BEGINNING BIOETHICS

Introduction
•It is perhaps no accident that the medical
profession was the first profession in
history to provide itself with a code of
ethics
 Introduction …..
•New technologies produce new ethical
problems
•These technologies raise disturbing
questions about what we ought to do-they
raise ethical questions about the limits and
purposes of the practice of medicine
 Three Main Ethical Principles

Beneficence Respect for Justice

Autonomy
The principle that The principle that The principle that
one should attempt one should attempt one should treat like
to do good; that one to give due weight cases alike:
should attempt to to the goals, Differences in
benefits others preferences, and treatment must be
interests of others justified by appeal
to relevant
differences between
cases
 Beneficence
•Comes from the Latin for “doing good”
•Is an ethical principle
•The aim to “do good” is often considered
an essential part of any ethical perspective
that hopes to suggest acceptable solutions to
ethical dilemmas, of whatever kind
•Without the desire to do good, health care
would not exist
 Respect for Autonomy
•“Autonomy” comes from the Greek
words meaning “self-governance”,
meaning the capacity to select your own
fate, to rule yourself, to choose what you
do and what is done to you
 Respect for Autonomy…..
•Conflicts between beneficence and respect
for autonomy
•For the moment we can sketch out two
broad approaches to such conflict. These
might be labeled paternalism and
libertarianism
 Paternalism
•A ‘paternalist” position is one that tends to
give precedence to the demands of
beneficence over those of respect for
autonomy.
•The paternalist believes that it is more
important to do people good than it is to deal
with them as they wish to be dealt with.
 Paternalism…..
•Typical paternalist sentiments are captured in
remarks such as:
–“Doctor knows best”; or
–“I know what’s good for you better than you
know yourself”; or
–“Believe me, I have your best interests at heart”;
or
–“You need to be saved from yourself”
 Libertarianism
•A “libertarian” position is one that prefers
to respect autonomy at the cost of
beneficence whenever the two come into
conflict.
•The libertarian thinks that it is more
important to allow people to do as they
wish than it is to do them good.
 Libertarianism…..
•Typical libertarian sentiments are captured
in remarks such as:
–“To each his own”; or
–“Let them go to hell as they choose”; or
–“You’re mad, but I’m not going to stand in
your way”; or
–“It’s your funeral”
 Justice
•The principles of justice, by contrast,
invites us to survey our ethical behavior in a
broader context.
•It invites us to ask if our behavior is
consistent; to ask if we are behaving in an
even-handed way; to ask if we are treating
people fairly.
 Informed Consent
 What is informed consent?
 What are the elements of full informed consent?
 How much information is considered "adequate"?
 What sorts of interventions require informed consent?
 When is it appropriate to question a patient's ability to
participate in decision making?
 What about the patient whose decision making capacity
varies from day to day?
 What should occur if the patient cannot give informed
consent?
 Is there such a thing as presumed/implied consent?
 What is informed
consent?
Informed consent is the process by which
a fully informed patient can participate in
choices about her health care. It
originates from the legal and ethical right
the patient has to direct what happens to
her body and from the ethical duty of
the physician to involve the patient in her
health care.
 What are the elements of full
informed consent?
It is generally accepted that complete informed consent
includes a discussion of the following elements:
 the nature of the decision/procedure
 reasonable alternatives to the proposed intervention
 the relevant risks, benefits, and uncertainties related to
each alternative
 assessment of patient understanding
 the acceptance of the intervention by the patient
Consequently, the discussion should be carried on in
layperson's terms and the patient's understanding should be
assessed along the way.
 How much information is
considered "adequate"?

o reasonable patient standard

o reasonable physician standard
o subjective standard
 Reasonable Patient Standard

o reasonable patient standard: what would the average

patient need to know in order to be an informed participant
in the decision? This standard focuses on considering
what a patient would need to know in order to
understand the decision at hand.
 Reasonable Physician Standard

o reasonable physician standard: what would a typical

physician say about this intervention? This standard
allows the physician to determine what information is
appropriate to disclose. Typical physician tells the
patient very little. Generally considered inconsistent with
the goals of informed consent as the focus is on the
physician
 Subjective Standard

o subjective standard: what would this patient need to know

and understand in order to make an informed decision?
This standard is the most challenging to incorporate into
practice, since it requires tailoring information to each
patient.
What sorts of interventions
require informed consent?

