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MedicalEthics-Lecture1-1717.pptx

Medical Ethics

Introduction to Bioethics

What is Ethics?

Also known as moral philosophy, is a branch of philosophy that addresses questions about morality — that is, concepts such as good and evil, right and wrong, virtue and vice, justice and crime, etc. There are multiple approaches to ethics. We will explore a number of these theories before using them to approach issues with in the biomedical field.

Application of Theory

We will begin by exploring the different theories, after that we will begin applying them to specific medical issues that hold ethical importance. You must remember that even when approaching an issue or problem from a particular theory not all theorists using that theory are going to have the same interpretation or “answer” as to the correct act or direction. Because of differing core beliefs and ideas. There is no set right or wrong way to interpret and respond to a given case all these are influenced by your own personal beliefs and morals.

While there may be a wrong way to interpret or apply a theory. There is not a wrong interpretation of the problem from an ethical perspective.

Remember, there are no black/white in ethics. It is more all gray area.

What is a moral theory?

A moral theory is a systematic perspective to moral problems that ranks the principles and rules valued by the approach.

Basically, it is a way of approaching or evaluating ethical situations by applying a set of values and rules to them to interpret the best action or course to take.

What makes up a moral theory?

There are two basic archetypes:

Normative Ethics

Meta-ethics

Normative Ethics

This area of ethics is basically interested in the answer to two “ought” questions:

What ought I do?

What ought I be?

In both cases a prescriptive is sought. Authoritative rules or directions for right action and good character.

Metaethics

This is the study within ethics that goes beyond simply determining right action or what is morally good or bad, but looks at and attempts to define the meanings of moral goodness.

For example it attempts to answer questions such as: Is there or is there not anything objectively right or wrong independent of human opinion?

Are there discoverable absolute standards for determining right and wrong? Or do right and wrong depend upon the context and the consequences?

What is Biomedical Ethics?

Biomedical ethics encompasses a broad range of practices and questions within the medical realm. Primarily deals with the application of ethics to life sciences, especially medicine and health care.

What is Biomedical Ethics? (cont.)

These range from the mundane (living wills and care of the elderly) to the sensational (abortion, stem cell research and physician assisted suicide). These are just a few of the issues that are looked at through the lens of medical ethics.

A brief history of Ethics in Medicine

Looking to find a moral and ethical grounding for decisions and actions in medicine is not a new under taking. We have been attempting to layout a code of Ethics and moral behavior as far back as the 4th century BC. The Hippocratic oath was devised to guide and hold doctors to a code of ethics.

Original Hippocratic Oath

I swear by Apollo, Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witness, that I will fullfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art— if they desire to learn it— without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

Hippocratic Oath (cont.)

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html

This is essentially the same oath that is sworn to by doctors today. We can see that it was set out to establish some guidelines as to proper conduct of a physician but there things that are covered in this oath that some physicians definitely no longer adhere to. For example:

No abortive remedies

Only schooling those of male linage in the arts and practices of medicine.

Others?

Modern Oath

The oath sworn to by most doctors now was actually written based off of the Hippocratic Oath in 1964. It is as follows:

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Ethical Theories

An Overview

Divine Command Theory

Essentially this is the theory that is based upon what God deems as right is right and what God deems as wrong is wrong. What God expects of us derives from his immutable moral nature.

Thus since God’s nature is unchanging our moral obligations are fixed, unchanging, and absolute.

Scriptural Basis

Augustine believed that the divine command theory could be deduced from the scripture. That if we were to follow the Bible we would be following God’s command.

Augustine felt that the Bible was the chief source of Christian Ethics.

Natural Law Theory

Aquinas’ theory is based upon the idea that the world was created by a supremely rational being (God) and that all things created were given a specific role or purpose. And thus since good is seen as a natural end, humans are naturally inclined towards it.

Aquinas reasoned that, because God created the world and everything in it with an order and a purpose reflective of his will, by examining the nature of things we should be able to discover what God expected of us. (36)

In other words, the mental powers given by God for discerning his existence has also enabled us to discern moral law.

Aquinas argues that things that we are naturally inclined towards are good. The examples he gives us are:

1. preservation of self

2. education of offspring, reproduction of species and so forth

3. natural inclination to according to the nature of his reasoning, leading to know the truth about God, live in societies and thus follow the natural law.

The Doctrine of Double Effect

The principle of double effect recognizes that sometimes it is permissible to bring about, as a merely foreseen side effect, a harmful event that it would be impermissible to bring about intentionally.(37)

The Doctrine of Double Effect (cont.)

Specifically , under the doctrine of double effect, a harmful effect is permissible if and only if:

1. the act itself is morally good or neutral;

2.only the good effect of the act is intended directly;

3. the bad effect of the act is not the means for achieving the good effect;

4. the good effect outweighs the bad effect.

