Title: MEDICAL ETHICS
1MEDICAL ETHICS
- A Brief Introductory Lecture
- Ms Shirley Chan / EL Dept / JJC. 2010.
2What 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?
3Ethics 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
4However
- 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
5And
- 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
6Where 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
7Where 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
8Where 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
9Where 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
10Where 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
11Where 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
12Where 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
13Where 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
14Are 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
15Are 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
16Are 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
17Are 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)
18Are 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
19Key distinctions
- Whats the difference between ethics, morals,
values, beliefs, principles, code of conduct? - What about RIGHTS?
20Key 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
21Key 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
22Key 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 -
23Key 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
24Key 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
25Key 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?
26Hippocratic Oath
- An oath historically taken by doctors swearing to
practice medicine ethically
27Values in medical ethics
- The common values that apply to medical ethics
discussions are - Autonomy
- Beneficence
- Non-maleficence
- Justice
- Dignity
- Truthfulness and honesty
- Confidentiality
28Values 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)
29Values 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
30CASE 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?
31CASE 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
32CASE 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?
33CASE 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?
34CASE STUDY IRANIAN CONJOINED TWINS
35CASE 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?
36CASE 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?
37Case 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
38Case 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?
39Values 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
40CASE 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?
41CASE 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?
42Values 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)
43Values 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?
44Values 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
45Case 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?
46Values in medical ethics
- Dignity
- Innate right to respectful and ethical treatment
47Case 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?
48Values 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
49Values 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
50Values 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
51More case studies
- Consider the following moral dilemmas in medical
science
52Case 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?
53Case 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.
54Case 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?
55ESSAY 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.
56ESSAY 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.
57ESSAY 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)