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MEDICAL ETHICS A Brief Introductory Lecture Ms Shirley Chan / EL Dept / JJC. 2010. ESSAY QUESTIONS Medical science should do what is always good, even though it ... – PowerPoint PPT presentation

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

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?

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

  • 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

  • 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

Where does ethics come from?
  • Philosophers have several answers to this
  • 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
  • Political power

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

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
  • So good things are the things that a sensible
    person realises are good if they spend some time
    pondering the subject

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
  • 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
  • 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

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

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

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

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

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

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

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

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)

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
  • there are a few absolute ethical rules
  • but a lot of ethical rules depend on the culture

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

Key distinctions
  • 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

Key distinctions
  • 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

Key distinctions
  • Morals motivation based on ideas of right and
  • 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

Key distinctions
  • 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

Key distinctions
  • 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)
  • A code of conduct is a set of rules outlining the
    responsibilities of or proper practices for an
    individual or organization

Key distinctions
  • 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?

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

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

Values in medical ethics
  • Autonomy
  • Respect for the individual and his ability to
    make decisions with regard to his own health and
  • 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)

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

  • 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
  • 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?

  • 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
  • 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

  • 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
  • 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?

  • 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
  • Q Where are the limits? Physiological pain
    versus psychological / emotional suffering?

  • 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?

  • 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?

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

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

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

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
  • Q Can someone live without a FACE?

  • 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?

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)

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
  • 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?

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

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?

Values in medical ethics
  • Dignity
  • Innate right to respectful and ethical treatment

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?

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

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

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

More case studies
  • Consider the following moral dilemmas in medical

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?

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.

Case study the bubble boy
  • The moment David was born, he was placed in the
  • 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
  • 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?

  • 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.

  • 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

  • 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
  • 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)
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