MEDICAL ETHICS

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MEDICAL ETHICS

• A Brief Introductory Lecture
• Ms Shirley Chan / EL Dept / JJC. 2010.

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What is ethics?

• Ethics is a system of moral principles
• They affect how people make decisions and lead
  their lives
• Ethics is concerned with what is good for
  individuals and society
• Ethics covers the following dilemmas
• how to live a good life
• our rights and responsibilities
• moral decisions - what is good and bad?

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Ethics is used to

• Provide a moral map
• Most moral issues get us pretty worked up - think
  of abortion and euthanasia hence, we use our
  hearts rather than our minds to argue
• Philosophers can come in to offer us ethical
  rules and principles that enable us to take a
  cooler view of moral problems
• Ethics provides us with a moral map, a framework
  that we can use to find our way through difficult
  issues

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However

• Ethics doesn't give the right answers
• For many ethical issues, there isn't a single
  right answer - just a set of principles that can
  be applied to particular cases to give those
  involved some clear choices
• Some philosophers go further and say that all
  ethics can do is eliminate confusion and clarify
  the issues. After that it's up to each individual
  to come to their own conclusions

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And

• Ethics can give several answers
• Many people want there to be a single right
  answer to ethical questions.
• There may be several right answers, or just some
  least worst answers - and the individual must
  choose between them
• We have to take responsibility for their own
  choices and actions, rather than falling back on
  convenient rules and customs

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Where does ethics come from?

• Philosophers have several answers to this
  question
• God and religion
• Human conscience and intuition
• A rational moral cost-benefit analysis of actions
  and their effects
• The example of good human beings
• A desire for the best for people in each unique
  situation
• Political power

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Where does ethics come from?

• God-based ethics - supernaturalism
• Supernaturalism makes ethics inseparable from
  religion.
• It teaches that the only source of moral rules is
  God
• So, something is good because God says it is, and
  the way to lead a good life is to do what God
  wants

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Where does ethics come from?

• Intuitionism
• Intuitionists think that good and bad are real
  objective properties that can't be broken down
  into component parts
• Something is good because it's good its goodness
  doesn't need justifying or proving
• They believe human beings have an intuitive moral
  sense that enables them to detect real moral
  truths
• So good things are the things that a sensible
  person realises are good if they spend some time
  pondering the subject

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Where does ethics come from?

• Consequentialism
• It bases morality on the consequences of human
  actions and not on the actions themselves
• Consequentialism teaches that people should do
  whatever produces the greatest amount of good
  consequences
• One famous way of putting this is 'the greatest
  good for the greatest number of people'
• The most common forms of consequentialism are the
  various versions of utilitarianism, which favour
  actions that produce the greatest amount of
  happiness
• Despite its obvious common-sense appeal,
  consequentialism turns out to be a complicated
  theory, and doesn't provide a complete solution
  to all ethical problems
• Two problems with consequentialism are
• it can lead to the conclusion that some quite
  dreadful acts are good
• predicting and evaluating the consequences of
  actions is often very difficult

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Where does ethics come from?

• Non-consequentialism or deontological ethics
• Non-consequentialism is concerned with the
  actions themselves and not with the consequences.
  It's the theory that people are using when they
  refer to "the principle of the thing"
• It teaches that some acts are right or wrong in
  themselves, whatever the consequences, and people
  should act accordingly

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Where does ethics come from?

• Virtue ethics
• Virtue ethics looks at virtue or moral character
• Virtue ethics is particularly concerned with the
  way individuals live their lives, and less
  concerned in assessing particular actions
• Virtue ethics teaches that an action is right if
  and only if it is an action that a virtuous
  person would do in the same circumstances, and
  that a virtuous person is someone who has a
  particularly good character

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Where does ethics come from?

• Situation ethics
• Situation ethics rejects prescriptive rules and
  argues that individual ethical decisions should
  be made according to the unique situation
• Rather than following rules the decision maker
  should follow a desire to seek the best for the
  people involved
• There are no moral rules or rights - each case is
  unique and deserves a unique solution

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Where does ethics come from?

• Ethics and ideology
• Some philosophers teach that ethics is the
  codification of political ideology, and that the
  function of ethics is to state, enforce and
  preserve particular political beliefs
• They usually go on to say that ethics is used by
  the dominant political elite as a tool to control
  everyone else

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Are there universal moral rules?

