BioethicsUseful Referencehttp://griffin.auhs.edu/medethex/index.html : BioethicsUseful Referencehttp://griffin.auhs.edu/medethex/index.html Marc Imhotep Cray MD
What is Bioethics? : What is Bioethics? Study of ethical issues arising from biological and medical sciences
Varieties of Bioethics : Varieties of Bioethics Medical ethics
Physician-centered
Health care ethics
Includes nurses & other healthcare professionals
Clinical ethics
Hospital care decisions with aid of committees and consultants
Bioethics in general
Includes issues in genetics, reproductive technologies, experimentation, and distribution of life-saving resources
Origins of Bioethics : Origins of Bioethics Emerged in early 1960s in the U.S.
Arose out of public concerns
E.g., issue of selecting patients for chronic haemodialysis in Seattle in 1962
Represented the view that ethical problems in medicine and biological sciences can be solved by applying moral principles
(Source: Albert R. Jonsen, Journal of Medicine and Philosophy (1991), pp. 113-30)
Why is Bioethics Important? : Why is Bioethics Important? Changing doctor-patient relationship
Recognition of patient autonomy in decision-making
New technologies
E.g., assisted reproduction, gene therapy, support and prolonging of life
Changing economics of medicine
Managed care, health insurance, commercialization of medicine (profit motive)
Who Should Do Bioethics? : Who Should Do Bioethics? Lawyers and Doctors
Historically, issue is for doctors to avoid or to deal with charges of negligence.
Philosophers
Ethical dilemmas go beyond issues of legality. Philosophers can help doctors to make sound ethical decisions and to justify them to their patients and the public.
“If you need an analysis, send the urine to the biochemist, and the ethics to the philosopher.”
Philosophy and Bioethics : Philosophy and Bioethics
What is Moral Philosophy? : What is Moral Philosophy? Distinguish morality from law
Distinguish moral philosophy from religious ethics and codes
What Moral Philosophers Do : What Moral Philosophers Do Use reason and arguments
Apply general moral principles
Provide conceptual and analytical tools
Justify or question moral practices
Normative Ethics : Normative Ethics Developing principles that tell us which actions are right, and what we are morally required to do.
Normative Theories : Normative Theories Deontological theories
Associated with German philosopher Immanuel Kant.
Consequentialist theories
Most well-known theory is utilitarianism.
Utilitarians seek to maximize general human happiness or well-being.
Famous utilitarian philosophers include John Stuart Mill and Jeremy Bentham.
Deontological Theories : Deontological Theories A type of action is right or wrong no matter what its consequences are.
Moral agents have duties which oblige them to do certain types of action.
Duties can be specified in the form of rules that must be universally applicable.
Persons and their autonomy should be respected at all times.
Consequentialist Theories : Consequentialist Theories What makes an action right or wrong are its consequences.
The consequences of an action can always be measured by a common standard: what it contributes to the good of all who are affected by the action
The right action is one that has the maximum beneficial results.
The same unit of benefit to any person should be given equal weight.
What is Applied Ethics? : What is Applied Ethics? Use of general moral principles to test the morality of particular actions.
Problem for Applied Ethics : Problem for Applied Ethics Presence of competing moral principles
Does this make applied ethics subjective?
Room for reasoning, argument and justification
Ethics is not a matter of taste.
Ethical dilemmas are real dilemmas
There are no easy answers.
Important to learn why people disagree
Ethical Theory and Bioethics : Ethical Theory and Bioethics Straightforward application of principles
Four-principles approach (Childress & Beauchamp)
Case-study approach
Methodology of casuistry (Jonsen & Toulmin)
Interplay between theory and case-study
Bioethics contributes to ethical theory as well as benefiting from it
Problems for application of principles : Problems for application of principles Choice of ethical theory cannot be justified
Real life is too messy and detailed
Priority of principles cannot be resolved
E.g., principles of autonomy and beneficence can be in conflict.
Problems for case-study approach : Problems for case-study approach Problem of bias
Intuitions need to be critically examined.
Too many mid-level principles in evaluating cases
Theoretical issues cannot be avoided
E.g., euthanasia raises questions about the value of human life; allocation of resources raises questions of distributive justice.
Bioethics and the Doctor : Bioethics and the Doctor Philosophers can help doctors to identify goals in medicine and to develop practical principles.
Moral philosophy will impact on clinical practice by improving understanding and affecting the way in which ethical problems in medicine are described.
Medical ethics : Medical ethics Medical ethics is grounded in philosophical ethics, it concerns itself with the ethical questions and dilemmas in medicine.
Medical ethics is not any special ethics but an ethics which deals with special cases from medical practice.
Doctor-patient relationship : Doctor-patient relationship Medical ethics has three centres: doctor, patient and society.
Its centre is the doctor-patient relationship.
