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F I F T H E D I T I O N

HEALTH CARE ETHICS PRINCIPLES AND PROBLEMS

Thomas M. Garrett

Harold W. Baillie

John F. McGeehan

Rosellen M. Garrett University of Scranton

Prentice Hall Boston Columbus Indianapolis New York San Francisco

Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto Delhi Mexico City

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Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall. Copyright © 2010 by Pearson Education, Inc.

Library of Congress Cataloging-in-Publication Data Health care ethics : principles and problems/Thomas M. Garrett . . . [et al.].—5th ed.

p. cm. Earlier ed. entered under: Garrett, Thomas M. Includes bibliographical references and index. ISBN-13: 978-0-13-218790-9 ISBN-10: 0-13-218790-6 1. Medical ethics. 2. Medical ethics—Case studies. I. Garrett, Thomas M., 1924- II. Garrett, Thomas M., 1924- Health care ethics 4th ed.

R724.G35 2010 174.2—dc22

2009008663

Publisher: Nancy Roberts Editor in Chief: Dickson Musslewhite Editorial Assistant: Nart Varoqua Editorial Assistant: Patrick M. Walsh Director of Marketing: Brandy Dawson Marketing Manager: Laura Lee Manley Senior Marketing Assistant: Ashley Fallon

Copy Editor: Nancy Wolfe Kotary Production Manager: Fran Russello Cover Art: Getty Images, Inc. Full-Service Project Management: Ravi Bhatt/

Aptara®, Inc. Printer/Binder: RR Donnelley &

Sons Company

This book was set in 10/12 Palatio by Aptara®, Inc.

Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook appear on the appropriate page within text.

Copyright © 2010, 2001, 1998, 1993, and 1989 Pearson Education, Inc., publishing as Prentice Hall, 1 Lake St., Upper Saddle River, NJ 07458. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. To obtain permission(s) to use material from this work, please submit a written request to Pearson Education, Inc., Permissions Department, 1 Lake St., Upper Saddle River, NJ 07458

10 9 8 7 6 5 4 3 2 1 ISBN 10: 0-13-218790-6 ISBN 13: 978-0-13-218790-9

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CONTENTS

Preface to the Fifth Edition vii

Preface ix

Principles of Health Care Ethics Chapter 1 Ethics, Professional Ethics, and

Health Care Ethics 1 Emotions and the Ethical Life 3

Human Nature and Ethics 3

Theories of Ethics 4

Key Issues 10

Applied Ethics 17

The Professions and Professional Ethics 18

The Health Care Professions 23 Summary 29

Chapter 2 Principles of Autonomy and Informed Consent 31 General Formulation 31

Patient Autonomy: Informed Consent 32

Paternalism: Weak and Strong 41

The Consent of Children, Adolescents, and Incompetent Patients 45

Exceptions in Emergencies 47

The Right to Refuse Treatment 51

Problem Areas 52 Summary 53 • Cases for Analysis 53

Chapter 3 Principles of Beneficence and Nonmaleficence 58 Introduction 58

Specifications of Beneficence 60

Specifications of Nonmaleficence 62

The Patient’s Obligation 67

The Health Care Provider’s Obligation 68

The Surrogate’s Obligation 71 Summary 78 • Cases for Analysis 79

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Chapter 4 The Ethics of Distribution 82 Introduction 82

The Goals of Health Care 82

Theories and Their Limits 90

Microallocation: Individual and Institutional Rationing 96

Summary 103 • Cases for Analysis 104

Chapter 5 Principles of Confidentiality and Truthfulness 109 Introduction 109

Truthfulness 110

Confidentiality 115 Summary 128 • Cases for Analysis 128

Problems of Health Care Ethics Chapter 6 Professional Standards and

Institutional Ethics 133 Introduction 133

Judging Quality 134

Institutional Ethics 136

Ethics Committees 141

The Obligation to Police 143

Competition and Institutional Ethics 153 Summary 157 • Cases for Analysis 158

Chapter 7 Ethical Problems of Death and Dying 163 Introduction 163

Ethics of the Patient 163

Health Care Providers and the Ethics of Suicide Prevention 168

Health Care Providers and the Ethics of the Death of a Patient 170

Physician Initiatives 176

Cooperation with Active Suicide and Euthanasia 178

Surrogates and the Termination of Treatment 182

Summary 189 • Cases for Analysis 190

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Chapter 8 Abortion and Maternal Fetal Conflict 194 Introduction 194

Does the Fetus Have Rights? U.S. Law 195

The Definition and Types of Abortion 197

The Moral Status of the Fetus 198

Moral Status: Summary 201

The Autonomy of the Pregnant Woman 202

The Ethics of Abortion as a Social Phenomenon 209

Abortion and the Health Care Provider 211

Maternal Fetal Conflict 215 Summary 219 • Cases for Analysis 219

Chapter 9 New Methods of Reproduction 224 Introduction 224

Artificial Insemination and the General Problems of Assisted Reproduction 225

In Vitro Fertilization 227

Surrogate Mothers 231

The Charge of Artificiality 235

The Ethics of the Health Care Provider 237

A Question of Distributive Justice 239 Summary 240 • Cases for Analysis 240

Chapter 10 The Ethics of Transplants 245 Introduction 245

The Ethics of Organ Donation from the Patient’s Perspective 246

Basic Questions Regarding the Idea of Transplants 249

The Ethics of Cadaver Organ Donation 252

Increasing the Supply of Organs: Ethical Problems 254

The Ethics of the Health Care Team 256

The Health Care Provider’s Ethics of Distribution 259

The Society’s Ethics of Distribution 263 Summary 267 • Cases for Analysis 267

Chapter 11 The Ethics of Testing and Screening 271 Introduction 271

Testing 272

Ethical Problems of Mass Screening 281 Summary 288 • Cases for Analysis 289

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Chapter 12 The Ethics of Biomedical Research 292 Introduction 292