• Moral Absolutism
• The belief that there are such universal rules
  that apply to everyone
• There are some moral rules that are always true,
  that these rules can be discovered and that these
  rules apply to everyone
• Immoral acts - acts that break these moral rules
  - are wrong in themselves, regardless of the
  circumstances or the consequences of those acts
• Absolutism takes a universal view of humanity -
  there is one set of rules for everyone - which
  enables the drafting of universal rules - such as
  the Declaration of Human Rights
• Religious views of ethics tend to be absolutist

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Are there universal moral rules?

• Moral Absolutism
• Why people disagree
• Many of us feel that the consequences of an act
  or the circumstances surrounding it are relevant
  to whether that act is good or bad
• Absolutism doesn't fit with respect for diversity
  and tradition of unique societies and countries,
  or religions and ethnic groups

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Are there universal moral rules?

• Moral Relativism
• Moral relativists say that if you look at
  different cultures or different periods in
  history you'll find that they have different
  moral rules
• Therefore it makes sense to say that "good"
  refers to the things that a particular group of
  people approve of
• They believe that relativism respects the
  diversity of human societies and responds to the
  different circumstances surrounding human acts

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Are there universal moral rules?

• Moral Relativism
• Why people disagree
• Many of us feel that moral rules have more to
  them than the general agreement of a group of
  people - that morality is more than a
  super-charged form of etiquette (E.g. the
  Universal Declaration of Human Rights make sense
  not just because many people agree to it. It is
  an intrinsic respect for the sanctity of life)

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Are there universal moral rules?

• Moral Somewhere-in-between-ism
• Most non-philosophers think that both of the
  above theories have some good points and think
  that
• there are a few absolute ethical rules
• but a lot of ethical rules depend on the culture

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Key distinctions

• Whats the difference between ethics, morals,
  values, beliefs, principles, code of conduct?
• What about RIGHTS?

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Key distinctions

• BELIEFS
• Beliefs convictions that we generally hold to be
  true, usually without actual proof or evidence
• Assumptions that we make about the world and our
  values stem from those beliefs
• Religious beliefs include a belief that God
  created the earth in seven days, or that Jesus
  was the son of God
• Non religious beliefs include that all people
  are created equal, which would guide us to treat
  everyone regardless of sex, race, religion, age,
  education, status etc with equal respect
• Our beliefs grow from what we see, hear,
  experience, read and think about. From these
  things we develop an opinion that we hold to be
  true and unmovable at that time
• From our beliefs we derive our values, which can
  either be correct or incorrect when compared with
  evidence, but nonetheless hold true for us

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Key distinctions

• VALUES
• Values beliefs of a person or social group in
  which they have an emotional investment (either
  for or against something) "he has very
  conservatives values"
• Values are about the worth an individual gives to
  a person, article or idea
• Values include courage, respect, patriotism,
  honesty, honour, compassion etc
• E.g. We value family piety in our society, as we
  believe that the elderly are core to the
  foundations of our society.
• Beliefs and values determine our attitudes and
  opinions

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Key distinctions

• MORALS
• Morals motivation based on ideas of right and
  wrong
• Morals are concerned with the judgement of
  goodness or badness of human action
• Both morals and values are a part of the
  behavioural aspect of a person

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Key distinctions

• ETHICS
• Ethics A theory or a system of moral values /
  The rules or standards governing the conduct of a
  person or the members of a profession
• Ethics define the code that a society or group of
  people adhere to

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Key distinctions

• PRINCIPLES
• Principles are general rules and guidelines,
  intended to be enduring and seldom amended, that
  inform and support the way in which an
  organization / profession sets about fulfilling
  its mission (method used etc)
• CODE OF CONDUCT
• A code of conduct is a set of rules outlining the
  responsibilities of or proper practices for an
  individual or organization

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Key distinctions

• RIGHTS
• Rights are explained as legal, social, or moral
  freedoms to act or refrain from acting, or
  entitlements to be acted upon or not acted upon
• Link between RIGHTS and ETHICS
• Our rights (which different societies may / may
  not recognise) are determined by our ethical
  system (which determines what is right or wrong)
  informed by our values, morals and beliefs
• Q Is there such a thing as a universal right? Is
  it ABSOLUTE?

