadcast, well, now 30 or 35 years ago, when all this started and the term bioethics was not a general term, but rather a rare technical term. I don't know where I went, but they called me and the speaker had a
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little piece of paper where my name was and who I was. And then the man went to read "Bioethics Professor" at the Faculty of Medicine of the Complutense University.
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That "Bioethics" did not sound to him. And then something that was very fashionable, something that I think has happened, which was macrobiotics, all this was biotics, macrobiotics, and then he made me a biotic professor. What is not surprising is
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that in these 30 years this term has been generalized and practically made of the common domain. And I know that in any magazine or newspaper, for example, in the newspapers of these days, as a consequence of the application of
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CRISPR-Cas9 technique in some embryos in China, well, it has come out to all the media, everyone has been interested, everyone has been worried about what is happening, and I think that this anxiety makes us all have a certain receptivity to this that used to seem somewhat strange. What is happening?
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Well, here there are very young people, so I have to talk a little about what they have not known, but here there are some people who are not so young and there is a colleague of mine from the Faculty of Medicine, therefore, and they remember what has happened since the
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50s until today. Therefore, in this last half a century long. And what has happened is that what has happened, what in the history of science, and Francis Bouillos knows it well, is called a scientific revolution. In the 20th century we have witnessed two scientific revolutions. A scientific revolution is a
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very strange thing. One was given in the time of Copernicus, the so-called Copernican revolution, and it took a long time for another to appear, the so-called Einsteinian revolution, which is the one from the first half of the 20th century. And all of you know it, how it was discovered at
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a speed of vertigo from 1900 to 1930 and so, the basic elements of the constitution of inorganic matter, the atoms, the interior constitution of the atom, the electrons, the protons. The theory of relativity is elaborated. First, the relativity restricted in the year 5,
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then the relativity generalized in the year 12. In the 20s, the matrices of the so-called quantum mechanics are put to the point. And a world that was absolutely unknown before begins to be seen. And as always happens when basic science
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progresses, there comes a time when practical applications of what in principle had none or seemed to have no practical application begin to be seen. And in a German physics magazine, in the "Physikalische Blätter" in 1933, some German physicists described what we all know today as
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nuclear fission. And the energy that could arise as a consequence of nuclear fission. Immediately, a few of them were lit up saying, "Man, that energy can be used." Well, the result was atomic bombs. And this was in 1933, they
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developed in the second half of the 30s, at the beginning of the 40s, and you know what happened, well, starting with the Manhattan Project and Oppenheimer and such, and the bombs of Hiroshima and Nagasaki. The father of the Manhattan Project, a great
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physicist, Oppenheimer, then he was giving chest blows until he died and wrote a book in which he says: "In Hiroshima and Nagasaki, physics knew the pectin." And this happened to Oppenheimer, it happened to Einstein, who had advised Truman to make the nuclear bomb, it happened to
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almost everyone. That is, first they put together what they put together and then they began to blame themselves as a consequence of what they had done. I'm not telling you what happened in the 50s with the appearance of what was then called the H-bomb and what happened. Remember
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that, for example, when the hydrogen bomb appeared, which had much more power, I don't know how many, 15 or 16 Nobel Prize in German Physics wrote a letter to the German government saying that be careful because what was at stake now was the present and future of
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life on the planet. And, for example, a doctor and philosopher, Carl Jaspers, wrote a little book, The Atomic Bomb and the Future of the European Man. Heidegger in those years began to write about the technique, that is, European intellectuality began to reflect on that. But
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And the philosophers, that is, the philosophical study of the idea of space, time, matter as a consequence of the great advances made in the first decades of the century was total. The philosophers were dedicated to that and that was the so-called philosophy of science. What happened in the second half
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of the 20th century? Well, in 1944, some British biologists Avery, MacLeod, and McCarthy realized for the first time that genetic information was probably encoded in nucleic acids, acids that had been described in the middle of the 19th century in the D'Estrurian sperm and that were known
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but were not known for what they were used for. Of course, genetics already had a life cycle, and the geneticists were looking for the physical basis of the genetics, of heredity, because for Mendel a gene is not what for molecular biology is
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today a gene, but it was a logical unit of information. Remember what you studied in your bachelor's books, if there are pink roses, if there are white roses and they mix, of course, there must be some elements that are the ones that mix,
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that is a gene for the mind. That is, it is a unit of information.
