From narrower to broader

Since the 1970s bioethics has had an intense focus on medical ethics, and specifically on clinical ethics. One of its central aims has been to reconceive relationships between patients and medical professionals, in particular doctors. This preoccupation has, unsurprisingly, mainly focused on clinical practice in rich societies, and has paid less attention to the ethics of public health, to the health problems of poorer societies (which suffer a high share of the global disease burden), or to connections between health and environment.

This approach to medical ethics emerged in a period during which the delivery of health care in the rich world shifted from a one-to-one, direct and often long-term relationship between patient and doctor, where each party knew the other and could make reasonable judgements about the other, to one in which increasingly complex health care was provided in complex institutional settings. Patients often encountered a phalanx of professionals, each with a fleeting presence in their lives, which made it harder to judge their probity and competence, and therefore harder to place and refuse trust with discrimination. Medical research changed in parallel ways. It was undertaken less and less by individual doctors, and increasingly by research teams with many members, complex organisation and multiple sources of funding, and often enough multiple locations. These transformations were described over twenty-five years ago in David Rothman's aptly titled Strangers at the Bedside and have been analysed in many works, including Renée Fox and Judith Swazey's perceptive Observing Bioethics.

In some respects Rothman's arresting title underplayed the magnitude of the transformation: those who appeared (briefly) at bedsides (and many others who never even appeared) were no mere strangers: they were strangers with highly specialised and valued knowledge and considerable power to provide or refuse specific interventions. A heightened imbalance in power and knowledge was seen as a source of risk to patients and research subjects, and one of the aims of modern bioethics was to contain this risk.

As is well known, a central claim of those who sought to refocus medical ethics was that traditional relations between doctors and patients were paternalistic, and those between researchers and research subjects potentially dangerously defective. In both contexts more formal relationships and procedures were needed to protect patients and research subjects.