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Hippocratic Oath

• An oath historically taken by doctors swearing to
  practice medicine ethically

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Values in medical ethics

• The common values that apply to medical ethics
  discussions are
• Autonomy
• Beneficence
• Non-maleficence
• Justice
• Dignity
• Truthfulness and honesty
• Confidentiality

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Values in medical ethics

• Autonomy
• Respect for the individual and his ability to
  make decisions with regard to his own health and
  future
• Actions that enhance autonomy are thought of as
  desirable and actions that 'dwarf' an individual
  and their autonomy are undesirable
• Respect for autonomy is the basis for informed
  consent and advance directives (living will)

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Values in medical ethics

• Autonomy
• Psychiatrists are often asked to evaluate a
  patient's competency for making life-and-death
  decisions at the end of life
• Persons with a psychiatric condition such as
  delirium or clinical depression do not have the
  capacity to make end-of-life decisions.
  Therefore, for these persons, a request to refuse
  treatment should be ignored
• Unless there is a clear advance directive to the
  contrary, persons who lack mental capacity should
  be treated according to their best interests
• On the other hand, persons who have the mental
  capacity to make end-of-life decisions have the
  right to refuse treatment and choose an early
  death if that is what they truly want. In such
  cases, psychiatrists should be a part of
  protecting that right

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CASE STUDY EUTHANASIA

• Euthanasia is the practice of terminating the
  life of a person or an animal because they are
  perceived as living an intolerable life, in a
  painless or minimally painful way either by
  lethal injection, drug overdose, or by the
  withdrawal of life support
• Euthanasia is also known as mercy killing.
• In Singapore, the signing of the Advance Medical
  Directive (AMD), allows doctors to put an end to
  a patients sufferings under specific conditions
  only
• Medical experts cannot and should not defy the
  wishes of a dying person, because if this is so,
  he/she will be deemed as lacking in human
  compassion and empathy, a treasured quality which
  is implicit in all areas of science
• Q What determines quality of life? How much
  suffering is truly unbearable?

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CASE STUDY EUTHANASIA

• Dignitas is a Swiss assisted dying group that
  helps those with terminal illness and severe
  physical and mental illnesses to die assisted by
  qualified doctors and nurses
• Additionally, they provide euthanasia for people
  with incurable mental illnesses provided that
  they are of sound judgment and submit to an
  in-depth medical report prepared by a
  psychiatrist that establishes the patient's
  condition as fulfilling the specifications of the
  Swiss courts
• Swiss laws on assisted suicide clearly state that
  people who assist in an assisted suicide can only
  be prosecuted if they are motivated by
  self-interest
• Approximately 7,000 is charged for an assisted
  suicide and funeral
• 21 of people receiving assisted dying in
  Dignitas do not have a terminal or progressive
  illness, but rather "weariness of life
• Several countries (such as Netherlands and
  Belgium) allow assisted suicide, but only
  Switzerland allows foreigners leading to the
  coining of the term suicide tourism
• EXIT is another Swiss organization providing
  assisted suicide. In 2008, it had 50,000 members.
  However, EXIT strictly denies suicide assistance
  for people from abroad

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CASE STUDY EUTHANASIA

• Chantal Sébire
• In 2000, she was diagnosed with a rare form of
  cancer which left her face severely disfigured.
  She also lost her senses of sight, taste, and
  smell and suffered severe pain 
• In 2008 she made a public appeal to the French
  president, Nicolas Sarkozy, to allow her to die
  through euthanasia, stating that "One would not
  allow an animal to go through what I have
  endured.
• This was rejected, as the French courts allow
  only for removal of life-support equipment for
  terminally ill patients, it does not allow a
  doctor to take action to end a patient's life
• One month later, she died in her home, from a
  drug used commonly around the world for assisted
  suicide, though not found in France
• Q What is the difference between ACTIVE and
  PASSIVE involvement of the doctor in assisted
  suicide? Does it make a difference?