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But Mendel did not know what a gene was, he did not know the physical structure of a gene. So what is clear is that if they mix, a 25% of red roses will come out, a 25% of white roses and a 50% etc. All this, or
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the shiny, shiny, and so on. Until the year 1944, no one knew that genetic information was encoded in nucleic acids. And nucleic acids, fortunately, are much easier to handle in the laboratory than what they were looking for before, which were proteins. Proteins are very complex, very difficult to handle, and
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it was assumed that this genetic information had to be so complex that it should be in the most complex biological structures. And the research was on a completely deviated path. When this is fixed, from the year 44, the discoveries happen in
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cascade. Remember how in 1953 Watson and Crick, in short, describe the tridimensional or helicoidal structure of the nucleic acid-oxygen that shortly after, in the year 58, in 1998 Severo Ochoa gets the synthesis in the laboratory of nucleic acid that in the 60s the so-called genetic code is put
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to the point. The genetic code is not, for example, what was later called the Human Genome Project at the end of the century. The genetic code is simply to discover the way in which, in some bases of nucleic acids, which are
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four, the 20 amino acids can be coded. It cannot be one by one because it would not be coded more than four, nor can they be two by two, they have to be three by three. And this is called
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triplets or codons and the union of three units of bases coded each number. That is known.
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the same that happened in nuclear physics in the 30s, it became a technique that was only theory before. Well, in molecular biology the same thing happened, until the 70s everything was theory. And in the 70s, what was then called genetic manipulation or genetic engineering was put to the point. They
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discovered what they continue to use, some enzymes that produce viruses and that have the characteristic of cutting the sequence of nucleic acid by specific places. These are called restriction enzymes. And then there are other enzymes that have the characteristic of hitting pieces of
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nucleic acid, ligases. And they said, "Well, now we can do what no one has been able to do before, which is to try to put vectors, for example, the virus, to put the genetic information we want in the cell nucleus
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and through these procedures to combine with the nucleic acid structure. A technology was developed. the technology that was called, there were others, but this is the one that triumphed, the technology of recombinant DNA, which has been used a lot since then. In fact, now
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diabetics, when they go to the pharmacy, They can ask for different types of insulin. There is a classic type of insulin, which was used before all this, and it is still used, which are insulin produced by the pancreas, both of the pig and of the cow.
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They are heterologous proteins, because they are not produced by a human being, purify them as much as they can so that they do not produce antibodies that produce in small numbers, but they produce them in the body of diabetics and
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they are injected. But every diabetic knows that when they go to the pharmacy they can buy an insulin called recombinant insulin. and it is because it has been produced with the combination DNA technique that started in the 70s. Well, all this that we are seeing these days in the news
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and is what the Chinese researcher in human embryos is made of, is not more than this, it is with a And it is that about two years ago a manipulation technique was put to the point, now it is called gene editing. It is no longer about
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genetic engineering or genetic manipulation, it is about gene therapy and gene editing. Talking about gene therapy is not correct either. because the products are only therapeutic when they have gone through the whole verification process through clinical trials, etc. And this has not happened. Therefore, that experimental gene editing
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should not be called gene therapy because it is not yet. And the serious problem of the Chinese is that it seems that he is doing gene therapy when he should not do it. Anyway, what is happening today is that a new gene editing technique, the
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technique of the so-called CRISPR-Cas9, has revolutionized the whole issue of gene editing because it allows for much more efficient and much more secure the introduction of genes within a structure determined, therefore, all the laboratories are in this moment, the molecular biology laboratories are all
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using the CRISPR-Cas9 technique. Why? Because we have in front of us, and now this is very fashionable, the so-called rare diseases, which are 7000, of which it is already known, it is assumed that 80% are of genetic basis.
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the genetic loci of more than half are known, therefore of three thousand and more. And if with these techniques we were able to avoid these diseases, to correct the genetic errors that exist in those DNA structures, then think about the benefit that would be
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to humanity. Therefore, it is so much the potential that it is also logical that everyone is behind it. Well, what does this mean? Well, in the second half of the 20th century a phenomenon similar to what already happened in the first half has
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occurred. If in the first half we were able to know the infinitely small in the order of inorganic matter, now we are knowing the infinitely small, the genes, in the order of organic matter, of living matter. and therefore a revolution is being produced in a
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certain way similar or perhaps superior to the one produced in the first half of the century. In fact, the United Nations named in the years, at the beginning of the 70s, a world commission, which was called the World Commission of Environment and Development, which presided over
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a woman I don't know if she has died, but in any case it has been very important. Her name was Grobrunland. This woman was president of the government in Norway. She was appointed president of this commission and then she was president of the World Health Organization, about a decade
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ago. And in the report, this report, the report of the World Committee on Environment and Development, which was published in 1987 and is titled "Our common future", our future as a spectacular report, for example, in that report is where the expression appeared for the first time, which has
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then been disseminated and with reason, and today it is more or less known, sustainable development. The idea of sustainable development was born there.
