Unit 7 Journals

13.1: Major Aspects of Human Sexuality

1. 13.1 Distinguish between the public and the private aspects of sexuality

LISTEN TO THE CHAPTER AUDIO:

The first distinction that must be made when discussing morality and human sexuality is that which exists between its public, or societal, aspect and its private aspect. First of all, the public aspect is concerned with the way in which matters of sex overtly affect others, and the basic governing principles of morality here are life, goodness, and justice. The private aspect, on the other hand, is concerned with sexual relations between or among consenting adults, and the basic governing principles in this case are those of goodness, justice, freedom, and honesty.

In other words, it is important to distinguish between two kinds of actions involving human sexuality:

· Those that have such an adverse effect on people other than the participants that they should be forbidden by moral commandment or by law.

· Those that affect only the participants and should therefore be left up to the private moral deliberations of the people concerned.

Needless to say, one of the main issues surrounding human sexual activity is whether society should greatly restrict such activities on the one hand or allow a great deal of sexual freedom on the other. Before dealing with arguments concerning restriction or liberalization of sexual activity, it probably would be of value to examine what the meaning and purposes of human sexuality are deemed to be.

13.2: The Meaning and Purposes of Human Sexuality

1. 13.2 Evaluate the meaning and purposes of human sexuality with respect to morality, public aspect, and sexual freedom

LISTEN TO THE CHAPTER AUDIO:

The meaning and purposes of human sexual activity appear to be four-dimensional, involving (not necessarily in order of importance) procreation, pleasure, an expression of love for other people, and an expression of friendship and liking. These, of course, need not be mutually exclusive, and often they are not. However, sexual activity may also be limited to only one of these purposes. Although procreation is a rather obvious purpose of sexuality, sexuality is also—in the opinion of many—the deepest and most intimate expression of the love of human beings for one another. This does not mean that one cannot love others without sexual activity—if that were true, one could never love his or her children, brothers, sisters, parents, or grandparents without being incestuous. What it does mean is that when a love involving meaningful sex occurs, it is deeper than any other kind of love. For instance, two people need not have sex to love each other, but deep and loving sex between two persons can add a rich new dimension to any love.

It is, many feel, a terrible oversight on the part of society in general that the loving aspect of sex has been considered relatively unimportant when compared to its procreative aspect or to other areas of human relationships. Our society has, at least until recently, often emphasized that sex is somehow a necessary evil. This approach to human sexuality implies either that its primary purpose is to produce children or that sexuality is not a very important aspect of human relationships and human life. This is an attitude reflected in many of our laws, which are throwbacks to nineteenth-century Victorianism. In the Victorian era, all kinds of private sex acts between or among consenting adults were forbidden to the extent that if a husband and wife wished to practice oral sex, for example, they would, under the law, be guilty of a felony.

Many of these archaic and unfair laws (unfair, that is, when applied to all human beings) have been repealed in many states and revised in accordance with the American Bar Association’s suggestions. The reason for this change in attitude is that these laws reflected a view of human sexual activity that does not square with studies made in the nineteenth and twentieth centuries, including those of Freud (1856–1939), Kinsey (1894–1956), and Masters (1915–2001) and Johnson (1925–2013).2

Almost all the research conducted by twentieth-century psychologists reveals the following:

1. Sexuality as it is practiced did not and does not adhere to the general societal moral pronouncements and laws.

2. It reveals that human sexuality for many people is very limited and that sexual relations often are unsatisfying because of people’s upbringing, which has been strongly influenced by the taboos against meaningful sexual relations set up and generally sanctioned by their society.

3. This research reveals that psychologically, sexuality is extremely important to human living and especially to human relationships.

In view of such strong evidence, it seems that the expression-of-love and friendship-and-liking aspects of human sexual activity should be emphasized more than they have been—in fact, that they should be emphasized at least as much as procreation and pleasure.

The conservative, or restrictive, view of sexual activity often emphasizes either the procreation aspect of sex or the view that sex is a “necessary evil”—that is, a biological urge felt by men (but not, it is implied, by women) that must be satisfied. Advocates of complete freedom in sexual matters, on the other hand, usually emphasize the pleasure aspect and the rights of individuals to enjoy such pleasure. There is also a more moderate position of which proponents tend to accept both the procreative and pleasure aspects while also including—and often emphasizing more strongly—the expression-of-love and friendship-and-liking aspects. Lines are not always drawn this clearly. A proponent of sexual freedom may, for example, strongly emphasize the expression-of-love aspect—as may a supporter of the conservative view. However, the general tendency is for each group to emphasize the aspects of human sexual activity in the ways described earlier.

13.2.1: Moral Issues and the Public Aspect of Human Sexuality

LISTEN TO THE CHAPTER AUDIO:

Those sexual acts that immediately affect the public or individuals in such a way as to bring them possible harm, that are generally considered immoral, and that are usually controlled by laws are rape, child molestation, and  sadism  performed on unwilling victims. The possible harmful effects that can ensue from these three types of acts are bodily harm and/or death and the general perniciousness of forced sexual activity. No matter what set of ethical principles they endorse, most people generally agree that these acts are immoral and that there should be laws and/or moral taboos forbidding them.

Other activities considered by many to be against the public interest are pornography, homosexuality, sex outside of marriage (including premarital and extramarital sex and adultery), prostitution, masturbation, nonmonogamous marriages, and “unnatural” or “perverted” sexual activity. Agreement about the immorality of these activities is not, however, as general or as clear as is agreement about the first three activities. Specific arguments for and against these issues will be presented, but first it is worthwhile to examine some arguments for and against sexual freedom in general.

13.2.2: Arguments Against Sexual Freedom

LISTEN TO THE CHAPTER AUDIO:

The first argument against sexual freedom is that such freedom is a violation of the traditional moral “absolutes” embodied in our Judeo-Christian heritage. According to this tradition, heterosexual sex is the only morally permissible sexuality. Furthermore, sexual acts should be performed as “God and nature intended” (i.e., generally in the “missionary position,” with the man on top and the woman on the bottom). Finally, sexual activity must take place only within a legally and, preferably, a religiously sanctioned marriage between one man and one woman who are joined together mainly for the purpose of bringing children into the world. Outside of marriage the only acceptable approach to sexuality is abstinence. Of course, pornography, homosexuality, sex outside of marriage, prostitution, masturbation, nonmonogamous marriages, and “unnatural” or “perverted” sexual activity are considered to be violations of these traditional moral teachings, either because they tend to undermine our family and societal structure or because they eventually will lead to the destruction of these institutions.

The domino argument applies here, as it does to so many moral issues, and this time in two ways. First, allowing sexual freedom in any of the areas named previously will eventually lead to violations in more dangerous areas. It is argued that if, for example, we allow people the freedom to read, view, and acquire pornography openly, eventually there will be an increase in rapes, child molestation, and sadism performed on unwilling victims, all of which may lead to sexual murders. According to this argument, pornography so inflames the sexual appetites and desires of people that they will have to find outlets for these appetites and will resort to these unacceptable means. Second, it is argued that allowing more sexual freedom in these areas will undermine our society and all the good and decent things it stands for, such as the family, respect for marriage, love rather than lust, respect for the human body, respect for women and men, and respect for children.

The offensiveness to public taste argument presumes a certain general agreement concerning what is acceptable and what is offensive to the public taste. Heterosexual relationships are acceptable, whereas homosexual ones are not. Monogamous marriages are acceptable, whereas polygamous (more than one wife) or polyandrous (more than one husband) ones are not. Sexual activity within a marriage is acceptable, whereas outside of marriage it is not, and so on.

The social diseases argument cites the probability of getting certain social diseases, such as syphilis, gonorrhea, herpes, chlamydia, and the dreaded and fatal  acquired immuno deficiency syndrome (AIDS) , through sexual promiscuity and sexual freedom. The proponents of this argument state that all of the so-called sexual freedom of the 1960s, 1970s, and 1980s has led to an increase in such diseases, which are not only painful, destructive, and contagious but also in many cases (especially with AIDS) fatal. A return to and reemphasis of traditional sexual morality would be the best way to eliminate such terrible diseases, according to proponents of this argument.

13.2.3: Arguments for Sexual Freedom

LISTEN TO THE CHAPTER AUDIO:

The main argument presented by the proponents of the individual freedom position is that people ought to have the freedom to do what they want to do as long as they are consenting adults and are not materially or directly harming other members of society by their actions. Obviously, people should not be free to rape, to molest children, or to perform sadistic acts on unwilling victims. However, they ought to be completely free to have any kind of sex they wish with other consenting adults or by themselves, in or outside of marriage, as long as they do not harm others.

Even though the prosexual freedom advocates recognize that there are Judeo-Christian or other traditions that have, in the past, served as guides for sexual morality, they do not consider such traditions to be “absolute.” In fact, they argue that such traditions are based upon archaic views of the biological and psychological makeup of human beings—views that twenty-first-century advances in the sciences and social sciences have revealed to be inaccurate. Now that we know more about human sexuality, the prosexual freedom forces argue, we should allow a wider and more open expression of one of the most important human drives in existence.

Prosexual freedom advocates also argue that there is no clear-cut indication of what “God and nature intended” in sexuality except what is condoned or prohibited in certain religious teachings, which one may or may not believe. They state that the marriage contract is merely a piece of paper and that there is evidence that sex that takes place outside of marriage can be just as meaningful as that which takes place within it. Furthermore, sex between homosexuals and in polygamous or polyandrous relationships or marriages can be as meaningful as sex between heterosexuals in monogamous marriages. Because human beings are so varied and unique in their feelings and desires, sexual-freedom proponents argue, they ought to be allowed the greatest freedom of sexual expression possible as long as they do not harm others.

The sexual-freedom proponents would argue that there is no hard evidence to suggest that allowing greater sexual freedom in the seven questionable areas will lead to violations in the areas of rape, incest, and forced sadism. They argue further that some evidence exists that in countries such as Denmark, where pornography has been made totally legal and freely available, the rate of sexual crimes, such as child molestation, has dropped. Sexual-freedom supporters see pornography as a force that relieves sexual repressions and eliminates the need for these more harmful types of sexual activities.

Even if, however, there are abuses of freedom in relation to pornography—for example, sexual murder or so-called “kiddie porn”—laws can be passed restricting and punishing people involved in those activities without restricting people’s general freedom of access to pornography. Second, this argument states that rather than undermining our society, greater sexual freedom will enhance it by allowing for fuller sexual expression. This in turn will deepen the love, respect, and intensity of human relationships, which can only improve marriage, family life, and society in general.

Offensiveness and Social Diseases

LISTEN TO THE CHAPTER AUDIO:

According to the sexual-freedom proponents, offensiveness to public taste is not in itself a reason to halt the activities of others, and therefore it should be considered more of a violation of customs and manners than a violation of morality. Bodily harm and/or death are immoral under most ethical principles, but offensiveness to public taste is not unless it can be shown that the principle of justice has been seriously violated. This does not mean that the rights and feelings of others in matters of taste should not be considered; what it does mean is that the excuse that something is offensive to others, even though they are not required to participate in any way, is not sufficient to bar someone, either by moral censure or by law, from engaging in certain activities.

Discretion certainly should be employed in the public display of pornography and other sexual activities offered for those who wish to participate (topless or nude shows, films, etc.), and there should be control of indecent exposure, overt solicitation, or coercion to participate in any sexual activities. However, this is not to say that an open display of affection that does not involve indecent exposure or overt solicitation or coercion is immoral even though—especially between or among homosexuals—it may offend some people’s tastes. Therefore, if sexual activity does not violate any of the preceding criteria, and it often does not, it then becomes, according to the sexual-freedom proponents, largely a private matter to be dealt with between or among consenting adults.

There are many ways in which the problem of offensiveness to public taste can be handled. For example, if people want to sunbathe or swim in the nude, then special locations can be purchased or set aside for them to do so. Those who do not wish to do so need never go near these locations. If some adults want to view pornographic films, buy books, or see live nude people, then as long as those who do not want to do such things are not forced to do so, and as long as these theaters, bookstores, and nude shows are obviously marked and advertised to show what they are, then how can there be an overt offense to taste?

Furthermore, there is no conclusive evidence that participation in any of these activities has caused harm to society in general; that is, that people who read pornographic books, for example, go out and molest children or rape others. In fact, as mentioned earlier, some studies have shown that in countries where laws against pornographic shows, films, and books have been relaxed, overt sexual crimes have tended to decrease. The proof for this is not conclusive either, but if there is no conclusive proof either way, then such activities should not be considered immoral or illegal merely for the reasons previously cited.

Proponents of sexual freedom certainly recognize the dangers of social diseases and especially AIDS; however, proper precautions can certainly be taken to avoid or minimize the contracting of such diseases, such as abstinence (if a person desires), the use of condoms and other devices and chemicals, and the careful choosing of one’s sexual partners. Such choices, however, should be free ones, and no one’s freedom should be curtailed just because such diseases might be contracted. After all, smokers may get cancer and drinkers may get cirrhosis of the liver, but this does not mean we have the right to restrict their freedom to indulge in these activities.

13.3: Premarital Sex

1. 13.3 Examine the arguments for and against premarital sex

LISTEN TO THE CHAPTER AUDIO:

Premarital sex  refers to those sexual relations that occur prior to marriage. It is referred to in the Bible as fornication.