For a wide range of decisions, written

consent is neither required or needed, but
some meaningful discussion is needed
When is it appropriate to question a patient's
ability to participate in decision making?

Patients are under an unusual amount of stress

during illness and can experience anxiety, fear, and
depression. Precautions should be taken to ensure the
patient does have the capacity to make good
decisions. There are several different standards of
decision making capacity.

Understand his or her situation,

 understand the risks associated with the decision at hand, and
 communicate a decision based on that understanding.
 What about the patient whose decision
making capacity varies from day to day?

Patients can move in and out of a coherent

state as their medications or underlying
disease processes ebb and flow. You should
do what you can to catch a patient in a lucid
state - even lightening up on the medications
if necessary - in order to include him in the
decision making process.
What should occur if the patient cannot give informed
consent?

If the patient is determined to be

incapacitated/incompetent to make health care
decisions, a surrogate decision maker must speak for
her. If no appropriate surrogate decision maker is
available, the physicians are expected to act in the
best interest of the patient until a surrogate is found
or appointed.
 Is there such a thing as
presumed/implied consent ?

The patient's consent should only be "presumed", rather than

obtained, in emergency situations when the patient is
unconscious or incompetent and no surrogate decision maker
is available. The patient's presence in the hospital ward, ICU
or clinic does not represent implied consent to all treatment
and procedures. While the principle of respect for person
obligates you to do your best to include the patient in the
health care decisions that affect his life and body, the
principle of beneficence may require you to act on the
patient's behalf when his life is at stake.
 Truth-telling and Withholding
Information

 Do patients want to know the truth about their condition?

 How much do patients need to be told?
 What if the truth could be harmful?
 What if the patient's family asks me to withhold the truth from the
patient?
 When is it justified for me to withhold the truth from a patient?
 What about patients with different specific religious or cultural
beliefs?
 Is it justifiable to deceive a patient with a placebo?
 Truth-telling and Withholding
Information

When physicians communicate with patients, being

honest is an important way to foster trust and show
respect for the patient.
Yet there are situations in which the truth can be
disclosed in too brutal a fashion, or may have a terrible
impact on the occasional patient.
 Do patients want to know the truth
about their condition?

A number of studies have demonstrated that patients do

want their physicians to tell them the truth about diagnosis,
prognosis, and therapy. Similarly, a number of studies of
physician attitudes reveal support for truthful disclosure. For
example, whereas in 1961 only 10% of physicians surveyed
believed it was correct to tell a patient of a fatal cancer
diagnosis, by 1979 97% felt that such disclosure was correct.
How much do patients need to be
told?

In addition to fostering trust and demonstrating

respect, giving patients truthful information helps
them to become informed participants in important
health care decision. Complete and truthful
disclosure need not be brutal; appropriate sensitivity
to the patient's ability to digest complicated or bad
news is important.
 What if the truth could be
harmful?

There are many physicians who worry about the

harmful effects of disclosing too much information
to patients. If the physician has some compelling
reason to think that disclosure would create a real
and predictable harmful effect on the patient, it may
be justified to withhold truthful information.
 What if the patient's family asks
me to withhold the truth from the
patient?
Often families will ask the physician to withhold a terminal or
serious diagnosis or prognosis from the patient. Usually, the
family's motive is laudable; they want to spare their loved
one the potentially painful experience of hearing difficult or
painful facts. In unusual situations, family members may
reveal something about the patient that causes the physician
to worry that truthful disclosure may create real and
predictable harm, in which case withholding may be
appropriate.
 When is it justified for me to
withhold the truth from a
patient?
There are two main situations in which it is justified to
withhold the truth from a patient. If the physicians has
compelling evidence that disclosure will cause real and
predictable harm, truthful disclosure may be withheld. This
judgment, often referred to as the "therapeutic privilege," is
important but also subject to abuse.
The second circumstance is if the patient him- or herself
states an informed preference not to be told the truth. If they
chose to make an informed decision not to be informed,
however, this preference should be respected.
What about patients with different
specific religious or cultural
beliefs??