Self-evidence of Natural Law

Aquinas’ said that “a thing is said to be self-evident in two ways: first, in itself; secondly, in relation to us. Any proposition is said to be self-evident in itself, if its predicate is contained in the notion of the subject…”

For example: Man is a rational being. This idea is self-evident in the fact that men can reason and thus are rational by nature.

The second way takes the practical reasoning of man to be self-evident. In other words without the ability and knowledge of the subject nothing is self-evident about it. But since we have these abilities they become self-evident, such as the ideas of good and evil.

Secular Natural Law

John Locke’s formulation of natural law theory is based on our observations of nature itself.

Locke derived certain inalienable rights which flowed from nature’s laws, those being life and liberty.

He said that it was precisely and only to protect these natural rights and ensure equal treatment against the threats to them posed by conflicting and unrestrained self-interests that people formed societies. (38)

Legal and Moral Rights

Legal rights are those that we retain under a government. The right to vote for example.

Moral rights (human rights) refer to those that we hold on the basis of our humanhood.

Whereas a legal right is derived from law or a legal system, a moral right is derived merely from being a human being. (38)

Social Contract Theory

Idea put forth by Thomas Hobbes - It is the claim that it is the people who bring the state or government into being to secure and promote their basic rights and well-being. Empowering civil authority to spell out legal rights based on natural or moral rights, presumably to ensure the requisite mutual trust for the social cooperation needed to protect those rights. (39)

Essentially, we all agree to live together to maintain our personal rights and in order to do this we give up control of certain rights to ensure the preservation of the others.

Kantian Ethics

Believed that there all duties could be derived from the categorical imperative. We may only act and are bound to act in such a way that it doesn’t violate either premise of the theory.

Kant claims that there is only one thing that is good without qualification: good will.

“a good will is not good because of what it effects or accomplishes –because of its fitness for attaining some proposed end: it is good through its willing alone – that is, good in itself.”

Moral Choice

According to Kant, by telling us what to do…reason enabled us to go beyond natural instinct and narrow self-interest. Reason told us what principles of action had the force of an unconditional moral duty, …one that is universal and absolute; one that always applied, unexceptionally to all rational creatures. (42)

He termed this universal basis of moral obligation the categorical imperative.

The Categorical Imperative

Two formulations of the theory:

Principle of Reciprocity - “act only on that maxim through which you can at the same time will that it should be universal law”

Principle of Humanity - “act in such a way that you will always treat humanity never simply as a means, but at the same time as an end.”

Concluding Kant’s Theory

Moral Rights –

He expresses these as positive and negative rights. Or “freedom from” and “freedom to”

The rights to privacy, to not being killed, to not have our stuff taken from us, etc are all seen as negative rights.

The rights to education, medical care, food, housing and a fair trial are all seen as positive rights.

Kant points out that without both types of rights the categorical imperative would not work. In other words anything that you could will to universal law must not violate either set of rights.

Utilitarianism: Bentham

Bentham points out that two of the governing impulses in human nature are those of pain and pleasure. Within this we have a natural inclination towards pleasure and an avoidance of pain.

Bentham said that the purpose of morality is to maximize human happiness, as measured by pleasure and pain.

This being said Bentham didn’t have a strict structure of right and wrong but only that the right action was dependent upon the yield of greatest net happiness of all the alternatives.

Utility Principle

Idea put forth by John Stuart Mill. Essentially it states that the right act is that which creates the greatest good for the greatest number.

The most basic premise of utilitarianism is that acts are right in proportion to the amount of pleasure they produce while minimizing the amount of pain.

Moral Rights and the Harm Principle

Mill held that individual freedom be it of thought, speech, taste, action and political assembly was of the highest importance.

Individual freedom could only be curtailed by the harm principle.

“…the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.” (45)

To prevent harm to others individual freedoms can be limited.

Bentham in Bhutan

In the 1970’s the King of Bhutan decided that the Gross National Product (GNP) wasn’t the best way to determine the economic health of his country. He decided that using a system to determine the GNH (Gross National Happiness) was a more appropriate measure for the health of his nation. After developing a complex way of measuring a number of factors it was put into place. With updates done every couple of years.

Social interests

Utilitarianism is much different from egoism in that it wants to put the focus on maximum collective pleasure and minimum collective pain. In this they mean that all persons impacted by a decision or action must be taken into account to determine the correct action.

Preference Satisfaction

Not all pleasures are equal and often times it is said that not all potential pleasures need be judge on the same scale. It is pointed out that often times it is whether the greater problem is not fulfilling ones preferences because we no longer have that option.

And as Peter Singer points out we are not all equal actors either with regard to potential pleasures or pains.

Conclusions

Teleological ethics are those that correct action is based upon the consequence of the action.

Deontological ethics is based upon an concrete right and wrong without regard for the consequences.