13.3.1: Arguments Against Premarital Sex

LISTEN TO THE CHAPTER AUDIO:

As previously mentioned, the conservative position toward liberalizing sexuality states that one of the greatest problems created by encouraging or even allowing premarital sex is that it tends to undermine traditional Western morality and family values. According to this view, as we have said, sexuality should be something reserved for a heterosexual, monogamous marriage and used mainly, but not necessarily exclusively, for purposes of procreation. Allowing premarital sex discourages the special and unique relationship that exists between one man and one woman in a lifetime of marriage, it undermines marriage both as an institution and family values, and it encourages sexual activity that is separate from “true” love and from having children. According to this argument, the only acceptable form of sexuality for boys and girls and men and women is no sexuality, or abstinence until marriage.

The argument continues that if marriage breaks down, the traditional family unit breaks down, and the family unit is the basic building block of traditional Western society. Premarital sex also encourages an inflated view of sex as the most important aspect of marriage, thereby further eroding one of our most important social institutions. According to this view, sexuality is considered to be such an intimate part of the relationship between a man and a woman that it must have the stability and security of the marriage relationship to foster and support it.

The Encouragement of Promiscuity

LISTEN TO THE CHAPTER AUDIO:

Another argument that supports the conservative point of view is that premarital sex fosters promiscuity and encourages transitory rather than lasting human relationships. If sex is allowed outside of marriage, it becomes separated from its “true” purposes, which are to enhance marriage relationships and family values and produce children. Instead, according to this argument, the only purpose of premarital sex is to achieve selfish individual pleasures without accepting the responsibility for one’s own actions or the lives of others involved. Premarital sex also encourages promiscuity, in that without marriage the societal restrictions are loosened, and one can have sex with virtually anyone at any time. Therefore, the lasting, meaningful relationships between men and women that are established and developed through marriage are replaced by “one-night stands,” which reduce human relationships to the animal level.

Social Diseases and AIDS

LISTEN TO THE CHAPTER AUDIO:

One of the most powerful arguments against premarital sex is the possibility of spreading social diseases and especially AIDS. People who argue against premarital sex state that abstinence is the best way to avoid contracting these diseases. Therefore, as traditional family values have always taught, one should abstain from sexual intercourse or other sexual activity until one gets married. Before men and women get married they should voluntarily be tested for the AIDS virus to ensure that neither partner will infect the other. Obviously, however, premarital sex puts one in danger of contracting such diseases and passing them on to other sexual partners or future wives or husbands.

The Fostering of Guilt and Ostracism

LISTEN TO THE CHAPTER AUDIO:

Because premarital sex is frowned upon by our culture and our society, it can result in various degrees of guilt and ostracism for those who engage in it. Whatever is initially felt by individuals who want to engage in premarital sex, most of the people around them—especially their parents, other relatives, and sometimes their friends—generally are opposed to their actions, and because of this, they may experience guilt and be ostracized from accepted society.

Having Children

LISTEN TO THE CHAPTER AUDIO:

Within the accepted marital relationship, children who are brought into the world can be protected and raised with some security. They will also legally have a family name. There is always the possibility within the premarital relationship that children will be born, and if they are, they may be raised out of wedlock. If a couple decides on an abortion, then the premarital relationship has fostered yet another moral wrong: the murder of an innocent fetus. If children are raised in such a relationship, what will they think once they discover that their parents are not married while everyone else’s parents are?

The Compatibility and Experience Fallacy

LISTEN TO THE CHAPTER AUDIO:

One argument often given for premarital sex is that it allows people to gain sexual experience so that when they enter into marriage, they will know what they are doing. Another aspect of this argument is that people who have sex or live together are able to find out whether they are really sexually compatible, thus avoiding the misfortune of finding out after they are married that they aren’t and perhaps never will be.

According to the conservative view, this argument provides no excuse for premarital sex. After all, classes in marriage and the family and in sex hygiene are now offered in school, and there are many good scientific books available on the subject. The compatibility argument, furthermore, places the sole emphasis for a relationship upon sexual attraction, and a marriage is much more than that. Besides, any advantages gained in the way of experience or knowledge about compatibility are far outweighed by the violation of the sacredness of marriage and family values, the inevitable loss of respect that occurs when two people become mere sex objects in each other’s eyes, and the instability of the relationship. For if there is no marriage, people who live together can leave at any time they want to, experiencing no sense of concern for the other person or for any children who may have resulted from their relationship. Also, it is argued, there is something unique in the marriage of two people who come to each other as virgins because sex then becomes a very special offering of love from one person to the other. For this reason, as well as the others cited, premarital sex, therefore, should not be encouraged or allowed.

13.3.2: Arguments for Premarital Sex

LISTEN TO THE CHAPTER AUDIO:

Certainly the prevalence of premarital sex may change the society’s lifestyle, but, according to the liberal viewpoint, the old traditions already have been undermined because they simply are no longer applicable in an advanced, technological, and rapidly changing world such as ours. The family unit already has become more mobile and flexible in reaction to the complexity of our modern culture. Some of the changes that have taken place in society are for the better and some are not, but, according to the liberal view, what we need is a number of alternative lifestyles that will allow us to enjoy the freedom and individuality that are encouraged these days.

Besides, the sexual-freedom proponents argue, what is so great about the old style of marriage and family values in which the father is a dictator and the mother a slave to her housework and her children? Furthermore, what is good about hypocritical marriages in which unhappy couples stay together just because they are married or “because of the children”? Many adulterous relationships are spawned by these “sacred” but unsatisfying marriages, and how is that any better than premarital sex? At least the two people involved in a premarital relationship can have some prior agreement that if it doesn’t work, they will try something else.

It is unreasonable in our modern day and age to advocate abstinence from sexuality. The proponents of premarital sex state that abstinence is unnatural and is an elimination of one of humanity’s greatest pleasures. All one needs to do is take the proper precautions, such as using a condom and eliminating certain sexual acts that perpetuate the spread of AIDS, for example. Further, one can enter into a relatively monogamous premarital sexual relationship or limit one’s partners to those who are known to be free from these diseases. Social diseases in themselves, then, are not a sufficient reason for not engaging in premarital sex.

The Promiscuity Fallacy

LISTEN TO THE CHAPTER AUDIO:

First of all, many premarital sex arrangements do not condone promiscuity. Many of these affairs are long lasting—sometimes as long lasting as a marriage—and such relationships may even develop into marriages. Second, sexual-freedom proponents ask, is the level of promiscuity in premarital relationships any greater than that in marriages? Does being married preclude the fact that one or both spouses will be promiscuous? Third, even if unmarried people are promiscuous, as long as they are freely consenting adults, whose business is it but theirs?

Guilt and Contraception

LISTEN TO THE CHAPTER AUDIO:

People’s views of premarital sex have changed a great deal, and few people who engage in premarital sex nowadays are ostracized from society; this also applies to children born out of wedlock. People simply are not as concerned about these matters as they used to be. Guilt, furthermore, is a matter of private conscience, and as long as the consciences of the people who enjoy premarital sex are not disturbed, why should anyone else’s be? People who do not approve don’t have to condone or engage in premarital sex themselves, and they shouldn’t concern themselves with other people’s behavior as long as it doesn’t intrude into their lives. Parents of people involved in premarital sex certainly don’t have to condone these activities in their own homes, but what their children do on their own is their business as long as they are consenting adults.

People who engage in premarital sex can, of course, use contraceptive devices, and they probably do use them more often than not. Often, proponents would state, the children resulting from such relationships are cared for as well as or even better than they would be if they were born into a marriage. Furthermore, when such couples plan for or discover they are going to have a child, they often will get married out of respect for the child’s position in their relationship and in society in general. And, if an accidental or unplanned pregnancy occurs, then abortion exists as a viable alternative. This alternative often is used even within those marriages where children are not wanted, so why can’t it be used here also?

Sexuality and Privacy

LISTEN TO THE CHAPTER AUDIO:

Sexual experience and compatibility, according to those who would allow premarital sex, is one of its greatest advantages. They feel that learning through experience what sexuality is all about and relating to different people sexually will enable people to discover what type of relationship they want and what type of person they want to share it with.

One of the myths of our culture is that sexual activity is a natural ability that one can easily draw upon after one is married. As a matter of fact, a sexual relationship, not mere biological coupling, is terribly complex and requires a great deal of knowledge and ability. Sexuality does not “come naturally” and is particularly hard to acquire in a culture that has repressed it for so long. A good sexual relationship also requires a level of awareness of and comfort with one’s body and the bodies of others so that greater freedom can be attained. Premarital sex is the best means of achieving sexual experience and knowledge, especially if two people are considering a long-lasting relationship. If they live together from day to day, they will find out over a period of time whether they will be compatible in a marriage. Even if they discover that they are not compatible, they probably will have learned something about themselves that will not only help them to avoid making the serious mistake of entering into marriage but also will help them to discover what kind of partner they really do want.

Another advantage of premarital sex is that sexual activity is pleasurable in itself, whether or not it leads to marriage or even a lasting relationship. When premarital sex is allowed, sexual pleasure can be enjoyed freely to the extent any individual wishes without the need for permanent commitment. This kind of relationship may not be suitable for some people, but those who find it morally acceptable ought to be free to indulge in it without regard to society’s standards or the wishes of others who are not involved in their relationship or relationships.

Despite what the critics of premarital sex say about the undermining of Western traditions and family values, premarital sex is one of those private sexual matters that should be left to the discretion of free, consenting adults. Liberal arguments illustrate that premarital sex is a matter for individuals to decide, and just because some or even the majority of people living in our society do not approve of premarital sex, as long as it is not forced on them or their children, it should both be allowed and be considered moral.

Cases: Sexuality and Premarital Sex

LISTEN TO THE CHAPTER AUDIO:

The cases on morality and sexuality deal with both the public or societal aspects about how matters of sex overtly affect others and the private aspect of sexual relations between consenting adults. To what extent do the issues discussed in the cases challenge or undermine traditional family values? In evaluating these cases consider the following governing principles of morality: life, goodness, justice, freedom and honesty.

Cases for Study and Discussion

Case 1 Two Teenagers Living Together

Two college students, Tom, 19, and Barbara, 18, have decided to live together both for sexual reasons and because they enjoy each other’s company. Barbara intends to take birth control pills, they intend to share expenses, and they have an agreement to be honest with and faithful to each other throughout the entire relationship. They also have agreed that if either one of them wants to break off the relationship, he or she only has to say so and the relationship will end with no recriminations. Is what they are doing moral? Why or why not?

Case 2 Two Unmarried Seniors Living Together

Sarah and Ben, both in their seventies and widowed, have fallen in love and feel a strong need for each other’s companionship. Because Sarah would lose her social security pension if she remarried, they have moved into an apartment together without getting married and are enjoying a full sex life. Their grown children for the most part are very upset by this and constantly tell Sarah and Ben how they feel about their domestic arrangement. Some of the children even refuse to call or visit them because they are living together. Despite this situation, Ben and Sarah seem to be happy. Is what they are doing moral? Why or why not?

13.4: Sex in Marriage-Type Relationships (Including Nonlegal)

1. 13.4 Evaluate the role of sex in different types of marriage-type relationships

LISTEN TO THE CHAPTER AUDIO:

A marriage-type relationship is one that is continuous and lasting (or intended to be) rather than temporary or transitory. There is, of course, some overlap between this type of relationship and a premarital one. For example, some premarital sex relationships that begin as transitory or temporary may become permanent or lasting. Also, many people classify any sexual relationship occurring between two never-married people as premarital or  extramarital  (occurring outside of marriage). The latter term also is often used to mean adultery. However, here the use of the phrase “marriage-type” refers to any relationship that is intended by the two or more people involved to be permanent or lasting and in which sex is a deeper part of a more involved human relationship than is the case in many premarital relationships.

The purpose of sex in a marriage-type relationship appears to be twofold. First, it provides a deep and intimate expression of love between or among persons, including the giving and receiving of pleasure. Second, it provides the means for procreating, or having children. These purposes are not necessarily compatible or incompatible. That is, people may have a permanent or lasting sexual relationship without ever having children; or, in expressing their love for each other, a man and a woman may end up having children as a part of that expression.

Obviously, this description of “a deep expression of love” as the main purpose of sex does not square with some societal and religious views. Nevertheless, merely because the main way children can be created is through sexual intercourse between a man and woman, one need not assume that procreation must necessarily be the only valid reason or purpose for the sex act. To take this stand reduces human beings to the level of animals who mate instinctively and infrequently for purposes of procreating their species and relegates sex to a merely biological function.

The overwhelming evidence amassed by psychology in the twentieth and twenty-first centuries strongly suggests that human beings are not merely instinctive animals, mating only at certain times of the year for procreative purposes, nor is human sexual intercourse merely a biological function; rather, it is a deep and personal expression and communication of oneself to others that brings forth one of the greatest human pleasures and in which a great deal of oneself is involved.

This expression also may include the desire to join together in the creation of a child, but it need not do so—the expressing of love and the giving and receiving of pleasure are both valid reasons for engaging in sexual activity. That even animals express some love and affection before, during, and after sexual intercourse would seem to be supported by observation, but the type of expression they indulge in pales alongside that of which human beings are capable. Furthermore, because the need and desire for sexual love among human beings do not diminish after children are created and because even childless couples have such desires and needs, it becomes more questionable to classify human sexuality as being solely a means of procreation.

13.4.1: Various Types of Marriage Relationships

LISTEN TO THE CHAPTER AUDIO:

The phrase “types of marriage relationships” refers to nonlegal marriages as well as those that have been legalized by certificate or sanctioned by a particular religion. What is meant here by “marriage” is an agreement, legal or nonlegal, between people to live together and share each other’s lives in a deep, meaningful, and (intentionally) lasting way. Such a relationship usually includes sexual expression, but it need not (even some legal marriages—the so-called brother and sister marriages—are entered into for mutual convenience, and the people involved have agreed not to have sex as a part of their relationship). Given this definition, then, many different types of “marriage” relationships are possible.