The Ethics of the Researcher 293

The Ethics of the User of Research Results 305

Fetal Research 309

Genetic Therapy 313

Cloning 317 Summary 319 • Cases for Analysis 319

References 325

Index 340

vi Contents

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PREFACE TO THE FIFTH EDITION

Medical Ethics was not a course offered in my college, or in most colleges, in the early 1970s. Throughout my four years of medical school and three years of residency in the University of Pennsylvania health system, I cannot recall time devoted to lectures on ethics. I am sure that mentoring in those years has formed much of the professional I am now, but it was the opinion of those whom I respected that guided much of what I did. That time was filled with the promise of cure, early discovery, and amazing technical ad- vances. The medical world was one of excitement and optimism. We kept patients on ventilators and tube feedings believing that we could save them if we had a little more time. Medicine was our life. We talked about cases constantly, and even social events inevitably led to sharing tales of medical discovery and challenge. I entered into private practice in 1980 to partici- pate in a newly developed primary care residency program so that I could share what I had learned and instill in others the love for medicine that had been given to me.

Reality came slow and hard. Physicians soon came to realize that we did not have all the answers. Patients began to assert their desire not to be kept alive artificially when hope was really not in sight. The cost of medi- cine was skyrocketing, and for the first time a provider had to enter that into the equation of treatment. The magic of the doctor-patient relationship that can only be learned over time and experience was now added to the fulfillment of medicine. My patients became another family. I shared in their lives, celebrated times of successful treatment, and experienced those moments of sorrow that reality brings. I love being a physician.

Youth and a respectable education can create a dangerous self-confidence. It was at this time in my life when I met and became a friend of a patient, Dr. Hal Baillie. To those who preach that physicians should not treat friends, I would like to say that treating all patients as you would a friend can make your life full, and I suspect would result in a return in the trust that patients once had in us and a support for health care in general. Hal mentioned to me that he and Drs. Tom and Rosellen Garrett, all professors at the Univer- sity of Scranton (and all patients at the time) were writing a textbook on medical ethics.

Friends can and should be honest with each other. Hal and I were friends. We had a long, honest discussion. I made it clear that I thought it was ridiculous for philosophers to think they could write about medical ethics without knowing what it is like to care for patients in various situa- tions. Hal made it clear to me that he thought I was naïve to think I knew about ethics just because I had a medical degree. We were young, confident, and steadfast, and the result was that the friendship came to an end and we did not speak for a long time.

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Before the first edition of Health Care Ethics went to the publisher, I was asked to read it. That was a day that affected the rest of my career. Hal was right: I did not know how powerful a sound basis in ethics as applied to medicine could be. We spoke again, much to his dismay, and have been best friends since that day over 20 years ago. I have had the pleasure of offering comments, cases, and suggestions, and we have worked together on ethics committees and lectures.

When he asked if I would be willing to coauthor the fifth edition of Health Care Ethics, I was surprised by my sudden affirmative reply and the excitement surrounding the opportunity. Over my 30 years as a physician, I have realized that by combining experience, moral values, respect, and a constant desire to learn, the hours and challenges of health care become more gift than burden. I thank my family for making sure that I am more than a doctor, my patients for their friendship and all they have taught me, the profession of medicine for not becoming a job, and for the opportunity to apply practical wisdom in all aspects of my life though the foundation pro- vided by Dr. Baillie (and yes, we are still friends after this book).

John F. McGeehan, M.D.

viii Preface to the Fifth Edition

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PREFACE

The 20 years this book has been in print have seen many changes in health care ethics and similar changes in the lives of the authors. Tom Garrett has passed away, and Rosellen Garrett has retired. When Prentice Hall asked that I do another edition, my own circumstances had changed considerably as well. Clearly, it was necessary that I add another author if I was to ever complete a revision. I am deeply appreciative of the enthusiasm and per- spective John McGeehan has brought to the task. He is right; we remain friends. But as important (at least for the book) is that we remain caught up in the debate about the nature of health care and health care ethics.

Health care ethics has evolved considerably in the last few decades, and it continues to do so. That evolution creates a dilemma for the revision of a textbook. The original conception was to direct this work at an educated audience, who were not necessarily (or perhaps not yet) professionals but wanted a solid, comprehensive introduction to the subject. Tom, Rosellen, and I had in mind college juniors as we wrote. In writing this edition, John and I have kept that same audience in mind. Although professional health care ethicists have somewhat moved on from the basic concerns of establish- ing the foundation for informed consent or the right to refuse treatment, the new student starts much where students of health care have always started. Thus, John and I decided that there would be limits on how dramatic the al- terations of the original book would be. Much has been updated, but much has remained fundamentally the same. Discussion of principles has been en- larged, but remain basically the same. The later chapters on problems have received a fair amount of revision and updating.

We would like to thank Nancy Kotary for copyediting that caught errors 20 years old as well as in our more recent contributions. We would also like to thank our wives for tolerating our often meandering collabora- tion, and Tom and Rosellen Garrett for getting the whole enterprise started those many years ago.

Harold W. Baillie

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