Patient with certain religious beliefs or

ethnic or cultural backgrounds may have
different views on the appropriateness of
truthful disclosure. Thus, dialogue must
be sensitive to deeply held beliefs of the
patient.
 Is it justifiable to deceive a patient
with a placebo?
A placebo is any substance given to a patient with the
knowledge that it has no specific clinical effect, yet with the
suggestion to the patient that it will provide some benefit. In
general, the deceptive use of placebos is not ethically
justifiable. Specific exceptions should be rare and only
considered if the following conditions are present:
 the condition is known to have a high placebo response rate
 the alternatives are ineffective and/or risky
 the patient has a strong need for some prescription
 Confidentiality
 Where does the duty of confidentiality come from?
 What does the duty of confidentiality require?
 What kinds of disclosure are inappropriate?
 When can confidentiality be breached?
 What if a family member asks how the patient is doing?
Confidentiality is one of the core tenets of medical
practice. Yet daily physicians face challenges to this
long-standing obligation to keep all information
between physician and patient private.
 Where does the duty of
confidentiality come from?

Patients share personal information with

physicians. You have a duty as a physician to
respect the patient's trust and keep this
information private. Creating a trusting
environment by respecting patient privacy can
encourage the patient to be as honest as
possible during the course of the visit.
 What does the duty of
confidentiality require ?
The obligation of confidentiality both prohibits the physician
from disclosing information about the patient's case to other
interested parties and encourages the physician to take
precautions with the information to ensure that only
authorized access occurs. Yet the context of medical practice
does constrain the physician's obligation to protect patient
confidentiality. In the course of caring for patients, you will
find yourself exchanging information about your patients
with other physicians. These discussions are often critical for
patient care and are an integral part of the learning
experience in a teaching hospital.
 What kinds of disclosure
are inappropriate?
Inappropriate disclosure of information can occur in
clinical settings. When pressed for time, the
temptation to discuss a case in the elevator may be great, but
in that setting it is very difficult to keep others from hearing
the information exchanges. Similarly, extra copies of
handouts from teaching conferences that contain identifiable
patients should be removed at the conclusion of the session.
 When can confidentiality be
breached ?

Confidentiality is not an absolute obligation.

Situations arise where the harm in maintaining
confidentiality is greater than the harm brought about
by disclosing confidential information. ? Legal
regulations exist that both protect and limit your
patient's right to privacy, noting specific exceptions
to that right. These exceptions follow.
 Exception 1:
Concern for the safety of other specific
persons
Clinicians have a duty to protect identifiable
individuals from any serious threat of harm if they
have information that could prevent the harm. As
mentioned above, the determining factor in justifying
breaking confidentiality is whether there is good
reason to believe specific individuals (or groups) are
placed in serious danger depending on the medical
information at hand.
 Exception 2:
Concern for public welfare

To report certain communicable/infectious diseases

to the public health authorities. In these cases, the
duty to protect public health outweighs the duty to
maintain a patient's confidence.
What if a family member asks how
the patient is doing?

While there may be cases where the physician feels

compelled to share information regarding the
patient's health and prognosis with, for instance, the
patient's inquiring spouse, without explicit
permission from the patient it is generally
unjustifiable to do so. Except in cases where the
spouse is at specific risk of harm directly related to
the diagnosis, it remains the patient's, rather than the
physician's, obligation to inform the spouse.
 Patient Autonomy
 Dramatic change in the fundamental value governing the physician patient
relationship, from paternalism to autonomy.
 Physician :
o Knew best
o Decide what should be done
o Without informing
o Without involving them in the decisions
 Principle of patient autonomy
o Patient should be the one who ultimately decides what should be done.
 Potential conflict
o Patient refuses a treatment
o Patient’s right to refuse a treatment
o The family often plays a pivotal role
THEORIES IN ETHICS
 Theories in Ethics

1. DEONTOLOGY
2. ACT UTILITARIASM
 DEONTOLOGY

 Deontology is an ethical theory whose name is

derived from he Greek word deon, meaning duty or
obligation
 A very simple example of someone taking a
deontological perspective on an issue is a person
who thinks that you should always keep your
promises, however inconvenient it might be to do
so
 Only an action undertaken in accordance with my
duties and obligations is ethically correct
 Deontology and Consistency