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And the idea is that the development of the first world is unsustainable and the underdevelopment of the third world is also unsustainable and that therefore we have to walk towards a completely new goal, which is the goal of sustainable development. Well, in that report, almost at the end, there is
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a recommendation that impressed me. He says: "When the 20th century began, until the beginning of the 20th century, humanity had never had the possibility of altering the balances of life on the planet. Today, he said, in 1987, it
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has several. Well, this is the second revolution, the biological revolution that has to do with molecular biology, but not only with molecular biology. Molecular biology can be said to be revolutionizing and naturally producing, generating conflicts in everything related to the
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origin of life. But another revolution has occurred, almost as great or as great, in the management of the end of life, of living beings and above all of the human being. And this, well, what is it that is noticed? Well, this has to do with something that is now technically known
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as the name of vital support techniques. They started a little bit in the Second World War and above all they have developed from the 1960s. Vital support techniques are techniques, they are devices that allow us to temporarily fulfill
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biological processes or functions that are essential for life and without which we cannot live. This happened with the artificial respirator when we were medical students, for example, in the faculty where we studied medicine and in the hospital there was no intensive care
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unit. The first intensive care unit was in Spain, it was in the Jiménez Díaz Foundation in 1966. We were studying general pathology at that time. We were already in the clinic and doing practical tests, and there was no intensive care unit there.
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There was a respirator that no one knew how it worked and that was taken from one bed to another to the head of the bed because it was transportable to see what we were doing with it. But think that what
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has happened in the breathing has happened with practically all vital functions except the function of the super energy system.
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The respiratory function can be supplied, the digestive function can be supplied through the entire and parenteral diet, complete and continuous for practically indefinite time, And then there is the issue of the transplants, that is, the liver can be supplied, the kidney can be supplied, the
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heart can be supplied, the pancreas can be supplied, the intestine can be supplied, in short, you know it and therefore, but this is fundamental, that is, another huge revolution has occurred at the end of life, not only at the origin of life. And
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there is a third revolution that is never talked about, and that for me has been, I don't know if the fundamental, but almost the fundamental, which is the revolution in non-invasive diagnostic techniques, the technological revolution that has allowed us to see what the clinician
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always wanted to see and never could see. I remember many times that in the surgery classes that I was giving, The surgeon Dr. Moraza started the class always in the same way. We had the class from 2 to 3 because he had to be operating
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all morning. So it was after that when he finished the class. And the first thing he did was go with the bathe, he was not going with the bathe, he was going to another place, but in the end, there we had the morning surgical triumphs, the biceps,
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the stomachs, and he explained it to us. And one impressive thing is the enormous amount of exploratory parotomies he did. to see what was happening, especially in the abdomen of the people. The explanatory laparotomies, I still have one left, but they have practically disappeared. Why? Because
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we have some resolution methods of the very first category that allow us to see the clinical what in principle cannot be seen. There are many, right? The TAC, PET, the resonance. I always say that for me the most
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wonderful is a very small one. PET is very large, it is needed and costs a lot of money. A very small one that is the one that has revolutionized medicine and it is the ecograph. The ecograph, now they are more complicated because they
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are joined to a computer. The ecograph is a small thing and the ecograph has revolutionized everything. pregnancy control, abdominal pathology, hepatic pathology, renal pathology, so many. Therefore, there are no massive diagnostic techniques as a third revolution. What does this mean? has completely changed
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medicine. When I explained to my students the history of medicine, the evolution of medicine, I told them: in the last half century, medicine has changed even more than in the 20 centuries before. Which is, well, I don't know, It is an honor
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to be able to assist them from within this kind of evolution, but it is also a problem because the number of conflicts that these new techniques pose is continuous. Another revolutionary change is added to this.