The moral duties of the doctor : The moral duties of the doctor The duty to help, cure
The duty to promote and protect the patient’s health
The duty to inform
The duty to confidentiality
The duty to protect the patient’s life
The duty to respect the patient’s autonomy
The duty to protect privacy
The duty to respect the patient’s dignity
The moral rights of the patient : The moral rights of the patient The right to high quality medical service
The right to autonomous choice
The right to decide
The right to be informed
The right to privacy
The right to health education
The right to dignity
Principles of biomedical ethics : Principles of biomedical ethics Nonmaleficence
Beneficence
Respect for autonomy
Justice
Hippocratic oath5-4 centuries B.C. : Hippocratic oath5-4 centuries B.C. An obligation of nonmaleficence and an obligation of beneficence are both expressed in the Hippocratic oath:
“I will use treatment to help the sick according to my ability and judgement, but I will never use it to injure or wrong them.”
Nonmaleficence and beneficence : Nonmaleficence and beneficence The principle of nonmaleficence asserts an obligation not to inflict harm intentionally. Principles of beneficence potentially demand more than the principle of nonmaleficence, because agents must take positive steps to help others, not merely refrain from harmful acts.
The differerence of two principles : The differerence of two principles Nonmaleficence
One ought not to inflict evil or harm Beneficence
One ought to prevent evil or harm
One ought to remove evil or harm
One ought to do or promote good
The concept of autonomy : The concept of autonomy The word “autonomy” is derived from the Greek “autos” (self) and “nomos” (rule, governance or law).
It was first used to refer to the self-rule or self-governance of independent Hellenic city-states
Autonomy has since been extended to individuals and has acquired meanings as diverse as self-governance, liberty rights, privacy, individual choice, freedom of the will, causing one’s behaviour, and being one’s own person.
Autonomous person : Autonomous person We analyze autonomous persons in tems of
liberty (independence from controlling influences)
agency (capacity for intentional action)
Autonomous action : Autonomous action We analyze autonomous action in terms of persons who act
Intentionally
With understanding
Without controlling influences that determine their action
To respect an autonomous agent : To respect an autonomous agent Is to acknowledge that person’s right to hold views, to make choices, and to take actions based on personal values and beliefs.
Such respect involves respectful action, not merely a respectful attitude.
Respect involves treating persons to enable them to act autonomously, whereas disrespect for autonomy involves attitudes and actions that ignore, insult, or demean others’ autonomy and thus deny a minimal equity to persons.
Informed consent is analyzable : Informed consent is analyzable Through the account of autonomous choice.
A person must do more than express agreement or comply with a proposal.
He/she must authorize through an act of informed and voluntary consent.
in terms of the social rules of consent in institutions that must obtain legally valid consent from patients or subjects before proceeding with therapeutic procedures or research.
The standards used to determine the incompetence : The standards used to determine the incompetence Inability to express or communicate a preference or choice.
Inability to understand one’s situation and its consequences.
Inability to understand relevant information.
Inability to give a (rational) reason.
Inability to give risk/benefit related reasons.
Inability to reach a reasonable decision.
Paternalism : Paternalism is the intentional overriding of one person’s known preferences or actions by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose will is overriden.
Weak paternalism : Weak paternalism In weak paternalism an agent intervenes on ground of beneficence or nonmaleficence only to prevent substantially nonvoluntary conduct, i.e. to protect persons against their own substantially nonautonomous actions.
Strong paternalism : Strong paternalism Strong paternalism involves interventions intended to benefit a person despite the fact that the person’s risky choices and actions are informed, voluntary and autonomous.
A central problem in biomedical ethics : A central problem in biomedical ethics Whether respect for autonomy of patients should have priority over professional beneficence.
The concept of justice : The concept of justice The terms fairness, desert (what is deserved), and entitlement (that to which one is entitled) have been used by various philosophers in attempts to explicate justice. These accounts all interpret justice as fair, equitable, and appropriate treatment in light of what is due or owed to person.
Principles of distributive justice : Principles of distributive justice To each person an equal share (formal equity)
To each person according to need
To each person according to effort
To each person according to contribution
To each person according to merit
To each person according to free-market exchanges
Useful References : Useful References Tom Beauchamp & James Childress, Principles of Biomedical Ethics (Oxford University Press, 1994)
Nancy Jecker, Albert Jonsen & Robert Pearlman (editors), Bioethics: An Introduction to the History, Methods, and Practice (Jones & Bartlett, 1997)
Robert Veatch (editor), Medical Ethics (Jones & Bartlett, 1997)
Slide 41 : Q#: 1 Question: Under which circumstance is the mental health professional required to disregard doctor‑patient confidentiality in most jurisdictions by reporting to the proper peace‑keeping authorities?
A. The patient who states that he's going to kill his girlfriend the coming weekend by shooting her at home
B. The patient who says that at least once a week he feels like killing his boss, but that on other days he interacts adequately with his boss and coworkers
C. The patient who states that he secretly put arsenic in his brother's food over a three month period five years earlier, but that now he loves his brother dearly
D. The patient who says that he would like to see France bombed out of existence
E. The patient who threatens to kill himself
Slide 42 : Q#: 2 Question: A medical resident will be entering private practice next year and is concerned about the ethics of patient confidentiality and when it can be breached. There are certain circumstances under which physicians in most jurisdictions are obligated to violate patient confidentiality. Which of the following is a common one?