Virtue Theory

For Aristotle the virtuous act, or moral virtue, was the one that steered clear of the two undesirable extremes of deficiency and excess and, thereby, achieved the Golden Mean.

This made every moral act or virtue an appropriate middle between the two defects of too little or too much of something.

The virtue of courage, for example, was the mean between cowardice ( a deficiency) and recklessness ( an excess); generosity was the mean between stinginess ( a deficiency) and prodigality ( an excess); truthfulness was the mean between understatement ( a deficiency) and boastfulness ( an excess).

Aristotle taught that by practicing the doctrine of the Golden Mean human beings could achieve their natural purpose: eudaimonia, a Greek word for happiness

Feminist Ethics of Care

Gilligan contrasts what she puts forth as an ethic of care with the ethic of justice.

Ethic of justice is concerned with what is the just or right act, distribution or share of anything with little regard to the individuals other associations, such as family, community or culture.

Ethic of care takes into account all those points of interconnectedness when determining the best act, distribution and course of treatment.

The Emergence of Feminist Ethics

Much the way medicine was and has been practice for much of human existence as a paternalistic fashion (male oriented in this case) so has ethics. With the recognition of this there was a move to come up with a way of doing ethics that took into account those ideals held in high regard by the other half of the worlds population. One based on the ideals that were held to be uniquely feminine.

Caregiving, interconnectedness, relational to those that are effected beyond the patient in isolation, and with more concern to how our determinations of right and wrong action affect all persons connected to the decision.

Medical Ethics

Basic Principles of Bioethics

Paternalism

Medical paternalism was the way all medicine was practiced until recently. There was no or little thought given to patient choice. Doctors knew best and therefore prescribed a course of action without consulting the patient. Just did what as in the patients’ best interest according to the doctor. This system put the doctor in the position of make decisions for their patients much the way a parent makes decisions for a child.

The Belmont Principle

There was a report written in the 70’s that laid out a manner in which health care needed to move. It was based on four basic principles. They are:

Respect for autonomy

Justice

Beneficence

Non-maleficence

Autonomy

This is a respect for ones ability for self-reference and self-governing. This is the idea that we should be able to and have the ability to make our own decisions without having the will of others imposed upon us.

This is only to be limited in those that are not competent to make their own decisions either based upon age or mental capabilities.

This is thought to safeguard patients treatment choice. SO that they do not have treatments thrust upon them with regard for their preference.

Moral Limits

There are moral limits on our autonomy that go both ways. While the one protects us from being treated when we do not wish to be, the other puts some social constraints on our choices. A person with a contagious disease cannot willfully refuse all treatment thereby putting the general public at risk.

For example it is unlawful to knowing have unprotected relations with another person if you know that you have AIDS or are HIV positive.

Nonmaleficence

Essential this principle states, “Do no harm.”

The principle of nonmaleficence, or non- injury, basically requires of physicians that they not intentionally create a needless harm or injury to the patient by acts of commission or omission. In other words, physicians must not harm patients either by what they do or don’t do.

Thus doctors are liable for actions the do or fail to take in the treatment of their patients.

Beneficence

Do things that are good for the patient. The principle of beneficence enjoins physicians to maximize possible benefits, while minimizing possible harms to patients and the larger society.

At the same time, the principle of beneficence continues to focus attention on the moral importance of physicians’ doing what they believe serves the best interests of patients, which involves more than a calculation of medical risks and benefits or the details of intervention options in a feverish climate of malpractice litigation. Against the rigors of a pressured practice, beneficence still reminds the physician of the original “ call” to medicine—“ the desire to make a difference in people’s lives and the alleviation of pain and suffering.” This includes taking stock of the emotional, social, cultural, and spiritual aspects of the patient, almost in the ancient sense of physician as the doctor of the body and of the soul.

Justice

The correct decision or action is that which takes into account what is the just decision or action.

In addressing justice as a core ethical principle, the Belmont commissioners clearly had in mind what is called distributive justice. Distributive justice concerns the proper allocation or distribution of benefits and burdens in a society.

When people get what they deserve, that’s considered just or fair; when they do not, that’s considered unjust or unfair. Alternatively, justice requires that equals be treated equally. In other words, according to Belmont, in the absence of some allowable distinction— such as one based on “ experience, age, deprivation, competence, merit, or position”— like parties were to be treated alike. As for the respects in which people were to be treated alike or equally, the report named several widely accepted formulations of just ways to distribute burdens and benefits according to some relevant property. Thus:

to each person an equal share;

to each person according to individual need;

to each person according to individual effort;

to each person according to societal contribution; and

to each person according to merit.

Conclusions

By far the principle that gets the most attention and importance in the Belmont Principles is that of autonomy. Without a respect for patient autonomy we will return to a time and place where the paternalistic doctoring practice is commonplace. Where what the doctor feels is best may be in direct conflict with the patients’ wishes.