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which is no longer a doctor but a general of society and which is generally known as secularization. Of course, this has touched on ethics very closely. What is secularization? Well, traditionally, many things that were not directly religious were united in the religious trunk, but for historical
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reasons they were united in them. For example, if one analyzes ancient Egyptian culture, Mesopotamian culture or the culture of the Word of Israel, well, there priests and doctors are at hand. The priest does medical functions, etc. It is a nest. What happened to Hippocratic medicine
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at the height of the fifth century BC in Greece? That medicine emancipated. And it stopped being, they say it, in addition the Hippocratic texts say it, about sacred medicine, it is the title of a Hippocratic text. And it
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says at the beginning, the author, who we do not know who it was, says: "Epilepsy, the sacred disease, is neither more sacred nor less sacred than all the others." Let's not talk about sacred diseases, let's see what happens to the patient. Of
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course, what does this mean? Medicine became secularized, emancipated from a trunk that was the religious trunk that had been united for historical reasons for many centuries. It is a first process of secularization and no one argues that medicine is an
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autonomous discipline and that it has nothing to do directly with religion. We must wait for the Renaissance for the second emancipation to occur.
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And this second emancipation, or this second process of secularization, is the one that occurred in the political order. If you read Machiavelli, or Hobbes, or John Locke, the Second Treaty on Civil Government, you will see that what is emerging is a political autonomous and not
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what was given in the Middle Ages, in short, the so-called Gregorian Christianity, in which The Pope, Gregory VII, joined the two arms, the arm of the cross and the arm of the sword, but the arm of the sword had to be under the arm of the
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cross, because the category was superior. Well, that ends at a certain point and the policy, the management of public space, secularized. And all the liberal revolutions of the 18th century, well, they have to be neutral in religious matters,
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right? And it is a topic that we have to this day, right? In a public school, can there be religious symbols? Yes or no? Well, this is being planned. Second secularization. What is happening and what has happened, especially in the
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second half of the 20th century? Well, we have attended a third process of secularization. public life, the management of the public thing was already secularized. What is what has been secularized in the years, from the 60s to here? The management of private life. And what
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is private life management? It is the management of the body, of sexuality, of life and death. And this has taken us by storm.
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This is the story of my generation and the generation of many of you. which is a great change and very important, but it is a seed of conflict. all these medical revolutions, all these that I have mentioned, the one of genetic engineering, the one of the techniques of support and
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vitality, the non-invasive diagnostic techniques, and if this is added to the secularization process, autonomy and freedom as basic elements and the self-management of the body, of sexuality, of life and death by human beings, then you have there a lot of conflicts that nobody knew how to
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manage. And the health professional neither. In 1974, the first table of the rights of the sick was made. What is the clearest right of the table?
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The right to informed consent. When I go to a market, these were the associations of North American consumers with legal support from the Department of Health and Welfare of the United States. What was the request of the consumer associations? When
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I go to a supermarket I am a consumer of products and I want them to tell me clearly if they have transgenic corn, if they have sugar and what quantities, if the fats are saturated or unsaturated, etc. When I go
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to a hospital I am a consumer of health services and I want the same. This was the recommendation. Well, they started riots and you know that of all that, the first code of rights of the sick was the one that appeared in the article
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10 of the Act on the Sanitation of the Health. The clearest right of all those rights is the right to informed consent, which then appears. and that nobody explained to me in the career, I had to go through it because it did not exist. And the right
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to informed consent is: well, you professional are supposed to know things that the patient does not know, you have to inform the patient and the patient has to decide.
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Of course, this is very difficult for the doctor, because if the patient decides what he thinks he should decide, then the information has not served him at all. And if the patient decides the opposite of what the professional considers
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that he should decide, the information has been a disaster for decision-making. With which this has created a great concern in health professionals. What is biotic about? Why was biotic born in 1970?
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Because of this. The little older ones will remember the happy 60s. And what were the 60s?
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Well, among other things, it was the years of Martin Luther King, of the March on Washington, of the claim of civil rights. in Kennedy's time, when everyone lived like a spring, because it was the claim of civil rights by the minorities who did not
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fully enjoy them. Well understood that those minorities were not minorities, they were majorities, women, African-Americans, etc. We can add Of course, it was a very strong movement for human rights. What will happen in the law of the sick in the year 74? Well,
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that all this movement is applied to the solitary woman. So the doctor says: "Be very careful, you have to respect the rules." And of course, the problem is that the professional did not explain those rules to her. and he
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didn't know how conflicts could be managed. Why was there no bioethics? The term bioethics was coined in 1970. It was coined by a man who was not a doctor, who was a North American chemist and biologist named Van
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Rensselaer Potter. And this man published an article in the 70s where he appeared the neologism, bioethics in the title. And in 1971 he published a book, and the book is called "Bioethics, the bridge to the future", and he analyzes in the book the
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metaphor of the bridge. And he says, of course, biomedical sciences are evolving at a dizzying speed.