Monogamy

LISTEN TO THE CHAPTER AUDIO:

The most common type of marriage relationship in the Western world is  monogamy , which involves two people. The most common type of marriage relationship in the Western World is a monogamous relationship between a man and a woman. There are advantages, both legal and otherwise, to having a monogamous marriage relationship:

1. The love relationship can be so intimate and involved that most people would find it very difficult to have more than one such relationship.

2. Financially, it usually is much easier for two people to support each other.

3. Legally, in our present societal structure, it is nearly impossible for a husband to have more than one wife or for a wife to have more than one husband.

4. As has been argued earlier, such a relationship, if kept monogamous, will avoid the contracting of social diseases and AIDS.

Despite these advantages, there are no evident rational moral reasons why monogamy need be the only valid marriage-type relationship. The Bible decrees that monogamy is the most accepted form of marriage, but unless one feels morally obligated to follow that particular set of teachings, there seems to be no reason why other forms of marriage should be deemed either illegal or immoral as long as ethical principles are adhered to. (It would be terribly unfair, for example, for a person to have more than one spouse if the two spouses did not know about it and had not agreed to such an arrangement.) From experience, then, it appears that monogamy relates best to Western culture, but that does not mean that other forms cannot coexist.

Polygamy

LISTEN TO THE CHAPTER AUDIO:

Strictly speaking,  polygamy  means having more than one husband or wife,  polyandry  means having more than one husband, and  bigamy  means having two wives or two husbands. However, all of these types of situations will be referred to as polygamy. As long as all of the people involved are informed about the situation and agree to be involved in it, no form of polygamy need be considered immoral in and of itself.

Many cultures (including the ancient Hebrew culture depicted in the Bible) have accepted various forms of polygamy, and they have worked with varying degrees of success. Quite often men have had more than one wife and kept them subordinate and submissive; this is considered by many to be immoral—unless the wife knowingly prefers it this way—under principles involving justice and freedom. However, especially where there has been a shortage of men or women, some form of polygamy often has saved from extinction the culture in which it was practiced, protecting it by ensuring procreation and also by making it possible for men or women who did not want to live without a mate of the opposite sex not to have to live alone. The Islamic and early Mormon cultures are good examples of polygamy’s success. There may have been violations of ethical principles in these cultures, but one would be hard put to blame them necessarily on the fact that polygamy rather than monogamy was being practiced.

Group Marriage

LISTEN TO THE CHAPTER AUDIO:

A great deal of experimentation with marriage-type relationships has occurred during the last half of the twentieth century. One example of this is the “ group marriage ,” with or without “free love.” This approach to marriage grew out of the desire in the 1960s to return to a communal and cooperative kind of living in which various people, sometimes already married (legally or nonlegally) and sometimes not, chose to live together in a community—sometimes small (as in one house), sometimes large—usually partially or completely outside of the larger society from which they originally came. In most of these types of marriages, the children are raised in common and all of the adult members are parents; however, some of these groups retain the small family unit.

Some groups indulge in “ free love ”; that is, any two or more people in the group may have sexual relations as they so desire on a “free” basis as long as no force or coercion is used and without regard to any previous monogamous arrangements. Other groups keep a monogamous autonomy, merely choosing to live more closely together with other couples or single people than our society generally encourages or makes possible. Again, the children may either be raised in common by all of the people or be kept within the usual monogamous relationships, while at the same time having a closer relationship with other children and adults than our society usually makes possible.

It is very difficult to assess the results or effects on the human beings concerned in such relationships because this kind of experimentation has not been going on for very long; also, few scientific studies are being made of these groups because of the members’ desire for privacy. One of the advantages of group marriage cited by members or former members is that the children (when all the adults were considered to be their parents) received a great deal of attention from all kinds of adults and were never without supervision or diversified companionship. A second advantage often cited is that when members of such groups are compatible, very meaningful communities often develop, thus avoiding much of the isolation and alienation often found in our dehumanized technological society.

Most reports indicate that those group marriages in which free love is not accepted tend to have less friction and upheaval than those in which it is accepted. This may indicate sexuality is so intimate, intense, and personal that it is difficult to diffuse it among several adults without engendering strong feelings of jealousy, guilt, and sadness at being separated from a loved one who goes off with someone else. It also may indicate that because our culture has been so steeped in monogamy that it is extremely difficult to adjust to free-love relationships. Another advantage to the non-free-love approach is that any chance of contracting or passing on social diseases or AIDS is minimized.

13.4.2: Arguments Against Nonmonogamous Marriages

LISTEN TO THE CHAPTER AUDIO:

The conservative view of family values accepts monogamy as being the exclusive marital relationship for the reasons already described. To summarize them: First, marriage is prescribed in the Bible, which is the great moral book of Western tradition and family values. Second, whether one believes in the Bible or not, marriage is part of our society’s tradition. Third, the love relationship is too intimate to involve more than two people. Fourth, such a relationship will eliminate any problems connected with social diseases or AIDS provided spouses keep their marriage vows. And, finally, children are better off when they are raised in the traditional family structure. This does not mean that groups of families cannot live in some kind of communal situation, but according to this conservative view, the immediate family structure, the nuclear family unit, should remain autonomous.

13.4.3: Arguments for Nonmonogamous Marriages

LISTEN TO THE CHAPTER AUDIO:

The liberal view does not prescribe a specific type of marriage; instead, it encourages alternative family lifestyles and family values as ways of adapting to our changing culture. Proponents of liberalization also would remove all laws forbidding nonmonogamous marriages on the grounds that they constitute an interference with private sexual and family matters. The emphasis, if this group had its way, would be on the freedom of consenting adults to experiment with or adopt any type of freely chosen marriage or family lifestyle as long as people were not directly harmed (e.g., children were not abused or neglected).

They would not accept offenses to taste or to tradition as valid excuses for legislating against or otherwise forbidding these alternative lifestyles, but they would insist that everyone involved in a relationship fully understand and accept it. For example, if a man wanted to have two separate wives and families, then each wife and family unit should know about the situation and agree to it. This is merely a matter of dealing honestly and truthfully with people.

13.4.4: Homosexual Marriage

LISTEN TO THE CHAPTER AUDIO:

Homosexuality  means sexual attraction or love for a man by a man, or sexual attraction or love for a woman by a woman. The latter is also called  lesbianism . Homosexuality is, for the most part, frowned upon in our culture, although it is accepted in some areas of the world. In some nations outdated (now legal in all 50 states) it is illegal, and often it is considered immoral. The Bible, especially the New Testament, is firmly opposed to it, a fact that concerns people who adhere to the Bible, but it need not be a concern for those who do not. Furthermore, if the main purpose of sexuality is a deep and intimate expression of love, and if procreation is only secondary, then one cannot attack homosexuality as unnatural merely because it can never result in the creation of children as can heterosexual relationships (i.e., sex between or among members of the opposite sex). It is an obvious empirical fact that some men prefer to have sex with and can truly love only other men and that some women feel the same way toward other women.

Arguments Against Homosexuality

LISTEN TO THE CHAPTER AUDIO:

A few arguments against homosexuality are as follows:

1. The basic argument against the morality of homosexuality is that it is unnatural and perverse; that is, it goes against the laws of God, traditional family values, and the moral values of nature. There are sections of both the Old and New Testaments of the Bible that call homosexuality “an abomination” and prohibit it as an unacceptable sexual activity. In fact, many if not most of the world’s major religions are opposed to it, branding it as immoral. An argument also used by nonreligious people is that homosexuality is unnatural—that is, one that goes against the moral laws of nature. The main evidence for this conclusion is that the primary purpose of sexuality is to procreate, and because homosexuals obviously cannot do this, they are perverting the true meaning of sexuality.

2. Second, it is argued that homosexuality sets a bad example for children and that it attempts to proselytize (i.e., gain followers or adherents for its cause), thereby undermining our traditional family and cultural values. In this proselytizing process, the argument continues, young boys and girls are often molested by homosexuals, and this of course is a terrible crime. Furthermore, if their proselytizing is greatly successful, what will become of the human race when procreation is no longer feasible because most, if not all, people have become homosexual? Our tradition under God’s law and in accordance with nature is heterosexual, and we owe it to our children to see both that they are informed of this and that they are protected against homosexuals’ teaching or preaching their immoral beliefs to them.

3. Third, those who argue against homosexuality feel that the homosexuals bear significant responsibility for the AIDS crisis because they are in a high-risk group (along with drug abusers) and because many of the first AIDS victims in the United States were homosexuals. Many, especially religious people, feel that AIDS is a manifestation of God’s displeasure with homosexuality; but religious or not, many feel that homosexuality and bisexuality are the major causes of the spread of AIDS and that therefore homosexuality should be banned. They also feel that the AIDS crisis weakens any argument supporting homosexuality as a private type of sexuality that doesn’t affect or harm others.

4. Finally, homosexuals and homosexuality are offensive to our taste and our sense of family values in our basically heterosexual society. Therefore, we have absolutely no obligation to condone or legalize homosexuality in any way; as a matter of fact, we have, instead, the obligation to legislate against and otherwise prohibit it to protect our children and family values and the moral future and physical survival of our society.

Legislation has presented “loud and clear” this rejection of homosexual marriage, in that the U.S. Congress and various state legislative bodies have passed laws freeing the states from condoning legal homosexual marriages and other benefits, such as rights against job discrimination. One such example of legislation is the Defense of Marriage Act (DOMA) passed by the U.S. Congress in 1996. This act defined marriage solely as a union between a couple of the opposite sex. However, as states now recognize same-sex marriages, the Defense of Marriage Act (DOMA) has resulted in a host of legal challenges and court cases. The various legal challenges reflect a change in public attitudes toward homosexual marriage.

Arguments for a Homosexual Alternative

LISTEN TO THE CHAPTER AUDIO:

Following are the arguments for a homosexual alternative:

1. First of all, there is no conclusive evidence that because most people are heterosexual in our society, homosexuality is therefore immoral or unnatural. Also, it cannot be proved that natural moral laws do indeed exist. As for religious laws, they have force if one is a member of a particular religion, but they have little effect on those who aren’t. Furthermore, many members of various religions interpret religious teachings differently. For example, Christians who favor homosexuality or who are homosexual themselves argue that Jesus’s commandment to love one another is much more important than minor references to sexuality between members of the same sex.

2. Second, the main issue involved in homosexuality is the right of freely consenting adults to engage in private sexuality in any way they see fit as long as it does not directly harm others. This is, after all, a private, not a public, sexual matter, and even if it offends some people’s tastes and family values, that is no reason for branding it as immoral. As long as no other laws are broken and people are not harmed or killed as a result of homosexuality, freedom in this sexual matter ought to be allowed. Furthermore, as far as the AIDS crisis is concerned, as soon as it became clear what types of sexual activity caused AIDS, homosexuals as a group lowered the rates of infection and contagion tremendously through more careful behavior—much more so than drug abusers, who are now probably the largest group of AIDS victims because they use and share infected needles. Therefore, people who believe that homosexuality is moral argue that we don’t discriminate against heterosexuals when they contract the other social diseases or even AIDS, so why should we do so with homosexuals?

3. Third, the condoning of homosexuality does not mean that child abuse or molestation is also condoned—it isn’t, and it should continue to be branded as immoral. Most child molestations, in fact, are probably more heterosexual than homosexual in nature, except for the recent scandals of abuse of young boys by priests in the Roman Catholic Church, and usually involve men and young girls. Sadism performed on unwilling victims, child molestations, and forced sexuality of all kinds have no direct connection with homosexuality as a lifestyle, and laws against such activities should remain in force. That some homosexuals, like some heterosexuals, are guilty of such crimes doesn’t mean that homosexuality itself is immoral. There already are laws, the argument continues, that forbid proselytizing for any type of overt sexuality in schools, and there also are laws protecting children against pornographic sexual materials (films, books, and live shows). Furthermore, it is difficult to prove that homosexuals proselytize any more than heterosexuals do.

4. The last appeal made by those who believe that homosexuality is morally acceptable is that although homosexuals may have different sexual preferences, they are still human beings; therefore, they should not be discriminated against in any way by society.

As far as family values are concerned, those who argue for acceptance of a homosexual or lesbian lifestyle state that, whether there are children or not, a monogamous homosexual or lesbian couple can establish and maintain a healthy family atmosphere regardless of the fact that they are of the same sex. They argue further that there are many examples of cases in which lesbians or homosexuals have given birth to or adopted children and have raised or are raising them in a healthy environment, one which they allege has no adverse effects upon the children. In fact, the argument continues, such children are more tolerant of diverse lifestyles because of their experiences and are treated just as lovingly as if they were living with heterosexual parents.

The fact that homosexual marriage is becoming somewhat more acceptable was evidenced by the fact that during the 2012 presidential campaign Barack Obama (1961–) voiced his support for legalization of same-sex marriages. This endorsement for marriage equality was the first such endorsement from a sitting U.S. president. As of June 26, 2015, same-sex marriage has been legal in the United States. The United States Supreme Court ruled in Obergefell vs Hodges that state–level bans on same-sex marriages are unconstitutional. Thus, this ruling legally granted marriage rights to same-sex couples nationwide. Yet despite legislation of same-sex marriage and a major shift in favorable public opinion to support the high court’s decision, many moral issues surrounding this type of marriage continue to be debated.

13.4.5: Adultery

LISTEN TO THE CHAPTER AUDIO:

Before leaving the topic of marriage-type relationships, it is important to discuss the matter of adultery, sometimes also referred to as  extramarital sexual relations  (sexual relations outside of a marriage contract, agreement, or relationship).  Adultery  actually means voluntary engagement in sexual intercourse with someone other than one’s marriage partner. It involves infidelity or unfaithfulness in the marriage relationship, especially in its sexual aspects, and generally is considered to be immoral by our society. Our question, however, is not what society in general thinks but what grounds we can give for describing adultery as being moral or immoral.