 One very important quality of deontology is

its consistency
 A deontologist will tend to act in predictable
and reliable way
 A deontologist can be relied upon to take his
or her promises seriously
 ACT UTILITARIANISM

 The opposite of deontology in this respect is the

ethical theory known as act utilitarianism, which
takes account of nothing except the consequences
of actions
 For this reason, act utilitarianism is sometimes
called a consequentialist theory of ethics
 The slogan: “Act for the greatest good of the
greatest number”
 ACT UTILITARIANISM…

 For the act utilitarian, the “good” is measured

in terms of happiness or of satisfaction; the
“bad” is measured in terms of suffering or of
dissatisfaction
 The act utilitarian seeks in every action to
maximize the overall amount of happiness in
the world and to minimize the overall
amount of suffering
 ACT UTILITARIANISM…

 The act utilitarian is concerned only with the

results or consequences of actions; so that
only an action which has good consequences,
or which has the least bad consequences, will
qualify as an ethically good action
 ACT UTILITARIANISM…

 How does the act utilitarian decide which is the best

action to perform in any given situation? There are
three stages
 First stage is to survey all of the possible courses of
action
 The second stage is to predict what consequences, in
terms of happiness and suffering, each of those courses
of action will have
 The third stage is to calculate which course of action’s
consequences represent the best balance of good results
over bad results
 ACT UTILITARIANISM
-An Example-
 Suppose that an expedition of ten botanists, led by
an act utilitarian, is captured by bandits in a place
far from help.
 Suppose that the bandit-chief tells the expedition
that they will all be shot unless the leader of the
expedition agrees personally to shoot four of the
botanists, then the surviving six members of the
expedition will be allowed to go free.
 ACT UTILITARIANISM
-An Example-
 Suppose in addition that the bandit-chief clearly
means exactly what he says; suppose that there is
no hope of escape; and suppose that there is no
hope of rescue.
 What does the act utilitarian expedition leader do?
Reproductive Rights and
Abortion
 Introduction

 Few things affect us more intimately than

reproduction.
 We are all a product of it, and many, if not
most of us, have either already had children
or are likely in due course to do so.
 The family, often thought to be the basic unit
of human social life, depends upon
reproduction.
 Introduction….

 The future, which is the focus of all our hopes and

aspirations and ambitions, will be peopled with our
children, so some of our most fundamental drives
are directed toward the propagation and the
nurturing of generations yet to come.
 Given the centrality of reproduction to human life,
then, it is not surprising that reproductive issues
should also be of deep ethical concern to us.
 Reproductive Rights

 Once one understands the ethical principle of

respect for autonomy, for example, and grasps its
importance, one will be in no doubt that it is wrong
to force someone into a reproductive partnership
against his or her will.
 Now it has become technologically possible to alter
the mechanics of reproduction almost beyond
recognition.
 Reproductive Rights…