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It is one side of the bridge, it is one of the pillars of the bridge. But there is another pillar that is not science, it is ethics. And the thesis of Potter is that since ethics does not evolve in parallel to science, the bridge is completed
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and the consequences can be catastrophic for humanity. It should be taken into account that Potter was a theorist, he has already passed away, he was a theorist of ecology and globalization. Twenty years later he wrote another book, today
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it is a very debated topic, which was titled "Global Biod." Potter does not speak of medical biotics, he speaks of global biotics. That is, the problem is the present and future of life on the planet. This was very new in the 70s, today
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that we have all become ecologists, it appears as less novel, but thanks to the work of all these people. Well, this happened in the 70s.
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And almost at the same time, not in Wisconsin, at the University of Wisconsin, which is where Potter was, but in Yorktown, in Washington, The term also appears. And well, there is a debate about who was first if there was communication or not.
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The case is that it appeared in the hospital of the University of Georgetown and specifically by the work of an obstetrician and very important gynecologist named Andre Hellegeertz.
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Here begins what we can call medical bioethics or clinical bioethics. Van Rensselaer Potter is another bioethics, as important or more than the clinical one. What happened? Well, George Towne took the cat to the water, so that they created with money from the
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Kennedy family for historical and family reasons that I do not have time to analyze, but in short, the Kennedy family funded a bioethics center at Georgetown University, which until today, and we have all been there, is called the Kennedy Institute of Bioethics. And then it has been one of
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the goals. Who has been there? Well, the clinicians or people. In such a way that clinical bioethics arises in Georgetown. in Georgetown for these reasons. And it also emerged in 1970. All this was accompanied by terrible scandals that came out
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in the press. For example, in the New York Times, in 1971, a famous case came out that you may know because there is also a film about it, which is called "The Study on the Syphilis of Tuskegee". Tuskegee is a town in the Midwest
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of North America, very poor, so almost everyone was against the Syphilis. and they decide to do a study to confirm the natural history of this. There were already treatments for syphilis. Think that the salbarzan had been introduced at the beginning of the 20th century and shortly
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after the neo-salbarzan and that, above all, from the 1940s until the penicillin. Well, in Tlaxquili, financed by the health institutes of the United States, A study was done that lasted until the seventh century, studying the natural history of the sifs, that is, leaving the sifilitics
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untreated to see how they evolved. Well, then they had doctors, they visited them, they were noting the whole evolution, but they did not treat them.
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The only ones they treated were those who escaped from the study, that is, those who changed Then they came to another doctor who was not in the trial, he said, "Well, no, all those who remained," this is curious, "were the faithful who suffered the
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consequences of the Tuskegee." I was in the United States, quite a few years ago, because I was the president of the United States then, and I saw on TV how the president had called the Oval Office, to those who were left behind, who were very
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few, to ask them for forgiveness publicly for what had been done. Well, the jaleo that took place in the United States when New York Times published this, which was in the year 61, was terrible. And also others came out, because there were other
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studies, there is a list, And in 1974, the American government said, "Well, this has to be analyzed." And it named a commission. And that commission, which has been basic in the development of bioethics, that commission was called the National Commission. Do
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you know it? Today, I had to go to the United States to see the reports. Today they are on the internet, in PDF, and everyone can see them. National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research.