It would be foolish, of course, not to recognize that many marriages are not ideal, that one (or both) of the partners may not relate well to the other at any level, including the sexual. This means that dissatisfied partners often look for other human relationships that will fulfill them in ways their own marriage relationship will not, and when their marriage relationship is an unhappy one, people are often tempted to engage in adultery with a person they feel will make them happy or give them pleasure, if only for a brief period of time. (Occasionally, this time lengthens and leads to some form of permanence.)

What usually happens when people are tempted to engage in adultery is that they simply begin the adulterous relationship and worry about the consequences later. The problem with this approach, however, is that the damage is done before any attempt is made to solve the marital problems with any degree of honesty or justice. Once an innocent spouse has been betrayed in this way, it is very difficult to resolve marital problems and to maintain the unity of the marriage relationship.

Arguments Against the Morality of Adultery

LISTEN TO THE CHAPTER AUDIO:

The main argument against the morality of adultery is that adultery is a direct violation of traditional family values and of the most personal and intimate human contract into which two people can enter. When people get married, they usually contract to live together as husband and wife and to be faithful to each other—this especially means sexually faithful. Committing adultery involves lying, cheating, and infidelity on the part of one marriage partner or another, and these actions are viewed as being morally reprehensible by most ethical systems.

Adultery also is destructive of the marriage relationship; it can lead to separation or divorce and to the injuring of innocent children. Even when both spouses agree to adultery (e.g., in so-called “wife swapping” or “swinging”), they are making a mockery of marriage, which is our greatest traditional human institution. If they want to have this much freedom, why do they marry at all? The only virtue of such activities as wife swapping and swinging, as opposed to most other forms of adultery, is that at least the spouses know and have agreed to what they are doing, so lying and dishonesty are not issues. There is again the problem of social diseases and AIDS, which an adulterous spouse can contract and then, even worse, pass on to his or her spouse. Hence, this is another important reason not to indulge in adultery.

Arguments for the Morality of Adultery

LISTEN TO THE CHAPTER AUDIO:

The basic argument for the morality of adultery is that individuals ought to be free to do what they want to do in terms of their own private sex lives, and whether they lie, cheat, or are unfaithful to their spouses is their business and no one else’s—certainly not society’s. Some people who condone adultery would say that the basic ethical assumption here is that “what they don’t know won’t hurt them”; bad results occur only when adultery is discovered. If adulterers are discreet and can avoid breaking up their families, then what’s wrong with adultery? One of the problems certainly is the contracting of social diseases or AIDS, but if the adulterer practices safe sex, then whose business is it what he or she does?

Furthermore, some argue that families should not be broken up under any circumstances because of the children involved and for economic and social reasons, and, according to this argument, adultery provides a means by which unsatisfied spouses and their families “can have their cake and eat it, too.” That is, wives, husbands, and children continue to have economic security and social status while the adulterous spouse or spouses additionally enjoy a satisfying sex life. As long as these affairs can be conducted smoothly and discreetly, what’s wrong with adultery? Finally, wife swapping and swinging are no more than sexual lifestyles, and as long as adult couples freely consent to such arrangements, no harm is done. These are, after all, private sexual matters, and society should not interfere in any way.

Cases: Sex in Marriage-Type Relationships

LISTEN TO THE CHAPTER AUDIO:

The cases on morality and sexuality deal with both the public or societal aspects about how matters of sex overtly affect others and the private aspect of sexual relations between consenting adults. To what extent do the issues discussed in the cases challenge or undermine traditional family values? In evaluating these cases consider the following governing principles of morality: life, goodness, justice, freedom and honesty.

Cases for Study and Discussion

Case 1 Two Homosexuals Living Together

You have been working with Richard for about a year and have always found him witty, intelligent, compassionate, and friendly. One night he invites you to have dinner with him and his friend Walter at their apartment. You discover that the two men are homosexuals and that they have been living together for about three or four years. You are surprised to find that they are not effeminate in any way; in fact, except that they prefer homosexuality to heterosexuality, they are in no way different from a lot of other nice people you know. They do not molest children, nor do they attempt to impose their values on anyone else; all they want is to live together happily and in peace. Is what Richard and Walter are doing moral? Why, or why not?

Case 2 Adultery

Eric, 45, is married to Joanne, 43, and they have three teenage children. Generally speaking, they have a pretty good marriage, except for their sex life. Although they both know it is poor, they don’t discuss it very often. Over a period of several months Joanne notices a change in Eric, and finally she asks him if there’s anything wrong. Eric blurts out that he is in love with another woman with whom he’s had an affair for several months. Joanne is so angry and hurt that she immediately demands that he leave the house and states that she wants a divorce. They both refuse to seek help from marriage counselors, and eventually the divorce ensues at a great emotional cost to Eric, Joanne, and their three children. Was what Eric did moral? Why, or why not? Do you feel Joanne handled his adultery well or not? Why, or why not? Should Eric have told her? Why, or why not?

13.5: “Deviant” Sexual Behavior

1. 13.5 Review arguments for and against "deviant" sexual behaviors

LISTEN TO THE CHAPTER AUDIO:

Masturbation is a sex act that people usually perform with and by themselves.

In earlier times, all kinds of superstitious arguments were applied against masturbation—for example, the notion that people who performed this act too often would go insane or deplete their physical strength. However, there are basically only two arguments used against it today. First, there is the religious argument that it is an abuse of one’s sexuality, which is a gift given by God. The second argument is that it causes people to become preoccupied with sex and can lead them to other sexual “violations” of morality (fornication, pornography, adultery, etc.). Another argument that serves as a corollary to both of these is that masturbation constitutes a failure in self-control.

All the information revealed by modern science indicates that masturbation is a perfectly normal act, both biologically and psychologically, and that it causes no ill effects whatsoever. As a matter of fact, the argument continues, it is probably one of the earliest and best ways that human beings can become familiar with, knowledgeable about, and at ease with their own bodies and their own sexuality.

Through masturbation, individuals can learn what about their bodies causes orgasm and gives them the greatest pleasure, and this could aid them in finding more meaningful sexual relations with others. At any rate, sexual liberals can see no disadvantages in masturbation, and because it can harm no one else because it is usually a private act performed by one person alone, they argue that it cannot be considered immoral. It also can be considered the safest sexual act in an age of AIDS and sexually transmitted diseases.

Pornography  is a vague term, difficult to define. It usually refers to obscene literature, art, film, or live display. The word  obscene  usually means morally offensive according to the general and prevailing standards of morality in any particular culture, society, or group. The Supreme Court of the United States has tried to use the standard definition that pornography is that which appeals to the prurient interest (lust and desire for the impure in thought and deed) and which has no redeeming social, literary, or artistic value. However, within the last 50 years, legal attempts to permit or ban so-called pornographic works or activities have run into problems because it is extremely difficult to decide what is or is not pornographic and to whom.

Pornography seems to involve a definite matter of taste on the part of most people, and tastes differ tremendously. Such things as formalized instruction in sex hygiene are labeled obscene by some, and any kind of nudity (e.g., even in a classical Greek sculpture) or any work that contains four-letter words is labeled obscene by others. Some people, on the other hand, can view the most explicit scenes involving bestiality or sadism and find nothing obscene about them. With such differing tastes and opinions about “obscenity” and “pornography,” how do we determine whether or not pornography is moral?

As an industry, pornography has expanded exponentially along with the growth of the Internet and brings in $100 billion worldwide. Somewhere between $10 billion and $12 billion of the total revenue is generated in the United States. To put this figure in perspective, the pornography industry is larger than all professional basketball, baseball, and football franchises combined. And, additionally, pornography generates more revenue than the combined networks of ABC, NBC, and CBS. Twelve percent of Internet websites are pornographic, and child pornography accounts for nearly $3 billion each year.3

13.5.1: Arguments Against Pornography

LISTEN TO THE CHAPTER AUDIO:

Following are the arguments against pornography:

1. Those who would argue against pornography consider it degrading to humans. A preoccupation with pornography, they maintain, will lower the viewer’s, listener’s, or reader’s humanity to the animal level, and as such preoccupation becomes more widespread, it will destroy the moral fabric of our civilization.

2. Because some restrictions on pornography have been lifted, it has escalated to an even greater level of criminality, including the filming of actual sadistic sexual murders and the use of children in pornography (child molestation and kiddie porn). This would not have occurred if pornography had continued to be restricted by law.

3. Pornography constitutes a degradation of family values, human sexuality in general, and the sexuality of women in particular. It emphasizes lust rather than love and exploitation and domination rather than tenderness, respect, and reciprocation.

4. Pornography encourages the trafficking in sex, rape, homosexuality, child molestation, sadism, prostitution, exhibitionism, voyeurism, and all kinds of other sexual “perversions,” and for this reason it cannot do anything but lower and destroy human dignity.

For all of these reasons, sexual conservatives argue, pornography should not be considered moral in any way and, in fact, should be considered perniciously immoral and be severely restricted or completely banned.

Arguments for Pornography

Arguments for pornography are as follows:

1. The basic argument for the morality of pornography is that because tastes and opinions in this area differ so widely, the use of pornographic materials is obviously a matter of individual discretion. As long as people are not coerced into reading, listening to, or viewing it, it should be available to consenting adults.

2. There is no proof that pornography is degrading (it is, after all, a matter of opinion and taste) or that it will destroy our moral fabric. Furthermore, there is evidence to indicate that it helps to eliminate sexual repression, relieve sexual tensions, and actually lower sex crime rates rather than raise them. In one study, done after 11 years of having no restrictions on pornography in Denmark, child molestation was down 56 percent, indecent exposure was down 58 percent, and voyeurism was down 80 percent. Rape, however, was on the increase “but only by a small fraction relative to the rising rates of robbery and vandalism.”4 In fact, the study further maintains that after restrictions have been lifted for a while, the interest in pornography begins to drop off and sales go down as people begin “to take it in stride.”5

3. Although it is true that pornography can involve actual sexual crimes, our laws against murder and against child abuse and molestation can be enforced to stop this type of criminality.

4. That pornography is degrading and exploitative is again a matter of personal opinion, taste, and definition. Some might find pornography exciting, pleasurable, and fantasy fulfilling.

Furthermore, because the men and women who perform in pornographic movies, for example, generally do so willingly, how can they be considered to be degraded or used? Pornography may not present the loving and tender aspects of sex, but no one can deny that lustful and aggressive aspects of sex also exist, and their depiction therefore has its own validity. For these reasons, proponents state that pornography should be considered a moral activity when indulged in by free and consenting adults. It also should be considered a private sexual matter that should not be legally controlled unless it causes harm to others.

Cases: Pornography

LISTEN TO THE CHAPTER AUDIO:

The cases on morality and sexuality deal with both the public or societal aspects about how matters of sex overtly affect others and the private aspect of sexual relations between consenting adults. To what extent do the issues discussed in the cases challenge or undermine traditional family values? In evaluating these cases consider the following governing principles of morality: life, goodness, justice, freedom and honesty.

Cases for Study and Discussion

Case 1 Pornography in Theaters and Stores

One street in a small town has several stores that sell pornographic materials and a theater that shows pornographic films. Various parents and religious groups in town want the licenses for these places of business to be revoked because, as they put it, these places are a “blight on the community” and a bad influence on everyone, particularly the young people of the town. The managers of the stores, however, carefully check identification cards to make sure that no one who is underage can enter, and there are no pornographic displays in the windows or anywhere outside the buildings. The owners of the stores and the theater feel that those who enter their businesses want to be there and seem to enjoy themselves. Should their licenses be revoked, and should pornography in the town be further restricted because what these proprietors are doing is immoral? Why, or why not? If you think there should be further restrictions, then what should they be?

13.6: Prostitution

1. 13.6 Recognize some of the arguments favoring prostitution and some that go against it

LISTEN TO THE CHAPTER AUDIO:

Sometimes referred to as the “world’s oldest profession,” prostitution is, like pornography, a confused issue in morality. Some regard it as a victimless crime, whereas others brand it a terribly immoral act. What prostitution essentially means is that people pay others (prostitutes—male or female) to have sex with them.

13.6.1: Arguments Against Prostitution

LISTEN TO THE CHAPTER AUDIO:

The conservative position is, of course, opposed to sex prior to or outside of marriage and doubly opposed to the commercialization of sex when pleasure is the only reason for it. It may be the world’s oldest profession, but it is also the world’s most immoral one, according to this argument. Prostitution fosters a lack of respect for the prostitute (usually a woman) and for human sexual activity itself, which is supposed to enhance the intimacy of a relationship between partners and also to contribute to the creation of children. Instead, prostitution limits human sexuality to an animalistic act of lust.

Prostitution is a big business, one usually managed and run by the criminal element in the United States. Prostitutes are often treated like animals by their pimps and customers; many are beaten, and ultimately some are killed. In addition, many prostitutes have been addicted to drugs by their pimps to keep them dependent upon them and always in need of money. According to the critics, because of all of this, prostitution is the most degrading and immoral of activities and should be eliminated from our culture.

There is no faster or more certain way of transmitting social diseases and AIDS than prostitution, for in addition to its being transmitted sexually, prostitutes may also become infected by needles as drug abusers. Because prostitutes and their customers, or “johns,” generally don’t know each other, there is no clear way of knowing who might or might not have these diseases. Further, because prostitutes and their clients may have many partners, the chances of spreading these diseases are multiplied.