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CASE STUDY EUTHANASIA

• Assisted suicide for HEALTHY people?
• Case 1 In July 2009, British music conductor Sir
  Edward Downes and his wife Joan died together at
  a suicide clinic outside Zürich "under
  circumstances of their own choosing." Sir Edward
  was not terminally ill (though he had near
  deafness and blindness), but his wife was
  diagnosed with rapidly developing cancer
• Case 2 Betty and George Coumbias were a Canadian
  married couple who sought to become the first
  husband and wife to complete simultaneous suicides
   with legal authorization. Although assisted
  suicide is illegal in Canada, they hoped to end
  their lives with the approval of the government
  of Switzerland
• The couple's request was unusual in that, while
  George Coumbias suffers from heart disease, Betty
  Coumbias was reported to be in excellent health
• This was ultimately rejected by the Swiss courts
• Q Can a claim of inability to live with the
  death of a loved one be a valid reason for
  euthanasia?
• Q Where are the limits? Physiological pain
  versus psychological / emotional suffering?

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CASE STUDY IRANIAN CONJOINED TWINS
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CASE STUDY IRANIAN CONJOINED TWINS

• The adult twins came to Singapore in July 2003
  for a highly controversial operation to separate
  them into two individuals but they died on the
  operating table
• The twins read up widely on the risks of the
  surgery and decided to take a chance even though
  they knew of the possibility of a high failure
  rate. Also, they were the ones who wanted to have
  the operation carried out on them, not the
  doctors. They knew there is always a risk
  involved in all operations, including simpler
  ones like Lasik
• Q Because of the high risk involved, should
  doctors have agreed to this operation?
• Q How important are the rights of the twins to a
  meaningful life?

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CASE STUDY OTHER CONJOINED TWINS

• The Siamese twins from Iraq were separated
  recently in early July 2010. One of the twins had
  an abnormal growth and was endangering the other.
  Their father agreed to take the risk even though
  the mentioned twin had a poor chance of survival
  upon separation.

• Well known case of conjoined twins
• Jodie and Mary the twins were born in 2000 in
  UK. Mary was totally dependent on Jodie for
  survival. Medical reports showed that Jodie was
  mentally alert, but not Mary. Mary was sapping
  Jodies strength. Jodie would soon die.
• Their parents refused to separate the two, for
  religious reasons. The doctors / hospital brought
  this to the courts.
• The courts decreed to go ahead with the
  operation. Mary died immediately. Jodie survived,
  but required extensive operations and surgeries.
  She is now a normal child.
• Q Can parents make decisions for their children?
• Q Should 1 child be sacrificed for another?
• Q Can courts interfere in family affairs?

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Case study Ashley X Pillow Angel

• Ashley X was born in 1997 (United States) with
  severe and permanent brain damage
• Her parents argue that keeping her "frozen" as a
  girl rather than letting her go through puberty
  and growing into a woman will give her a better
  life

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Case study Ashley X Pillow Angel

• When she was 9, they authorised doctors to remove
  her uterus to prevent menstruation, to limit her
  breast growth through the removal of breast buds
  so that she would not experience discomfort when
  lying down, and give her doses of hormones to
  stop her growing taller
• The parents argue this would ease them in looking
  after Ashley, and she would have less discomforts
  from puberty
• Opponents have accused Ashley's parents of
  "Frankenstein-esque" behaviour - of maiming the
  child for the sake of convenience
• After a year of surgery, Ashley reached her adult
  height of 53 inches and weight of 63 pounds, an
  estimated reduction of her potential height and
  weight of 20 and 40, respectively
• Q Whose rights are more important? The patient
  or the caregivers?
• Q Who can protect the right of the disabled
  child?

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Values in medical ethics

• Beneficence
• Actions intended to benefit the patient or others
• Some argue that beneficence is the only fundamenta
  l principle of medical ethics
• They argue that healing should be the sole
  purpose of medicine, and that endeavours
  like cosmetic surgery, contraception and euthanasi
  a fall beyond its purview

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CASE STUDY Isabelle Dinoire

• Dr Bernard Devauchelle, the French doctor who
  performed the worlds first face-transplant was
  accused of self-glorification and fame-seeking
• The doctor was merely doing his best to serve a
  patients need (in the case of the French woman,
  Isabelle Dinoire, who underwent the
  face-transplant, she had been mauled by her dog
  and lost her nose, lips and chin), knowing that
  such needs stems from the basic desire of human
  beings to look their best. In doing so, he
  contributed to the knowledge of medical
  transplant surgeries worldwide too.
• It takes time for medical science to be fully
  developed and mature and carrying out the face
  transplant before such techniques were recognised
  by the medical community. This reflects a
  disregard for the rest of the researchers as well
  as to the nature of science for methods to be
  tested and proven
• Q Should doctors take risks? Should the RIGHTS
  of the patient matter, or is it outweighed by the
  potential harm if the operation did not take
  place?
• Q Can someone live without a FACE?