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And this commission was making very interesting reports between 1974 and 1978. And in 1978, the period was over, that is, it was a four-year commission. In 1978 they decided, after making ten or twelve splendid reports, they decided to make a report of the
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reports. After all this report, one was about the investigation of prisoners, another about the investigation with mental ill people, the investigation with soldiers, therefore, the neurosurgery. That report was made, to a large extent, as a consequence of the problems that created in
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the United States, that created the experiments of Rodríguez Delgado. I don't know if you remember who was an important Spanish physiologist who spent many years in the United States and then returned to Spain in the 80s and so on. They made many reports and in the end
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they made a report. After all this, what can we deduce? and they made a report, which is famous and basic in the development of bioethics, which is known as the Belmont Report, the Belmont Report, because it was done in a population called Belmont. And there the three
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principles of bioethics were established. They established that all the problems that we have encountered over these four years have to do with three points. And these points are: first, what they called "respect for people"; the second principle was the relationship between risk
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and benefit; and the third principle was called "equitative selection of the sample". It is research, therefore, where is research done? Where has medicine been traditionally researched? Until the time I was studying. Well, it was investigated in the poor of Soleimani, that is, in the marginal groups. And then
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what the BELMOND report did, and before the commission reports had done it, that is, that every marginal group by definition has to be excluded from the investigation. It must be done in people who are not in those conditions. And then the The third point was the equitable
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selection of the research sample, which has to be a selection that cannot be made in marginal groups for economic, social, racial, religious reasons or because they are in the army and have to comply with authority criteria that prevent them from being completely free. Well, that is
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the first systematization of bioethics in three principles. The following year, a professor from the Kennedy Institute in Washington, Bicham, along with another one who was there, James Childress, made a book that has been the basic book, which was called Principles of Biomedical
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Ethics and was published in 1979. And in that book is where the famous four principles are, which today almost everyone knows: autonomy, what the report of Belmont called "respect for people", now it is called autonomy, relationship, kriosco-benefit, they
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will call it beneficence, and equitable distribution of the sample becomes justice. And they add a fourth principle, which is non-maleficence. And then the four appear, which are known and are everywhere. This is what constituted the first body of the Bible, elaborated from the pure
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experience. It was not theorized much. but it began by looking at the conflicts, seeing how they could be analyzed, how they could be solved, and therefore from practice to theory, not from theory to practice, as it had traditionally been. Moreover, those who were in the National Commission
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say that when the government appointed them to be part of the Commission, well, because they had a category, both as scientists and as moralists, all, before going to Washington to the first meeting, studied what they could, that is, the Nuremberg Code,
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what there was, the little there was of the ethics of research. And when they got to Washington, they started to argue, and there was no way to agree. They were discussing the issue of whether it could be experimented
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in prisoners, inside the prisons, because there were pharmaceutical laboratories that had clinics to experiment with prisoners in large prisons, of course. And then they started to argue, well yes, well no, there was no way to agree until one of the members said: "Why don't we do one thing, and that is to
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go to jail and interview the gentlemen who have passed through the clinic and something in which they have been experienced." He says they went to a jail, there they quote "a huge jail" inside which there were, for example, two supermarkets.
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and a clinic that financed a large pharmaceutical laboratory in North America. And then they interviewed everyone who had been there, and the first thing they told them was: "Everyone, be careful not to prohibit this from the investigation." Of course, they received money, They passed within the recluse population by some altruistic
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gentlemen who did good to society. They were seen, they were very well seen within the group of prisoners, right? And they were like an elite, and they considered themselves an elite, and on the other hand, it is true that most
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of those essays are what is now called "zero risk". The case is that after the interview they said: "No, it can't be completely forbidden, there will be to make some distinctions." And then they elaborated a distinction that continues to this day,
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which are the levels of risk in research. So there is the risk called minimum, there is a risk higher than the minimum, there is a risk higher than the minimum, and there is a risk higher than the minimum. And another scale.
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The commissioners of the National Commission, when they finished their report on prisoners, they established some conclusions that had to be passed on to the Minister of Justice of the United States. And they said that the investigation with minimum risk could be done in prisons, but the
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investigations with a minimum risk, no. They arrived in Washington, they were handed over to the and the minister said: "Look, this will be ethically correct, but politically it is unthinkable, and since then, the investigation in prisons is prohibited with any kind of
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law." Well, but that's how they were being beaten. The Belmont report is the consequence of all this. What does this mean? Well, between 1970 and 1990, in the United States, a new ethic is put to the point, a new
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way of dealing with moral conflicts in the world of life sciences, related to life and health. This, a bioticist of this first generation, who has been in Spain many times, Albert Johnson, he historized it, now he is much older, he has not
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yet passed away, but a few years ago, in 1998, he published a thick book where he historized all this, he made the history of this whole process in the United States. The book, which is splendid, is called "The birth of bioethics", and he tells these things and many
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more. If you want to have a good time, there you will have, but Johnson, a very smart and very versed man, nevertheless says one thing that the Europeans felt or did not feel very bad about. And it is that, first thing, he says that bioethics is
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the consequence of what he calls "the American is", the ethos American. This has happened to us because it is our ethics, first thing. And second, the idea that ethos is universal and therefore can be spread to the whole world.