13.6.2: Arguments for Prostitution

LISTEN TO THE CHAPTER AUDIO:

Prostitution is the world’s oldest profession because human beings have sexual needs that are not always able to be satisfied by dating and marriage, partially because of all our taboos against sex as pleasure giving and against sex outside of marriage. With prostitution, people can have the pleasure of sex by paying for it and not having to become involved with their partners—sex can be enjoyed for pleasure only, without any commitments and with no strings attached. It also provides a safe sexual release, which may eliminate the desire to rape or molest children (not in all cases, of course, but in general).

Proponents of prostitution as moral argue that it should not be considered either immoral or illegal because there really are no victims. Presumably, prostitutes have chosen at some point to do what they are doing, and so have their clients. It is a crime only because society has legislated against it, but there shouldn’t be such laws. People should be free to be prostitutes or to go to them, and such freedom shouldn’t be interfered with.

The solution to any problems arising out of prostitution, such as crime, abuse of prostitutes, and social diseases, would be solved by social acceptance or at least social permissiveness and proper government regulation and control. “Houses of ill repute” could then be privately run but regulated by city, county, state, or federal governments so that sanitary conditions could be established and testing for social diseases could be done. In addition, the criminal element could be eliminated by such control and policing. All of these problems, according to the proponents of prostitution as moral, could be eliminated if society would just accept that people have sexual needs and allow them to satisfy them in an acceptable yet regulated manner.

13.7: Sexual Perversion or “Unnatural” Sexual Activity

1. 13.7 Report reasons as to why certain sexual acts are considered sexual perversion or unnatural

LISTEN TO THE CHAPTER AUDIO:

Sexual perversion often is as difficult to define as pornography. Some people think that any sexual activity other than sexual intercourse between a man and a woman in the traditional  missionary position  described earlier is perverted or unnatural. Others feel that any type of regular sexual intercourse between a man and a woman, but nothing else, is all right, and still others allow that “anything goes” as long as pleasure is given and received.

Many sexual activities, such as oral sex, anal sex, sadism,  masochism , homosexuality, group sex, and bestiality (sex acts between human beings and animals) have been listed as “unnatural” or “perverted.” The conservative viewpoint is that all of these except for traditional sexual intercourse between a man and a woman are perverted. The liberal viewpoint varies, but essentially it states that as long as a sex act is performed between or among freely consenting adults, it is a matter of individual freedom and should not be legislated against or forbidden in any way.

Bestiality  presents a special problem. Although it is probably rare (though perhaps less rare in rural areas), it does not fit the description of sexuality “between or among consenting adults.” One partner to the sex act, that is, the animal, cannot consent. Therefore, one could say that bestiality is immoral because the animal is not a consenting adult human being. However, when we consider that we kill animals for food without their consent, we can ask if it is worse to have sex with them and to let them live than to kill and eat them. Some people also feel that sex between a human being and an animal is even a greater crime against natural laws than are sex acts between human beings of the same sex. The extreme liberal would condone bestiality, whereas the moderate liberal might or might not condone it; the conservative, of course, would vehemently condemn it.

Introduction: Bioethics—Ethical Issues in Medicine

Learning Objectives

1. 14Report the way ethics can be applied to specific areas of human life as in bioethics

2. 14Apply three major views to the relationship between health care professionals, patients, and their families

3. 14Analyze the importance of truth telling and informed consent to significant relationships between professionals and patients

4. 14Recognize the need for a serious consideration of intercultural bioethics to ensure health care cultural competency in America

5. 14Analyze the importance of confidentiality to significant relationships between professionals and patients

6. 14Recognize the importance of suspending personal feelings that can cloud professional judgment in medicine

7. 14Identify the ethical issues concerning the areas of behavior control, human experimentation, and genetics

8. 14Identify the ethical issues concerning stem cell research

LISTEN TO THE CHAPTER AUDIO:

Ethical problems arising in areas such as medicine and business have fostered a revival of interest in ethics, not only as theory or as an aspect of religion but also as something that must be applied to human affairs in a practical way. The issues that have arisen in medicine have served as the greatest catalyst in our time for the renewed interest in applied ethics. It is expected that issues in medical ethics will become more prevalent in the United States because of the recently passed Affordable Care Act, commonly referred to as “Obamacare.” This act has stirred controversy since its inception, and although the law is not yet fully implemented, numerous court cases regarding areas of this legislation are pending. Regardless of one’s stance on health care, the Affordable Care Act will generate ethical issues concerning wealth and resource redistribution, the nature of the doctor–patient relationship, confidentiality and choice, sustainability and health care costs, privacy rights, quality of care, and medical research. Legal decisions and political policy will determine how the Affordable Care Act is implemented, but the above ethical issues and other ethical issues in medical ethics will continue to be debated.

14.1: What Is Bioethics?

1. 14.1 Report the way ethics can be applied to specific areas of human life as in bioethics

LISTEN TO THE CHAPTER AUDIO:

Bioethics  means “life ethics,” or ethics in medicine. It covers a larger area of concern than the phrase “medical ethics,” which often is used to refer strictly to the doctor–patient relationship or to such issues as whether doctors should advertise, split fees, or report incompetence within their ranks. Bioethics covers the following areas in medicine:

· Treatment of dying patients,  allowing someone to die ,  mercy death , and  mercy killing

· Behavior control

· Human experimentation and  informed consent

· Genetics , fertilization, and birth

· Health care delivery and its costs

· Population and birth control,  abortion , and sterilization

· Allotment of scarce medical resources, organ transplantation, and  hemodialysis

· Stem cell research  and  cloning

· Truth telling  and confidentiality in medicine.

In short, what bioethics really is concerned with is the establishment and maintenance of vital and moral human relationships between the sick and the dying on the one hand and the health and medical professionals on the other. It is concerned with “treatment” in the broadest sense; that is, it deals not only with how to treat patients in a medical sense but also with how to relate to, or deal with, our fellow human beings, especially in matters of illness, injury, dying, and death.

14.2: Health Care Professionals and Patients and Their Families—Rights and Obligations

1. 14.2 Apply three major views to the relationship between health care professionals, patients, and their families

LISTEN TO THE CHAPTER AUDIO:

Health care professionals are doctors, nurses, attendants or aides, therapists, technicians, and all others involved in medical aid. There are three major views of what the relationship between health care professionals and patients and their families should be.

14.2.1: Paternalism

LISTEN TO THE CHAPTER AUDIO:

Paternalism , as the name suggests, is the position that argues that health care professionals should take a parental role toward patients and their families. According to this position, professionals have a superior knowledge of medicine; therefore, they and they alone are privileged, because of their long and specialized training, to decide what is in the best interest of patients and their families. This attitude is characterized by the old cliché, “The doctor always knows best.”

A number of arguments are put forth to support this viewpoint which are:

1. First of all, laypeople lack the professional knowledge of medicine to deal with both physical and mental illness and injury; therefore, they have no way of knowing what is best for them.

2. Second, because of their long, hard professional education and because of their experience, professionals (especially doctors) know the characteristics of diseases and injuries; therefore, patients should place themselves totally in the professionals’ hands.

3. Finally, any and all decisions about patients’ care and treatment, including the information that should be given to them and decisions concerning hospitalization, tests, and so on, should be completely in the hands of the doctors and their professional assistants. Patients must trust them and not interfere with the treatment suggested.

Under paternalism, there are two possible models:  the engineering model  and  the priestly model .

The Engineering Model

LISTEN TO THE CHAPTER AUDIO:

According to Robert Veatch, a renowned bioethicist, this model is an outgrowth of the biological revolution in which a physician behaves like an applied scientist. As such a scientist, the physician must be value-free and purely scientific in his approach to treating patients. Physicians in this model, therefore, supposedly separate themselves from any values that they or their patients might have. These physicians are “engineers,” technically and mechanically well qualified to treat their patients as if the latter were biological machines.

The foolishness and dangers of this model have been powerfully revealed in the development of the atomic and hydrogen bombs and in Nazi medical research and experimentation on human beings in World War II. Also, such physicians cannot logically be value free because each choice and decision they make requires a frame of values on which it is based. Practically every decision physicians make on a daily basis requires them to consider values. For example, whether to give a genuine drug or a placebo or whether to start or stop treatment of a patient is as much a value as a medical decision. Further, if physicians could really be value free, that would make them mere engineers or plumbers, making repairs, connecting tubes, and flushing out systems with no questions asked.1

Priestly Model

LISTEN TO THE CHAPTER AUDIO:

The second model that Veatch describes goes to the opposite extreme, making the physician a new priest. Veatch quotes Robert Wilson (1932–2007), a sociologist of medicine, as saying, “The doctor’s office or the hospital have somewhat the aura of a sanctuary.”2 Therefore, physicians now are acting as priests toward their patients who are their “parishioners,” and the emphasis is placed on the ethical principle of “benefit and do no harm to the patient.” This certainly is not an insignificant principle, but according to Veatch, there are other principles that may be overlooked because of an emphasis on this one principle, such as protecting individual freedom, preserving individual dignity, truth telling and promise keeping, and maintaining and restoring justice. By emphasizing the first principle described, the other principles may be ignored. The other problem with this theory is that the physician as priest is still making the decisions for the patient and doing, as priest, what he thinks “is best for the patient.”3

14.2.2: Radical Individualism

LISTEN TO THE CHAPTER AUDIO:

Radical individualism  is the position that patients have absolute rights over their own bodies and lives and therefore may reject all the recommendations of health care personnel (especially doctors).

There are number of arguments to support this position:

1. First, doctors are human like everyone else, and they are capable of making errors in judgment, diagnosis, prognosis, and treatment. They are even at times guilty of malpractice, negligence, or maltreatment.

2. Second, patients (or their families when patients are totally incapacitated) are best qualified to decide if, how, when, and what treatment is to be given; after all, their bodies and lives are at stake, not those of the professionals.

3. Third, many issues having to do with treatment are not strictly medical, and professionals sometimes are not qualified to make appropriate decisions concerning such issues (e.g., at what point debilitating, painful treatment should be stopped, because its negative effects outweigh any curative powers it may have).

4. Fourth, with the expansion of media information, such as the Internet, these days laypeople are better educated about their bodies and minds and about the illnesses and injuries that affect them. They are also able to understand their medical condition, diagnoses, and prognoses if professionals will only have the kindness and courtesy to explain things to them clearly and in plain language. Because they can understand these things, they are qualified to make decisions about how they should or should not be treated.

5. Finally, paternalism has often led to total patient dependence and sometimes to complete dehumanization, with a patient being regarded merely as a living body to be investigated, analyzed, medicated, or operated on without recognition that a person still resides within it.

The problem with this view is that it places all decisions in the hands of patients, who may not be as knowledgeable about their medical problems or as well qualified to make such crucial decisions as they need to be. Second, many patients do not want to be responsible for making decisions completely on their own without the help of their families or health care personnel, including their doctors.

14.2.3: The Reciprocal View

LISTEN TO THE CHAPTER AUDIO:

The reciprocal view involves a team approach to treatment much like the hospice approach to care for the dying. In this view, patients and their families are key members of the team, and doctors, nurses, and other health care professionals work together to do what’s best for patients and their families. This position is supported by a number of arguments, some of which are similar to those made for radical individualism.

These arguments are:

1. Professionals, particularly doctors, are neither gods nor valid parental figures. Rather, they are human beings with specialized education, training, and experience, which makes them an important element in the care of patients and their families.

2. Many of the decisions concerning the treatment of patients and their families are not strictly medical in nature and therefore should not be made solely by medical professionals. Doctors need to rely on other health care personnel, such as nurses; psychiatric, physical, and occupational therapists; and nurses’ aides. They also need the support of nonmedical personnel such as clergy, social workers, and trained volunteers if they are to properly treat patients and their families as whole human beings rather than medical specimens.

3. It is important to recognize the right of individual patients to make free choices concerning their treatment because it is their bodies and lives that are at stake. Such a right is not “absolute” but is, and should be, given high priority. The recognition of this right is exemplified by the creation and dissemination of a list of patients’ rights. In addition to the right to participate actively in decisions regarding medical care, including the right to refuse treatment, patients also have the right to considerate and respectful care; information about their diagnosis, treatment, and prognosis; the information they require to give their informed consent to any procedure; and full knowledge about human experimentation, and the right to refuse it.4

All of this means that neither patients nor professionals alone “know best,” but that decisions involving care and treatment are to be reciprocal (i.e., involving give and take) rather than dictatorial, paternalistic, or anarchistic. Obviously, professionals do “know best” in certain areas, but they should share their information and expertise with patients and their families. In this way, proper recommendations can be made as to alternatives of care and treatment, and proper decision making can be accomplished. Furthermore, patients and their families are entitled to more than one professional opinion.

Patients must realize, however, that no matter how well informed they are, they can’t know everything about medicine, and they must defer to professionals in some areas. However, once they have become well informed (and they have a right to be), they certainly are qualified to make decisions about their care and treatment. In some areas, they definitely “know best.” In other words, patients and their families are entitled to be apprised of all the expertise that can be brought to bear on their cases so that they can make important decisions. According to this view, in short, all decisions should be arrived at through a free exchange of ideas and a full discussion of alternative methods of care and treatment, with final decisions being made jointly by patients or their families (when patients are incapacitated) and their doctors.

In other words, reciprocal care calls for proper, intelligent, and informed communication between patients and their doctors. Doctors can facilitate such communication, as one family practice doctor in Seattle did, by furnishing their patients with a list of questions to ask:

1. What is wrong with me?

2. What caused it?

3. What should be done about it?

4. What will it cost?

5. How long will it take?

6. What tests should be done and why?

7. What is my prognosis?

8. What will you do next?

9. Is it necessary?

10. Is it dangerous?

11. Do I have any alternatives? If so, what are they?

12. If I must go into the hospital, how long will I be there?

13. How long will I be laid up, and when can I go back to school or work?5

Such a list of questions can really help to stimulate communication between doctors and patients and also enhance the doctor–patient relationship.