A. Gunshot wounds
B. Intravenous drug abuse
C. Venereal diseases, including acquired immunodeficiency syndrome (AIDS)
D. Psychosis
E. Spousal abuse
Slide 43 : Q#: 3 Question: A 70‑year‑old female with a lifelong mental age of 18 to 24 months lives in a special care area where her special needs are met is referred to your hospital when she is observed to be somewhat pale. An examination of her peripheral blood reveals a pattern consistent with an acute leukemia. Her only living relatives are her two younger brothers, a 68‑year‑old retired automotive mechanic, and a 62‑year‑old retired police officer, who, on being informed of their sister's condition state, "Doctor you do what you think is best. We trust you to do the right thing for our sister!" How will you proceed?
A. Obtain a guardian ad litem
B. Obtain an ethics committee consultation for the patient
C. Obtain a written consultation from a colleague
D. Obtain a pastoral counseling consultation for the patient
E. Obtain an informed consent from the patient
Slide 44 : Q#: 4 Question: A 5‑year‑old child is brought to your emergency department with full thickness, third degree burns over seventy percent of her body. It is the strong opinion of the director of your burn unit that she must have blood transfusions or she will die. Her parents inform you that blood transfusions violate their faith. How do you resolve this issue?
A. Contact your hospital chaplain
B. Allow the parents to take their child home to die
C. Ask a colleague what you should do
D. Contact your hospital attorney
E. Ask a friend in law school what you should do
F. Order blood over the objections of the parents and their spiritual beliefs
Slide 45 : Q#: 5 Question: A 15‑year‑old female presents to your office, requesting a prescription for isotretinoin (Accutane). She has previously tried topical benzoyl peroxide, topical and oral antibiotics, and topical tretinoin (Retin‑A) products, with only minimal improvement in her acne. Family history is positive for cystic acne in her father and brother. Examination reveals nodulocystic acne localized to her face and chest, with diffuse comedones and pustules across the face, chest and back, and some scarring. You ask her mother to leave the exam room, and ask the patient if she is sexually active. She reports that she has had intercourse "a couple of times," but becomes tearful when you tell her that she will need to use two forms of contraception if you prescribe isotretinoin for her acne. She refuses to take oral contraceptives, saying that she promises not to have intercourse while on isotretinoin. What should you do next?
A. Tell her mother that she is sexually active and thus isotretinoin is contraindicated
B. Prescribe isotretinoin at only 10 mg, since the teratogenicity of isotretinoin is dose‑dependent
C. Counsel the patient regarding the teratogenicity‑pregnancy prevention program and do not prescribeisotretinoin
D. Tell the patient to avoid intercourse during the fertile period of her cycle
E. Prescribe isotretinoin, since the risk for pregnancy is low in a 15‑year‑old female and her acne is so severe
Slide 46 : Q#: 6 Question: A 35‑year‑old associate professor of chemical engineering returns to your office following surgery for terminal, metastatic ovarian cancer. She states that she has persistent dull pain so you obtain an x‑ray. The x‑ray reveals a ten‑centimeter metal clamp. What do you do now?
A. Say nothing to the patient about the clamp since she is terminal and may never find out about it
B. Inform her about the clamp and tell her you hope it will dissolve in time on its own
C. Inform her about the clamp and refer her back to her surgeon
D. Telephone your attorney and ask for advice
E. Telephone the surgeon and ask for advice
Slide 47 : Q#: 7 Question: A 42‑year‑old certified occupational therapy assistant (COTA) is diagnosed with ovarian carcinoma. After a long battle, including surgery and chemotherapy, she succumbs. As you are leaving her graveside funeral, having expressed your sense of grief and loss to her family and friends, the funeral director takes you aside and informs you, "I found a metal clamp inside of her when I was embalming her." The funeral director states further, "Doctor I have a whole box of clamps that I found while preparing bodies for burial". What do you do with this information?
A. Thank the funeral director and inform the operating surgeon immediately
B. Thank the funeral director and say nothing further since she is dead and buried
C. Thank the funeral director and inform your attorney immediately
D. Thank the funeral director and inform the bereaved family immediately
E. Thank the funeral director and inform any plaintiffs attorney in your community
F. Thank the funeral director and inform your hospital quality control office immediately
Slide 48 : Q#: 8 Question: During a first year medical school ethics class, a 25‑year‑old medical student interrupts stating, "Gosh I just don't understand why so much of our time is spent on ethics. I thought that ethics was if a patient wants to use your office telephone, do you or do you not charge him or her a quarter?" You are understandably aghast at his gauche interruption and you inform him that
A. He must leave the classroom as he has just failed the ethics course
B. He must leave the classroom and write one hundred times I will not interrupt our ethics class with silly questions
C. He must leave the classroom to prepare a special paper on the value of ethics in medical school
D. He must leave the classroom, as he is clearly a ninny
E. He must leave the classroom and report directly to the office of the dean for dismissal from medical school
ANSWERS TO QUESTIONS : ANSWERS TO QUESTIONS 1=A
2=A
3=A
4=D
5=C
6=C
7=F
8=C