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This is very dangerous and in fact, those who came from all over the world, from all parts of the world, they persecuted people, including me, to the United States to find out what was happening. We were in the Kennedy Center, we were in the Houston Center, we learned this and
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we returned. I returned to Spain, others returned to China or India. In the idea that what had to be done was to apply this, translate it into Spanish and apply it. And the same phenomenon occurred in all places in the world, and that
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is that direct application was not possible. Why? Well, the cultures are different. Do you think that informed consent is the same in New York as in a town in Andalusia?
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I tell you from the Andalusian town, a disciple of mine is a bioethics teacher in Doha. And well, what he tells me is that it has nothing to do with it, or in Africa undoubtedly not. That is, things are different and cultural peculiarities must be taken into account. And what
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are cultures made of? Well, cultures are made up of values. And then, little by little, in all the places of the world, it has gone from the famous four principles of that first generation. Now we are talking about generations. The first generation is the one I told you about. And
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where we are now is in the second or in the third, I don't know.
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Because when one approaches the events it is more difficult to see them clearly and the historian cannot history the situation because it is still present. But at least we are in the second generation. And the second generation, what is the difference from the
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first? First, bioethics is no longer a phenomenon in the world, it is a universal phenomenon. in all the medical faculties of the world, in all the faculties of medicine, in many faculties of law, of course in the faculties of theology, bioethics is taught. It is a global phenomenon.
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Therefore, a first thing has been produced, and that is that it has become global. And second thing, there has been no need to translate Anglo-Saxon bioethics to other languages, but to redo it. or recreate from those cultures. And this has been very complicated and it
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is the great task of the second generation. What can that recreation consist of? Well, cultures are deposits of values, religious, aesthetic, economic, social, family values. Deposits of values, that is what a culture is made of. And then, what
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was seen little by little, is that those four famous principles had to be replaced by another language, more plastic, probably more complex, which is the language of values. In all human decision there are facts, the clinician first evaluates the patient, the clinical facts, therefore, make the
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clinical history and know what happens to him and what he can do. This is clear, part of the facts is that. This is clear in medicine, in other disciplines it is not so clear. That is, if you watch television,
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you will see how in the courts it goes directly to ethics and to analyze the facts well. And in politics it is not. But in medicine we have at least one part won. And it is that everyone knows that the facts
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are basic, that you have to do the clinical history, that you have to do the anamnesis, that you have to explore and that if not, that the clinical eye itself is useless. And this is important. What happened to the classic
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doctor? Well, once he had the facts clear, he immediately made the decision. And now, what have we realized? Well, from the facts to the decision, there is a very important intermediate point, which are the values. And the values are not of the doctor,
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well, the doctor has his own, they are of the patient. And also, the doctor has the obligation to respect the values of the patient with informal consent, even if he is wrong. And second point, has the obligation to respect it, but it has another obligation, which is to
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mature. the values with the patient in order for the decision they have to make to be the most reasonable, the most prudent, the most responsible, the most mature. Because what is evident is that if someone is told that he has colon cancer, the
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first thing he is going to do is shoot what Freud called defense mechanisms and the first thing he's going to do is deny. Ah, well, I don't want to.
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Well, if he doesn't want to, look here that he doesn't want to and that's it. That cannot be done. So, we have to learn a new subject, which is what we are teaching, and what subject is to explore values, how to explore critical facts,
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and to see how the conflicts of values are handled, in order for the decision to be more adequate, more reasonable, more prudent, and therefore the best for the patient. This is of great complexity and requires an education and training. I
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don't know if you have noticed that the last Nobel Prize in Economics was given to a psychologist named Richard Thaler. And I don't know if you know that about 10 years ago they gave another Nobel Prize in Economics
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to another psychologist named Kahneman. This Kahneman has become very famous, he was very famous in the world, but now he is popular because he has written a book that has given bookstores, a bestseller, called "Thinking fast, thinking slowly". And what these psychologists have realized
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is that human beings, above all, more than thinking, value. When we value, we can value in two ways. We can value with pure rhinencephalus, emotionally at full capacity, and then, well, the valuations are extreme. I like people well or badly.