There are two models under the reciprocal view:  the collegial model  and  the contractual model .

The Collegial and Contractual Models

LISTEN TO THE CHAPTER AUDIO:

In the collegial model, “the physician and the patient should see themselves as colleagues pursuing a common goal of eliminating the illness and preserving the health of the patient. The physician is the patient’s ‘pal.’ ”6

Veatch sees the problem here as being that of whether doctors and patients can really assume mutual loyalty and goals of common interest. He goes on to say that ethnic, class, economic, and value differences make the collegial model more of an ideal than a reality.7

Veatch goes on to say that what is needed is “a more provisional model which permits equality in the realm of moral significance between patient and physician without making the utopian assumption of collegiality.”8 This contract should not be merely legalistic but more like a covenant as in the traditional religious or marriage sense. The bases for such a contract are freedom, dignity, truth telling, promise keeping, and justice, and there must be trust and confidence even though there is not a full mutuality of interests because of the value differences described previously.

Veatch believes that “Only in the contractual model can there be a true sharing of ethical authority and responsibility” because this model “avoids the moral abdication on the part of the physician in the engineering model and the moral abdication on the part of the patient in the priestly model. It also avoids the uncontrolled and false sense of equality in the collegial model.”9

The difficulties associated with this model are how to execute the contract (oral or written) and what to include in it. Isn’t this all rather vague? The health care field already has several contractual type forms—advance directives and various “Do Not Resuscitate” forms that the patient may sign—but Veatch seems to be talking about an agreement that is something more than these kinds of forms: an overall contract for medical care.

At any rate, it is important in using this model to consider the following:

1. To know the patients and to base the contractual relationship on their needs and personalities

2. To err on the side of patient autonomy when in doubt

3. To be cognizant of how power asymmetries and illness affect interactions and communication between physician and patient.

Cases: Obligations of Health Care Professionals

LISTEN TO THE CHAPTER AUDIO:

Bioethics means “life ethics” or “ethics in medicine.” Medical advances and technologies have also created a host of ethical problems. In addition to issues dealing with rights and obligations on the part of doctors, nurses, patients, families, chaplains and hospitals, there are questions about the morality of behavior control, human experimentation, the commodification of body parts, and stem cell research to name a few.

Cases for Study and Discussion

Case 1 67-Year-Old Cancer Patient

Richard is a 67-year-old man with terminal cancer. He has just had a liver scan and been told to visit his doctor, an oncologist (i.e., a cancer specialist whose work focuses on tumors), and get the results. When Richard arrives, the doctor says that there has been no change in his condition, which is, nevertheless, not good. Richard asks the doctor what can be done, and he replies that there is no remedy for this kind of cancer. Becoming somewhat agitated, Richard asks the doctor what he would advise him to do, but the doctor merely repeats his opinion that there is nothing to be done. By this time Richard is both frustrated and upset, and he asks the doctor why he won’t care for him and doesn’t care about him. In response the doctor gives Richard a prescription, but he makes it clear that the drug is being prescribed only as a psychological crutch—that it will not improve Richard’s health. When Richard finally leaves the doctor’s office, he feels totally depressed, abandoned, and dehumanized. Do you feel the doctor handled Richard’s case well? If so, why? If not, why not? How would you have handled the situation or advised the doctor to handle it? Discuss both the truth-telling aspect of what the doctor said and his methods of giving out information relating to his patient.

14.3: Truth Telling and Informed Consent

1. 14.3 Analyze the importance of truth telling and informed consent to significant relationships between professionals and patients

LISTEN TO THE CHAPTER AUDIO:

The issue involving  truth telling  is to what extent patients and their families should be told the truth about their illnesses, injuries, and/or dying. The term  informed consent  refers to a formalized procedure whereby patients (or family members, when patients are incapacitated) “consent,” usually in writing, to some sort of medical treatment, procedure, or surgery that may have questionable side effects, affect patients’ future lives, or even involve the risk of death. Somewhat akin to the discussion of patients’ and professionals’ rights and obligations, there are two views of truth telling in medicine: the paternalistic view and that of the patients’ right to know.

14.3.1: The Paternalistic View of Truth Telling

LISTEN TO THE CHAPTER AUDIO:

There are several arguments put forth to support the paternalistic viewpoint:

1. First, because patients are not medically trained, they cannot understand what doctors tell them; therefore, they do not need to know more than the fact that professionals are doing their very best for them.

2. Second, it is best both for patients’ morale and for their will to get better or will to live if they are not told the truth—especially if it is bad news, because full knowledge of their situation might cause them to “lose heart” and not fight to survive.

3. Third, it would serve no purpose to give them bad news, because if the prognosis is that they are going to die, for example, they will die anyway; therefore, one should let them live out the time they have left as happily as they can.

4. Fourth, it is all right to tell the families but not the patients—patients should be protected from bad news.

5. Finally, it is important for the doctor, nurses, and other professionals, as well as the family members, to avoid “being morbid” by discussing with patients the seriousness of their illnesses, injuries, or dying. Everyone connected with patients should try to cheer them up and to deny bad news whenever possible.

14.3.2: The Patients' Right to Know

LISTEN TO THE CHAPTER AUDIO:

There are a number of arguments made in support of the patients’ right to know, and many of these arguments are criticisms of the paternalistic arguments. These arguments are:

1. First, because it is the patients’ bodies and lives that are involved, not those of the health care professionals or even other family members, patients have a right to know everything and should be told all.

2. Second, it is much easier to treat and deal with patients if they are aware of what is going on and if professionals and family members don’t have to constantly pretend that patients’ illnesses or injuries are not serious or that patients are not dying.10

3. Third, patients often become angry when they don’t know in advance about the side effects or other painful or disturbing aspects of treatment (e.g., a woman whose radiation therapy made her arm swell and become very painful became angry because she was never told she might have this problem.)

One negative aspect of the patients’ rights position is that some professionals adopt this view so fervently that they are brutally frank with their patients, often leaving them without any hope or frightening them unnecessarily. However, it is a false dilemma to assume that you either must give people terrible news or lie to them.

14.3.3: The Moderate Position

LISTEN TO THE CHAPTER AUDIO:

A third view, one that lies somewhere between paternalism and brutal frankness, is a sharing of appropriate information with patients when they do want to know it and to the extent that they want to know it. This view lets patients be the guide in determining the information they will receive. It involves the following aspects:

1. Listening to patients carefully and hearing what they are really asking or trying to ask.

2. Not avoiding persistent, roundabout, or direct questions but rather answering them truthfully yet not brutally.

3. Not forcing information on patients when they are not ready just because the professional is ready to discuss the matter or is too busy to wait until patients are ready.

4. Not avoiding the truth by using medical and technical language or jargon, but trying instead to explain in lay terms everything that patients need or want to know.

5. Being aware that explanations or answers may have to be given in gradual doses or more than once because human beings will often defend themselves against the shock of bad news by not really “hearing” what is being said.

6. Always telling the truth clearly, gently, and humanely, never brutally, coldly, hopelessly, or cruelly.

7. Never leaving patients and their families without some hope, even if it is only the hope that professionals will keep trying to do the very best they can to cure patients and to keep them comfortable and out of pain.

14.3.4: Informed Consent

LISTEN TO THE CHAPTER AUDIO:

As mentioned earlier,  informed consent  is a more formalized approach to truth telling and to involving patients in decisions concerning their treatment. This approach has become necessary in our time because of the many complex technological tests, procedures, and surgeries required not only for individual therapeutic reasons but also for experiments that can help science to benefit others (by testing reactions to new drugs, for example).

In our country, the Department of Health and Human Services (HHS), with the agreement of the American Medical Association (AMA) and most hospitals, mandates that patients on whom complex, painful, risky, or dangerous procedures need to be performed, either for their own good or for the good of others, should be fully informed of what is to be done, why it is to be done, when it is to be done, and what to expect in the way of pain, discomfort, or risk. For example, except in emergency situations—in which saving a life requires immediate action—patients or their closest next of kin (wife, husband, parents, and children) must authorize any procedure of a serious nature such as surgeries and laboratory tests of certain kinds, as well as certain types of therapy, such as  chemotherapy  or radiation therapy.

The assumption behind the informed consent approach is that to intelligently consent to a procedure, patients must be fully informed; furthermore, they must agree in writing to undergo the procedure to avoid any later confusions and legal complications that may arise from it. To facilitate the informed consent procedure, many hospitals and laboratory groups have printed informed consent forms for patients to read and sign. These forms should do the following:

1. Explain the procedure and its purpose clearly and in ordinary language

2. Explain the kinds of discomfort or pain the procedure may cause patients to feel before, during, and after its completion

3. Explain any and all complications that may arise because of the procedure

4. State how long the procedure will take; and include a statement that the patient’s doctors have judged that the procedure should be performed for the patient’s best interests and welfare and despite any discomforts or risks.

The following four factors may inhibit consent:

1. The nature of illness of or injury to patients and the various medications they may be taking

2. Physicians’ attitudes; for example, arrogance

3. Patients’ attitudes; for example, submissiveness

4. Power asymmetries.

The best approach to getting informed consent is for the physician who is requiring or performing the procedure to explain it in some detail in addition to having the patient read the form. Patients and their families also should be encouraged to ask any questions they wish and should be given honest and clear answers. The idea behind such verbal explanations is that when patients sign these forms, it is important that they have truly been fully informed; merely reading a paper is often not enough, especially when patients are confused, worried, or even scared about the procedure.

14.3.5: Doctors' Reactions to Truth Telling and Informed Consent

LISTEN TO THE CHAPTER AUDIO:

Some doctors are opposed to full disclosure of truth to their patients and are also opposed to informed consent, except as a mere formality. The following are the reasons why doctors are opposed to full disclosure of truth:

1. Such doctors feel that patients don’t need to be fully informed because doctors know what they are doing and explanations of complicated medical procedures will only confuse patients and break down the relationship of faith and trust that should exist between doctor and patient (engineering or priestly paternalism).

2. Patients often don’t want to hear explanations, and forcing them to against their wills constitutes an invasion of their rights; furthermore, making them face facts about their physical or mental status or well-being that they aren’t ready to accept is a highly questionable, perhaps even dangerous, course of action.

3. Every procedure has its risks, but there is no reason to frighten patients unnecessarily when the odds are only, for example, two in one hundred thousand that a particular allergy or side effect will occur.

4. Such explanations may unnecessarily frighten patients to the extent that they will refuse to undergo a procedure that may be necessary to their health or well-being.

5. Doctors sometimes feel that by describing certain side effects, such as headaches, they can induce such problems through the power of suggestion. That is, patients may worry so much about getting a headache that the worry actually brings one on. Doctors sometimes feel that if patients don’t know that they are “supposed” to have some sort of reaction, they won’t get it, at least not psychosomatically.

The other extreme in truth telling is, of course, to go overboard and tell all. Some doctors feel that it is important that patients know every sordid detail of what is going to happen to them, whether they want to or not. For example, a woman in her mid-seventies who had broken her hip and was to undergo orthopedic surgery was told by the anesthetist that he was going to use curare, a paralyzing drug, to anesthetize her. He explained in detail how her heart would stop beating for a short while but assured her that he would be able to “bring her back from the dead.” The woman told the anesthetist not to give her so many details—to just do his work and not discuss it with her. It would seem that giving information to such an extent really serves no purpose unless the patient insists on knowing every last detail, which very few would. Except in such cases, overly detailed explanations merely cause unnecessary anxiety.

14.3.6: Patients’ and Families’ Reactions to Truth Telling

LISTEN TO THE CHAPTER AUDIO:

Some doctors base their decisions concerning what information to give on their own judgment as to what patients and their families do or do not want to know. It certainly is true that many patients and families don’t want to know the truth; they prefer to deny that terrible things are happening to them. However, most patients want to know what is happening to them because it is their bodies and lives that are at risk. Perhaps they don’t want or need to know all the details, but they do want to know the crucial facts.

Furthermore, just because patients and their families sometimes want to deny the existence of serious illness, injury, dying, and death doesn’t necessarily mean they don’t really want to know the truth. After all, there is often unfinished business that can be accomplished once the truth has been faced: dealing with inheritance and wills, settling family feuds, resolving other relationship problems, and doing things that families have always wanted to do but have put off. If patients and their families are not told the truth, they can miss an important opportunity to put their lives in order.

A great deal of sensitivity is required on the part of the whole health care team, especially doctors, to know what to tell and when to tell it and to be able to gauge possible reactions of patients and their families to different types of information. The team members must let patients guide them as much as possible in determining what information to give. Needless to say, it is difficult to deal well with the issue of truth telling, and health care professionals—especially doctors—should be given extensive training in patient–professional relationships.

Generally speaking, according to this point of view, patients and their families should be kept as fully informed as possible about their situation, especially when it is clear that they really do want to know. Such openness and honesty help to prevent the often painful game playing that goes on when people aren’t honest with each other. Patients and their families should be dealt with truthfully, honestly, and compassionately but without cruelty, coldness, or brutal frankness. If, however, they consistently indicate that they don’t want to be told about a specific situation, and if leaving them in ignorance would do no harm to them or their families, then one can avoid telling them until they indicate that they are ready to know. Finally, if patients want to know the truth about their illness but their families don’t want them to, the patients’ wishes should come first—family members should be counseled to allow the patients to be given the knowledge that they want and need.