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CASE STUDY Baby Fae

• Baby Fae was born premature on October 14 1984 in
  California with a fatal heart condition
• Her mother requested aid from Dr. Leonard Bailey,
  a heart surgeon
• On October 26, Bailey successfully transplanted a
  baboon heart into Fae, an astonishing medical and
  scientific achievement. The baby was in good
  health for two weeks, when her organs began to
  falter. She ultimately dies of kidney failure
• The surgery was widely condemned on moral
  grounds, from the Vatican to People for the
  Ethical Treatment of Animals (PETA)
• Baby Fae would be the first and last human to
  receive a cross-species heart transplant
• her surgery taught doctors around the world an
  incredible amount about organ transplantation
• Dr. Bailey and his team have performed more than
  500 organ transplants in very young children,
  saving their lives and the lives of countless
  others through what they learned from Baby Fae
• Q Should surgeons embark on potentially
  threatening procedures to save their patient?

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Values in medical ethics

• Non-maleficence
• Actions intended not to harm or bring harm to the
  patient and others
• The concept of non-maleficence is embodied by the
  phrase first, do no harm
• In practice, many treatments carry some risk of
  harm. In some circumstances, risky treatments
  that stand a high chance of harming the patient
  will be justified, as the risk of not treating is
  also very likely to do harm
• The principle of non-maleficence is not absolute,
  and must be balanced against the principle
  of beneficence (doing good)

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Values in medical ethics

• Non-maleficence
• Doctrine of double effect
• This doctrine says that if doing something
  morally good has a morally bad side-effect, it's
  ethically OK to do it providing the bad
  side-effect wasn't intended. This is true even if
  you foresaw that the bad effect would probably
  happen
• A commonly cited example of this phenomenon is
  the use of morphine in the dying patient, where
  use can ease the pain and suffering of the
  patient, yet simultaneously hastening the demise
  of the patient through suppression of the
  respiratory system
• Q Think about the issue of the conjoined twins
  where 1 twin may die as a result of a good to
  be accomplished. Is this ethically acceptable?

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Values in medical ethics

• Justice
• Distribution of scarce health resources, and the
  decision of who gets what treatment (fairness and
  equality)
• Actions are consistent, accountable and
  transparent
• not to discriminate on age, sex, religion, race,
  position or rank
• greater good of society
• respect of the Law

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Case study pricing drugs

• Pharmaceutical companies have a duty to uphold an
  ethical relationship within the marketplace.
• There is a duty of care to the health and safety
  of all.
• Issues are raised that as pharmaceutical
  companies have a large investment to protect and
  stakeholders to please - how do we ensure that an
  ethical standard is upheld.
• Despite the pharmaceutical industry's notable
  contributions to human progress, including the
  development of miracle drugs for treating cancer,
  AIDS, and heart disease, there is a growing
  tension between the industry and the public.
• Government officials and social critics have
  questioned whether the multibillion-dollar
  industry is fulfilling its social
  responsibilities. This doubt has been fueled by
  the national debate over drug pricing and
  affordable healthcare, and internationally by the
  battles against epidemic diseases, such as AIDS,
  in the developing world.
• Q Should such firms offer affordable prices for
  their medication? What implications will this
  have on innovation and research?

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Values in medical ethics

• Dignity
• Innate right to respectful and ethical treatment

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Case study conducting drug research in india

• Transnational drug companies are moving their
  clinical trials business to India, giving a new
  urgency to clinical trials registry reform there
• Drug companies are drawn to India for several
  reasons, including a technically competent
  workforce, patient availability, low costs and a
  friendly drug-control system.
• While good news for Indias economy, the booming
  clinical trial industry is raising concerns
  because of a lack of regulation of private trials
  and the uneven application of requirements for
  informed consent and proper ethics review
• Q Should we allow for dubious clinical trials,
  if the world at large benefits?