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I hardly like them regularly. Because emotions are extreme and valuations are very emotional. So, this one is good or bad, or this one, that's how we are, right?
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And what does that mean? Well, that our immediate evaluations, and this can be defined as a law, are all biased. And the function of ethics, when it analyzes values and delivers on values, is to try to narrow those biases in order for the decision that the
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patient makes, that he has to make, to be as adequate, as responsible as possible. Why do psychologists save the economy? Because we, the professionals, are interested in knowing all this to reduce the risk. But the economists and those who sell products, the knowledge of the risks interests
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them a lot, not to reduce them, but to see how they are used to sell products. Nobel Prize in Economics. Today the economics that is given in the faculties of economics is no longer that theory of the rational election of the 40s and 50s that failed in the war
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of Vietnam and that is why they do not win it, but it is another economy that is called the "Vigilio al economics" which is the economy of behavior, how do human beings make decisions? What risks do human beings have when
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making decisions? And how to use those risks to be able to sell the products that they do not want to sell? Well, this is the current situation of bioethics.
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Two words about the future and I end immediately. What is going to happen in the future? Man, the future is uncertain. The most complicated thing that medicine has always had is the forecast, and the forecast for the future is complicated. But
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there are several things that are already becoming clear. For example, the issue of globalization. Second, the issue of big data or data. This big data is impressive because it will allow, for example, that every human being who gets
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in touch with the health system to be part of biomedical research, whether or not they want to. For example, the Institute of Medicine of the United States, a few years ago, but since then it has been insisting on it, has put as
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a horizon a goal called the Learning Healthcare System. The system of assistance, of teaching and of research all at the same time. In such a way that every clinical act is an act of teaching and research. When I was a medical student, when I was a student,
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there were two completely different logics. The logic of the clinician and the logic of the researcher. Who investigated in Spain in the 60s in hospitals? Well, the one who wanted to make opposition to that category. And the thesis of the clinicians is that it was a danger for medicine. I don't
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know if some of you remember it, but something of that. Well, take today the New England and look to see that it is a clinical study. And what there are are clinical research works and research. And all the evidence-based medicine, the only thing
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that shows is that there is no logic, which was what I learned in the career, but there is more. and therefore those two logics have to converge. That is the cell, or it wants to be the so-called evidence-based
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medicine. But this evidence-based medicine is only the beginning. All clinical data will be research data. And this was not possible before. Why not? Because the technical media, the memories of the computers, did not allow this. Today they begin to allow it. And then the revolution that will occur, of
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course in teaching, in research and in assistance, will be total. Every subject who comes into contact with the health system, or let's not say in a hospital, will be a subject of research. And this is supposed to completely change the ethics of clinical trial and the ethics of clinical research.
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Five years remain. to the ethics of clinical trial that we all know and that we have studied. And the same, the ethics of health care. And therefore, I would say that the horizons and the problems of these horizons
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that we have in front of us are fascinating, but at the same time they are terrible, because they are going to pose conflicts like never before. One last thing.
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Of course, as Francesc Bullosa said, I was born in 1941, I am a child of the post-war era, I should say.
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I lived my adolescence in the 50s and 60s, and I remember that the debates we had when I was studying high school about issues of ethics, which were many, because we were worried, Whatever you spoke, the debate always ended the same. And
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it was a confrontation, this or that. Well, but who are you with? You are with the socialists or something. So it was when Marxism started to rise in the young people, right? Or are you with us? This was always the confrontation, it was this or that. And whatever you spoke,
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you ended that confrontation. Well, there was an iron bar, there was a Berlin Wall, all that, that was over. And it was over long ago. And now what is the great confrontation? Well, it is not the confrontation east-west, it is the confrontation north-south. And the north-south
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confrontation is the confrontation of life, that is, of the present and future of life on the planet. It is the confrontation between a third world that lives badly and a first world that also lives badly. It is no longer political ethics, which was the one of the
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60s. Now, whatever you talk about, you end up talking about this, about the ethics of life, about bioethics. What is bioethics then today? Well, it is not the ethics of doctors, it is the general ethics del siglo XXI, en los comienzos del siglo XXI. Muchas gracias.
Topics:bioethicsmedical ethicsgeneticsscientific revolutioninformed consentCRISPRnuclear fissionevidence-based medicinesustainable developmenthistory of bioethics
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