Cases: Informed Consent

LISTEN TO THE CHAPTER AUDIO:

Bioethics means “life ethics” or “ethics in medicine.” Medical advances and technologies have also created a host of ethical problems. In addition to issues dealing with rights and obligations on the part of doctors, nurses, patients, families, chaplains and hospitals, there are questions about the morality of behavior control, human experimentation, the commodification of body parts, and stem cell research to name a few.

Cases for Study and Discussion

Case 1 Videotaping Patients

A psychologist wants to videotape some of his patients during their therapy sessions, partly for a study he is doing and partly as a teaching device for advanced psychology students. He feels that if the patients know they are being taped, they won’t act naturally, which will both taint his study and diminish the film’s value as a teaching device. For this reason, he feels that the patients should not know that they are being taped even though what they do or say on the tape may reveal certain aspects of their private feelings and lives. What should the psychologist do? Should he tell the patients he is taping them, or should he just go ahead and tape without their permission, assuming that he is just going to use the tapes for his own research and as a teaching device? Are there any other alternatives you can think of for the psychologist to follow?

Case 2 Woman in a Mental Institution

Mary, 45, is in a mental institution on a ward for violent people. She is given to episodes of extreme violence during which she loses all control and becomes very dangerous. Between such episodes, she remembers at least some of what she has done, but when one of these episodes comes on, she just can’t seem to stop or control it. There doesn’t seem to be anything physiologically wrong with her brain, but a doctor suggests to her that she have a surgery performed that will eliminate her violence.

The doctor explains that this operation may cause extreme loss of memory—to the extent that Mary could read a newspaper and immediately forget everything she has read. Furthermore, the operation will make Mary so passive that she probably will not want to do very much with the rest of her life; however, after undergoing such an operation, she probably could be released from the institution. Mary is so deeply distressed by her violent episodes that she signs a release to have the surgery performed.

Describe the implications of informed consent in this case, and discuss Mary’s ability to give it freely as an inmate of a mental institution. Also, discuss the extent to which coercion exists in the doctor’s promise that Mary’s violent episodes will end and in the suggestion that she may be released from the institution. Can Mary fully understand what she is agreeing to? And even if she does not fully understand, because she hasn’t been cured by other methods, should she be allowed the brain surgery as a viable alternative or not?

14.4: Intercultural Bioethics

1. 14.4 Recognize the need for a serious consideration of intercultural bioethics to ensure health care cultural competency in America

LISTEN TO THE CHAPTER AUDIO:

America is becoming an increasingly pluralistic society. As the world continues to move more and more toward globalization and interdependence the United States, in particular, will continue to experience greater ethnic, cultural, and religious diversity. This plurality has profound implications for ethics in medicine and healthcare and points to the need for a serious consideration of intercultural bioethics.

The American health care system treats patients from around the world as well as multiple racial and ethnic groups within our society. Furthermore, we employ health care professionals from many cultures. How various groups and individuals understand ethical and value issues in medicine, how various cultural groups make ethical choices, and how medical professionals and providers care for and treat diverse populations is at issue. Non-Western ethical perspectives and increased focus on the ethics of care, in concert with Western ethical theory and traditional values will go far in contributing to health care cultural competency.

14.5: Confidentiality

1. 14.5 Analyze the importance of confidentiality to significant relationships between professionals and patients

LISTEN TO THE CHAPTER AUDIO:

Confidentiality in patient–doctor relationships would on the surface seem to be fairly clear—that is, whatever a doctor and patient discuss and whatever the patient reveals in this relationship are to be held in strictest confidence, just as in other professional relationships such as lawyer–client, counselor–client, or rabbi/priest/minister–parishioner relationships. And yet as it turns out, confidentiality is by no means so clear-cut an issue in the doctor–patient relationship. For example, what happens when a doctor tests a patient for a  sexually transmitted disease (STD) , including AIDS? The law is clear—STDs have to be reported—but it also is clear that test results showing that a patient is HIV positive or has AIDS are generally not to be revealed. Other infectious diseases, such as leprosy, tuberculosis, or plagues, must be reported by individuals’ names, but not HIV-positive or AIDS results, which can be reported only anonymously as numbers of such cases.

14.5.1: Positive HIV Tests and AIDS

LISTEN TO THE CHAPTER AUDIO:

Because of tremendous misunderstandings concerning the AIDS epidemic and the stigma connected with people who are HIV positive or who have AIDS, laws have protected such people from being singled out because they could lose their jobs, societal status, and even friends if these results were revealed. However, problems have arisen with regard to matters of justice or fairness, especially those relating to sexual partners or drug-using partners. For example, should this information be revealed to such partners or spouses so that they can protect themselves from infection, especially because AIDS is a fatal disease with no cure as of yet?

For example, if a man goes on a trip, has sexual contact with an HIV-positive man or woman, and then tests HIV positive himself, should his wife or other sexual partners be told about his infection, or should his confidentiality be protected as it would be under most other medical circumstances? One solution, of course, is to urge the man to tell his wife or partner or to get his permission to let the physician do so, but what if he refuses?

Health Caregivers with HIV/AIDS

LISTEN TO THE CHAPTER AUDIO:

Another problem has arisen with regard to health caregivers who are HIV positive or who have AIDS. If this information were to be revealed, then most such people would be out of a job; and yet, is it fair to their patients not to know that their health caregivers have this problem? A young woman died as a result of having been infected with the AIDS virus from her dentist, who has also since died from AIDS.

Some health caregivers feel that there would be a double standard if caregivers had to reveal their problems but patients did not because the livelihoods of the former would be at stake. As health caregivers, they should, of course, take the responsibility for their infectiousness and remove themselves from any part of their work that would involve the possibility of passing on their body fluids to patients. For example, a surgeon should stop doing surgery and retrain or go into a different area within the same medical field for which he or she already is trained. But again, what if such doctors choose not to take that responsibility? What should be done? Shouldn’t caregivers have the same protection as anyone else who tests HIV positive or has AIDS?

As one can see, the matter of confidentiality is not always so simple and straightforward as it might at first appear to be. It would seem that, as a general rule, confidentiality should be maintained to the utmost degree. At the same time, however, everything must also be done to protect the innocent from any kind of contagion. In these difficult times, every effort must be put into both of these areas of medicine, and people who are capable of infecting others must bear the responsibility of warning others. If they refuse, then confidential action must be taken to protect the innocent. Each case or situation must be dealt with on an individual basis.

14.6: Guilt and Innocence in Treating Patients

1. 14.6 Recognize the importance of suspending personal feelings that can cloud professional judgment in medicine

LISTEN TO THE CHAPTER AUDIO:

Another general medical ethical issue that sometimes arises relates to the effect on the treatment of patients by health care professionals who have judged their patients to be either “guilty” or “innocent”; that is, the degree to which a patient is deemed to be the cause of or contributor to the illness for which he or she is being treated. For example, it often is difficult for a health practitioner to be objective when dealing with alcoholics or drug abusers if any members of his or her family have used alcohol or drugs or, worse yet, died as a result of either form of abuse. Similarly, it must be hard for the parent of a small child to treat a child abuser for an injury or a disease.

This inability to suspend personal feelings that can cloud professional judgment has to some extent always been a problem in medicine, especially when medical personnel are obliged to keep treating patients who continuously abuse themselves and thereby give rise to their own injuries or disease. Allowing personal attitudes to compromise patient care has become a more prevalent dilemma since the increase in the number of AIDS patients.

Will a doctor or nurse treat an AIDS patient differently if that patient became infected due to receiving tainted blood from a transfusion as opposed to having acquired the disease as a result of sexual activity or drug abuse? Should this difference in treatment or attitude in giving treatment be allowed for, or not? 

Cases: Guilt vs Innocence of Patients

LISTEN TO THE CHAPTER AUDIO::

Bioethics means “life ethics” or “ethics in medicine.” Medical advances and technologies have also created a host of ethical problems. In addition to issues dealing with rights and obligations on the part of doctors, nurses, patients, families, chaplains and hospitals, there are questions about the morality of behavior control, human experimentation, the commodification of body parts, and stem cell research to name a few.

Cases for Study and Discussion

Case 1 Prisoner and Heart Transplant

Recently a 31-year-old, twice-convicted robber became the first California state prisoner—and likely the first in the United States—to receive a heart transplant, a scarce and expensive resource. He suffered from a viral infection that had damaged his heart valves. He experienced congestive heart failure and was placed higher on the list because of his urgent medical condition. Many people, including some ethicists, thought that taxpayers shouldn’t spend $1 million on a convict who was serving a 14-year sentence for a violent felony. Others, again including ethicists, thought that no distinction should be made between a convicted felon and anyone else who needed a heart. In 1976, the U.S. Supreme Court ruled that prisoners must receive adequate medical care. One of the biggest problems in heart transplantation is the many medications necessary to prevent the body from rejecting the new heart and biopsies necessary during the first year following the surgery. This difficulty became apparent in this case in that the inmate died within the first year. The comment was made by the prison warden that prisoners generally don’t take care of themselves and often don’t take their medications. Do you think that major medical care, such as transplants, should be performed on prisoners? Why or why not? Would it make any difference if they were on death row, serving life sentences without parole, or serving determinate sentences, such as this inmate? Support your position with logical argument and proof.

14.7: Ethical Issues in Medicine

1. 14.7 Identify the ethical issues concerning the areas of behavior control, human experimentation, and genetics

LISTEN TO THE CHAPTER AUDIO:

In this section three additional areas in bioethics will be discussed:

1. Behavior control

2. Human experimentation

3. Genetics

14.7.1: Ethics and Behavior Control

LISTEN TO THE CHAPTER AUDIO:

Behavior control  is that aspect of bioethics which deals with general questions concerning the extent to which the behavior of human beings should be controlled by the various technologies available to us in our century. In particular, the following specific questions arise:

· How do we determine what constitutes undesirable or socially unacceptable behavior?

· Who defines such behavior, and to what extent should we control or eliminate it?

· Which methods of controlling behavior are considered ethical, and which are not?

· Who should determine how and to whom behavior control is to be applied—the individuals suffering psychological problems, their families, others living around them, the government, their doctors, and medicine in general?

Ethical Issues and Problems with Behavior Control

LISTEN TO THE CHAPTER AUDIO::

Because much of behavior control is subtle, one must question whether anyone has the right to change people’s behavior whether they know it or not or whether they consent or not. Ardent probehaviorists would say “yes” for several reasons. They would insist that society has a good idea of what “normal behavior” is, and that when people don’t conform to it, their behavior should be changed for their own good and the good of others. The farther away from the norm the behavior is, they would argue, the more drastic the control must be (e.g., a scolding might be sufficient for a child who swears, but brain surgery would have to be considered for an adult given to episodes of uncontrollable violence).

Strong antibehaviorists, or individualists, however, would disagree. They believe that people don’t know what the standard for normal behavior is and that setting one arbitrarily would be highly dangerous. Individual freedom, uniqueness, and creativity are to be encouraged and prized, and if these are to exist, society must allow for some deviation from the norm. True, they say, some behaviors should be discouraged and some encouraged, but proper ethical procedures must be employed at all times. For example, simply because a person in a mental hospital is in favor of brain surgery to curb his violence does not necessarily mean that the doctors should comply with his wishes. According to the antibehaviorists, one must ask several important questions concerning the protection of such people’s rights as individuals. For example, can they really know, if they are so mentally disturbed that they must be institutionalized, what they are consenting to? Are they competent to judge what is best for them in such situations?

Another question that comes up with relation to changing behavior is how far one can carry the use of rewards, bonuses, or punishments. Doesn’t it constitute rather strong coercion to give a man a choice between three to six years in prison and castration, or to give an impoverished man in India a bonus for having himself sterilized? Can people be considered to freely consent when they are being forcibly or even subtly coerced by financial rewards or promises of freedom?

Yet another problem that arises involves the therapist or controller as well as the patient. First of all, who should such controllers be, and to whom should they be responsible? To the society in which they live? The institutions at which they work? Their government? Their patients? For example, if a homosexual who lives in a militantly heterosexual society comes to a therapist for help, what is the therapist’s duty? Should he or she help the homosexual to adjust to this type of sexuality and to the possibility of ostracism by some segments of society, or should the therapist try to steer the homosexual toward heterosexuality? Therapists’ decisions about their responsibilities affect their patients and, more indirectly, the rest of society.

14.7.2: Human Experimentation

LISTEN TO THE CHAPTER AUDIO:

Human experimentation means the use of human beings for experimental purposes for their own therapy, for the good of humanity in general, or for the purpose of advancing scientific knowledge. Why is the question of human experimentation even raised? Of course, arguments for the use of such experimentations can be made based upon the promise of advancement in medical knowledge as it concerns human health. In fact, much of what is known now about human diseases and effective means of treating them were derived from forms of experimentation performed on humans. Few people would argue that the consequences of such experimentation (effective vaccinations, organ transplants, improved medications, positive and negative effectives of certain types of medical treatments, etc.) are morally problematic. However, the means by which these medical advancements are achieved continue to be debated issues within the medical community and society as a whole. See the following case (Figure 14-1).11

Figure 14-1

Guatemalan syphilis experiment.

As with most ethical dilemmas, the issue of human experimentation is complex. The Guatemalan experiment is a clear example of why people need to critically examine the ethical implications of such experiments. For example, are individuals or institutions justified in performing hazardous experiments on unknowing participants if the results of the experiment lead to major medical breakthroughs? Is it always wrong to use a human being as a means to an end? The main questions raised here, then, are to what extent human beings can be experimented upon and under what conditions and to what degree must they be informed about and freely consent to such experimentation.

The Proexperimentation Argument

LISTEN TO THE CHAPTER AUDIO:

Those who take a strong proexperiment stance believe that as long as a specific experiment can advance scientific knowledge or aid humanity in some way, human experimentation is justified. People who are to be experimented on should be informed just enough so that they know something about what’s being done to them, but not enough to interfere with the outcome of the experiment.