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Values in medical ethics

• Truthfulness and honesty
• Obligation to full and honest disclosure
• Informed consent
• A person must be fully-informed about and
  understand the potential benefits and risks of
  their choice of treatment
• An uninformed person is at risk of mistakenly
  making a choice not reflective of his or her
  values or wishes
• If the patient is incapacitated (bedridden,
  crippled etc) , laws around the world designate
  different processes for obtaining informed
  consent, typically by having a person appointed
  by the patient or their next of kin make
  decisions for them
• The value of informed consent is closely related
  to the values of autonomy and truth telling

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Values in medical ethics

• Confidentiality
• Based on loyalty and trust
• Maintain the confidentiality of all personal,
  medical and treatment information
• Information to be revealed with consent and for
  the benefit of the patient, except when ethically
  and legally required
• Disclosure should not be beyond what is required

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Values in medical ethics

• Confidentiality
• Confidentiality is challenged in cases involving
  the diagnosis of a sexually transmitted disease
  in a patient who refuses to reveal the diagnosis
  to a spouse and
• In the termination of a pregnancy in an underage
  patient, without the knowledge of the patient's
  parents

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More case studies

• Consider the following moral dilemmas in medical
  science

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Case study embryonic stem cell tests

• The stem cell controversy is the ethical debate
  centered only on research involving the creation,
  usage and destruction of human embryos. Most
  commonly, this controversy focuses on embryonic
  stem cells.
• Stem cell debates have motivated and
  reinvigorated the pro-life movement, whose
  members are concerned with the rights and status
  of the embryo as an early-aged human life. They
  believe that embryonic stem cell research
  instrumentalizes and violates the sanctity of
  life and is tantamount to murder. The fundamental
  assertion of those who oppose embryonic stem cell
  research is the belief that human life
  is inviolable, combined with the fact that human
  life begins when a sperm cell fertilizes an egg
  cell to form a single cell. 
• Medical researchers widely submit that stem cell
  research has the potential to dramatically alter
  approaches to understanding and treating
  diseases, and to alleviate suffering.
• In the future, most medical researchers
  anticipate being able to use technologies derived
  from stem cell research to treat a variety of
  diseases and impairments such as spinal cord
  injuries and Parkinson's disease
• Q When does life start? Should the minority be
  sacrificed for the greater good?

53
Case study the bubble boy

• David Phillip Vetter (born 1971 in the United
  States) was a boy who suffered from a rare
  genetic disease. Forced to live in a sterile
  environment, he became popular with the media
  as the boy in the plastic bubble.
• His parents were told by doctors that any son
  they have would have zero immunity. They were
  then told by doctors that if they have another
  child, they would place it in a sterile
  environment while working on the solution.

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Case study the bubble boy

• The moment David was born, he was placed in the
  incubator
• Water, air, food, diapers, clothes, all were
  disinfected with special cleaning agents before
  entering his cocoon.
• As David's doctors searched for a cure for his
  genetic condition, he became a research subject
  as well as a patient, giving researchers an
  unprecedented opportunity to learn about the
  disease. 
• By 1984, there was no found cure for Davids
  disease. His parents then decided to let him
  undergo a bone marrow transplant from his sister.
  He died a few months later.
• Q Was it right for the doctors to persuade
  Davids parents to conceive a child to further
  their research? Is the greater good of the
  society worth it?

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ESSAY QUESTIONS

• Medical science should do what is always good,
  even though it might not be always right. How
  true is this statement?
• Should ethical concerns be second to pragmatism
  in Science?
• The need for ethical standards among scientists
  is greater today. Comment.

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ESSAY QUESTIONS

• NOTE
• Medical ethics are slightly different from those
  of other professions, such as media and politics.
  
• However, as these are all institutions of the
  same society, the overarching beliefs and moral
  values that construct the ethical system are the
  same. Slight variances of the ethics and
  accompanying principles and code of conduct will
  be specific to the role and responsibility of the
  profession.

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ESSAY QUESTIONS

• E.g.
• Journalistic ethic of Confidentiality is similar
  to that of the medical field.
• The confidentiality of the sources of news is
  considered sacred, and rarely overturned by the
  courts in more liberal countries. This upholds
  the credibility of the journalist to his
  informants.
• Journalistic ethic of Objectivity To be fair and
  unbiased in the reporting of the news (this is
  something not emphasised in the medical fields,
  where the needs and rights of one individual, the
  patient, is of utmost consideration)