People in prison or in mental institutions who are willing to participate should be allowed to volunteer to aid humanity; in this way, they can make up for their previous crimes or their present uselessness. As an incentive, such people can be offered rewards (e.g., parole, release, or a better living situation). It is, further, even justifiable to experiment on institutionalized children or on children whose parents have given consent, to cure them when nothing else has worked or to benefit future children with similar problems.

The Antiexperimentation Argument

LISTEN TO THE CHAPTER AUDIO:

According to this point of view, human beings generally should not be used for experimentation. If science can’t advance its knowledge by using animals, it simply cannot be advanced. No experimental drug or procedure should be used on any human being unless the following criteria are met: It is a last resort; it is meant to cure the person on whom it is used; the patient has given fully informed consent; and science has gone as far as it can with animal experimentation. Opponents of human experimentation point to the terrible experiments performed by doctors of Nazi Germany during World War II. Never again, these people argue, can science be given carte blanche to perform experiments on humans.

Furthermore, experimentation must never be done on human beings who are not mentally competent to consent, including people in mental institutions and all children, whether or not their parents are willing to consent. Experiments also must never be performed upon people who are not really free to consent, such as those incarcerated in prisons or other institutions. Finally, any human experimentation that is done, after all of these criteria have been satisfied, must also be extremely safe; it must not involve serious risk of illness, injury, or loss of life.

Immanuel Kant’s  Practical Imperative  can be useful for judging the moral acceptability of cases involing human experimentaion. The principle states that each human being must be considered as a unique end in himself or herself and never used merely as a means to someone else’s end. In human experimentation, this would mean that no human being could be used for experimentation unless it would be therapeutic for that human being and would not be more harmful or risky than other treatments that generally would be used for such patients. This would further mean that no experimentation only for “the good of humanity or others” could be done. If this good were an indirect result of the experimentation, then it would be allowed, but the experimental procedure must be for the primary benefit of the patient on whom it is to be performed.

Many medical ethicists will follow this imperative as a guideline, but they may also allow experimentation when the person to be experimented on can give fully free and informed consent, realizing that the experiment may not be therapeutic for him or her but for the good of humanity or the advancement of science. Where there is any doubt, however, the Practical Imperative forms a useful ethical criterion for human experimentation.

14.7.3: Genetics and Stem Cell Research

LISTEN TO THE CHAPTER AUDIO:

Genetics  is that area of medicine and science that is concerned with the manipulation and control of the human genetic makeup. Research in genetics includes everything from discovering the causes of genetic problems and correcting such problems to creating human life in the laboratory. The main problem caused by genetics arises from determining how to use the technology we have to help us acquire genetic information and manipulate genes. It is obvious that this problem is very important, especially when we consider the potentially enormous effect of genetic manipulation upon individuals, families, and the overall  gene pool .

There are, first of all, such procedures as amniocentesis and chorionic villus sampling and other investigative and diagnostic procedures that can bring important information about genetic defects or abnormalities. This information can, in turn, enable medical professionals to correct such deficiencies—if and when we can perfect the corrective procedures—or to avoid them altogether by means of either abortion or birth control, including sterilization. Genetic counseling is, therefore, intimately tied to important ethical questions.

Second, even more crucial ethical problems will arise as we approach the point at which we can correct and avoid genetic defects, cure diseases, or create life in the laboratory. Someday, humanity may even be in a position to decide what male and female types would best ensure the survival of the race and then reproduce them artificially. Society could go even further and decide, as in Aldous Huxley’s Brave New World, how many intellectuals, laborers, white-collar workers, and other types of people a “balanced, well-functioning society” needs and then create such a society in the laboratory.

At this point in scientific development these are somewhat exotic problems, but there is no reason to think that science will not be able to do these things in the future. Frogs and even mammals (e.g., sheep) have been cloned with some success. Also, scientists already have declared a  moratorium  on various types of experimentation having to do with creating life in the laboratory. As does human experimentation, the issue of genetic experimentation and development arouses strong opinions on both sides.

Arguments for and Against Genetic Experimentation

LISTEN TO THE CHAPTER AUDIO:

According to this argument, nothing and no one should stand in the way of advances in scientific knowledge and the chance to cure diseases or perfect the human race. The more that is known about genetics, the more science can improve the human race and condition, and the better things will be. This betterment should be our primary goal; one should not worry about such trivial matters as the effects of experimentation upon the gene pool, or whether our information and abilities will result in abortion, sterilization, the elimination of defects, or the ability to create life in the laboratory. Self-imposed moratoriums and laws that prevent scientific advancement cannot be justified.

According to this argument, in the case of anything that tampers with the natural life process or interferes with God’s or nature’s plan, no scientific experimentation in this area, especially the artificial creation of life, should be allowed. Nature or God had a purpose in allowing some imperfections to exist in the human species, and tampering with this purpose could prove disastrous, not only to the natural development and progress of humanity but also to its moral and spiritual development. Nature or God has placed upon this earth human beings with handicaps and genetic problems to help us recognize that human imperfections do exist and also to encourage us to love and care for less fortunate human beings. If we create completely perfect human beings and eliminate all of those with imperfections, we will lose our humanity, both from a biological–physical and a moral–spiritual point of view.

Cases: Medicine and Other Ethical issues

LISTEN TO THE CHAPTER AUDIO:

Bioethics means “life ethics” or “ethics in medicine.” Medical advances and technologies have also created a host of ethical problems. In addition to issues dealing with rights and obligations on the part of doctors, nurses, patients, families, chaplains and hospitals, there are questions about the morality of behavior control, human experimentation, the commodification of body parts, and stem cell research to name a few.

Cases for Study and Discussion

Case 1 Abortion for Reasons of Gender of the Embryo

A middle-aged wife became pregnant and underwent amniocentesis testing to see if the baby would have  Down syndrome . When the procedure was over, the genetic counselor was happy to inform the prospective parents that their baby would be quite healthy. She also told them, however, that the sex of the child was female. The husband and wife then decided to have an abortion because they already had several daughters, and the genetic counselor was beside herself with shock and concern. She felt that she might have done the wrong thing by revealing the sex of the child to the parents—that if she had merely told them about the Down syndrome results, they would not have decided on an abortion. Should the counselor have withheld the information about the sex of the child? Do the parents have a right to know all of the information disclosed by amniocentesis, only the information that is crucial to the health of the child, or only the information for which they ask? In short, what are counselors’ obligations in revealing the results of such tests?

Case 2 Experimenting on Children

A doctor-researcher in residence at a private institution for mentally retarded children discovers that the children in one of the dormitories have dysentery, whereas those in the other dormitories do not. She decides to experiment with the children, both to see what has caused this particular phenomenon and to study the effects of dysentery and its various cures upon children in general. She sets up a scientific study with control groups (in which some students receive medication and some do not), and part of her experiment involves infecting healthy children with dysentery germs. The institution for which she works has a long waiting list, and the doctor takes advantage of this, admitting only those children whose parents will sign a release allowing her to conduct experiments upon them. What are the ethical implications of what the doctor is doing? Should such experimentation be allowed? Why, or why not?

Case 3 Homosexual Seeking Help

John, 25, comes to a psychiatrist very depressed about his homosexuality. He has had two heterosexual relationships, neither of which was satisfactory, and numerous homosexual ones, some of which were satisfactory and some of which were not. He also has used his homosexuality as a means of getting jobs, money, and other benefits. John is not quite sure what he wants to do about his homosexuality, but he does know that he is not very happy the way he is. What should the psychiatrist do? Should he try to help John become a heterosexual? Should he try to get him to adjust to his homosexuality? Discuss both of these alternatives, and describe the psychiatrist’s responsibilities to himself, to John, and to society in general.

14.8: Stem Cell Research

1. 14.8 Identify the ethical issues concerning stem cell research

LISTEN TO THE CHAPTER AUDIO:

One of the most controversial types of genetic research today is stem cell research. Stem cells, the so-called master cells of the body, have the potential to become many different kinds of cells. They are the means by which cells in the body can be replenished. In the very early embryo, these cells have the power to become any kind of body cell. Adult stem cells, on the other hand, have the capacity to become a variety of cells, but not all kinds. They are difficult to obtain and very hard to coax into developing into other tissues; consequently, their use would involve much more time and money to obtain the desired results. Scientists hope to obtain lines of the embryonic cells, that is, large numbers of them grown from a common source, and coax them into becoming specific kinds of cells. The desire of these scientists is to use stem cells to repair damaged tissues in the body, such as heart tissues to repair damaged hearts and nerve tissues to repair damaged spinal columns or reverse the effects of Alzheimer’s or Parkinson’s diseases.12

14.8.1: The Moral Issue of Using Embryonic Stem Cells

LISTEN TO THE CHAPTER AUDIO:

Although embryonic stem cells are much easier to use than adult stem cells, the moral issue for many, especially strong antiabortionists such as the Catholic Church, is that the procedure of extracting stem cells from a five- to seven-day-old embryo kills the embryo. Many pro-life people argue if society allows this, it does not respect human life (assuming that human life begins at fertilization of the egg by sperm—the strong pro-life point of view) and what is done is tantamount to abortion or the murder of human life in the embryonic stage. The moral dilemma occurs because scientists figure they can use such cells to develop tissues which can be used in curing chronic, disabling diseases such as Parkinson’s, Alzheimer’s, diabetes, and spinal cord injuries.

14.8.2: Governmental Limits

LISTEN TO THE CHAPTER AUDIO:

President George W. Bush (1946– ), faced with this dilemma and torn between his pro-life views against abortion and the desire to cure various diseases, said that federal funds will be used only for research on existing stem cell lines that were derived as follows:

1. With the consent of the donors

2. From excess embryos created for reproductive purposes

3. Without any financial inducement to the donors.

No federal funds will be used for the following:

1. Stem cell lines derived from newly destroyed embryos

2. The creation of human embryos for research purposes

3. The cloning of human embryos.

The irony of his plan is that it satisfies neither the scientists, who want greater freedom and financial support for research, nor the pro-life supporters. Bishop Joseph A. Fiorenza (1931– ), president of the U.S. Conference of Catholic Bishops (1998–2001), states the pro-life position when he said, “The trade-off he [Bush] has announced is morally unacceptable. It allows our nation’s research enterprise to cultivate a disrespect for human life.”13 Scientists are disappointed because there are only a few stem cell lines available under Bush’s plan, which, of course, drastically limits their research. Some states, such as New Jersey and California, have passed legislation legalizing stem cell research with fewer limitations than Bush’s plan and with financial support coming from private, or nongovernmental, sources.

14.8.3: Possible Solution

LISTEN TO THE CHAPTER AUDIO:

The latest research has shown that adult stem cells can be isolated and developed. If such research continues to be successful, there may be no reason whatsoever to use embryonic stem cells, which, of course, would resolve the dilemma.14 It remains to be seen how long such research will take and whether scientists are willing to wait until the research is successful or whether they will deem the adult stem cells as useful as embryonic ones.

14.8.4: The Ethics of Body Trading and Tissue Banking

LISTEN TO THE CHAPTER AUDIO:

Rapid progress in biotechnology has outpaced regulation, and the public, too, lacks an awareness of, and understanding about, a highly lucrative global industry of body trading: body part buying, selling, retrading, and transplanting. Staggering advances in biotechnology and medical science concerning new uses for human tissue have given rise to a host of ethical, legal, and political issues that accompany the commercial enterprise of body trading. Altruistic donors, through ignorance, are routinely exploited, and relatives are stunned, dumbfounded, and outraged to learn that their loved ones have become products in the profitable tissue commerce business.

In addition to organ transplants, approximately 650,000 Americans each year undergo surgery that uses soft tissues, skin, bones, and tendons taken from cadavers. But there are serious issues about the clandestine nature of body part procurement and a range of possible risks associated with product lines. Companies that process human tissue purchase body parts from hospitals, universities, and other institutions to which bodies are donated in good faith for research purposes. Procurement of bodies from Third World nations is even more problematic. A cadaver often generates over $200,000 in market value. Tissue companies reap high profits and trade on the global exchanges. Much of this industry is market driven, and shareholders place pressure on management to show profits quarter after quarter.

Due to lack of regulation (much of the industry in America is still governed by Blood Shield laws passed in the 1950s and 1960s), there are a number of product risks. Tissue can transmit the following to a transplant host: hepatitis, HIV, mad cow disease, bacteria, and other communicable diseases. There is also a failure to disclose information about the cadaver’s lifestyle, sexual habits, prior illness, and whether he or she was a smoker, drinker, or drug user. Furthermore, there is not adequate research concerning the ways a cadaver’s former lifestyle might impact the transplant host.

There is a need for better global regulation of, and public disclosure and transparency within, the body trading industry. Ethical, legal, and social issues must be more clearly defined in those cases that determine the status of body parts.

Cases: Stem Cell Research

LISTEN TO THE CHAPTER AUDIO:

Bioethics means “life ethics” or “ethics in medicine.” Medical advances and technologies have also created a host of ethical problems. In addition to issues dealing with rights and obligations on the part of doctors, nurses, patients, families, chaplains and hospitals, there are questions about the morality of behavior control, human experimentation, the commodification of body parts, and stem cell research to name a few.

Cases for Study and Discussion

Case 1 Stem Cell Research

Do you think that stem cell research should be allowed to continue from embryos and/or adults? Why or why not? Support your answer with proof and logical argument. Should the government subsidize such research? Why or why not? If you agree that embryos should be used, which kind? Those from aborted fetuses? Leftover embryos from fertility processes? Should embryos be raised for research purposes? Why or why not?