 Just as artificial insemination, in vitro

fertilization, and surrogate motherhood have
contributed to an opening up of our
reproductive options, so have they
complicated those options, and raised
challenging, and sometimes unexpected,
ethical questions
 Reproductive Rights -
Naturalness
 The “natural” way of reproducing is for a
male and a female to have sexual intercourse,
and for pregnancy and ultimately birth to
ensue.
 Advances in our knowledge and skills,
however, have made it possible to diverge
from this pattern in some surprising ways.
 Reproductive Rights –
Naturalness…
 In artificial insemination (AI), a woman’s egg is
fertilized by a man’s sperm, within her body, but
not by means of sexual intercourse.
 In in vitro fertilization (IVF), the fertilization of the
egg takes place outside the woman’s body, with the
resultant embryo or embryos then being transferred
into her uterus (this is the process that results in so-
called “test-tube” babies).
 Reproductive Rights –
Naturalness…
 In surrogate motherhood, where one woman bears a
child for another, (the latter often known as the
“social mother”), either AI or IVF may be used.
 If AI is used, the surrogate mother’s own egg is
fertilized by the sperm of the social mother’s
partner.
 If IVF is used, the egg of the social mother is
fertilized by the sperm of her partner, and the
resultant embryo or embryos are transferred to the
uterus of the surrogate mother.
 Reproductive Rights –
Naturalness…
 Surrogacy by AI is sometimes called “full”
surrogacy; surrogacy by IVF, “partial”
surrogacy.
 The phrase “playing GOD” often crops up in
such contexts - the idea being that we
humans are somehow getting above
ourselves and are tinkering around with
matters better left to a higher authority.
 Reproductive Rights -
Significant Relationships
 When a surrogate mother and a would-be
social mother both lay claim to a child, who
is more appropriately to be seen as the
child’s “real” mother?
 Reproductive Rights -
Significant Relationships…
 What is it to stand in the ethically significant
relation of motherhood to someone?
 There seem to be at least two possible answers to
this questions.
 The first is that motherhood is a genetic matter: The
(female) genetic progenitor of a child is its mother.
 The second is that motherhood is a behavioral
matter: Whoever has behaved toward the child in
the ways appropriate to motherhood is its mother.
 Reproductive Rights -
Significant Relationships…
 In cases where a surrogate mother’s pregnancy
has been induced by AI, it seems that the
surrogate mother has a better claim to be
regarded as the child’s “real” mother on both
counts: She is both its (female) genetic
progenitor and also the one who has behaved
toward the child, by bearing it and birthing it, in
the obvious motherly ways.
 Reproductive Rights -
Significant Relationships…
 Where the pregnancy is by IVF, on the other hand,
and the fertilized egg is that of the would-be social
mother, it appears that both women might have a
claim to be regarded as the child’s “real” mother:
the would-be social mother is the child’s (female)
genetic progenitor, while the surrogate mother has
borne the child and seen it to term.
 Which of these claims, then, is the stronger ?
 Abortion – The Sanctity of Life

 The “sanctity of life” (or right to life) is one of the

many phrases that tend, in the context of the
abortion debate, to shed more darkness than light.
 “Sanctity” is the quality of being sacred or
inviolable; so when one speaks of the sanctity of
life, one is claiming that life itself is sacred, under
no circumstances to be violated.
 On the face of it, this sounds reasonable enough,
and people often seem to assume that once the
sanctity of life is mentioned the abortion debate is
as good as over.
 Abortion – The Sanctity of Life

 If a fetus is alive, they say, and life is sacred, then

one ought not kill fetuses.
 If taken literally, the phrase “the sanctity of life”
might just as well be used to show that eating things
– whether animals or vegetables – is morally
wrong.
 Proponents of the sanctity of life argument will of
course claim that I have misrepresented their view.
They don’t just mean life in general. They mean
human life, or potentially conscious life.
 Abortion – The Sanctity of Life

 Killing is justifiable when the person to be killed has

forfeited his or her right to remain alive. Let’s call this the
forfeiture position on killing.
 But two things need to be noted about this way of
answering the question.
 First, all reference to the sanctity of life has become
superfluous. On the forfeiture account, if it is wrong to
kill someone then that is not because life is sacred, it is
because the person has not forfeited his or her right to
remain alive.
 Abortion – The Sanctity of Life

 Second, it provides a much better argument

against abortion than the sanctity of life
argument does. On the forfeiture account, after
all, a human life may just justifiably be taken
only if the human being in question has
somehow forfeited his or her right to remain
alive.
 Abortion – The Sanctity of Life

 A strength of the forfeiture argument is that it

captures something of what is meant when people
say that abortion is wrong because it involves the
taking of innocent life.
 Fetuses are “innocent” on this account because,
being incapable of doing anything at all, they are
certainly incapable of doing whatever it is that
“guilty” people are held to have done when they
forfeit their right to remain alive.
 Abortion – The Status of the Fetus

 The first question to clear up is whether

fetuses are to be regarded as “alive” or not.
 Obviously they are alive.
 Inasmuch, then, as a fetus that is capable in
principle of being brought to term and born
plainly isn’t dead, it is alive.
 Abortion – The Status of the Fetus
 Fetuses are alive, and abortions kill them. But merely
saying this settles nothing.
 The fact that fetuses are alive doesn’t show anything
about the morality of killing them.
 Bacteria are alive, after all, and we kill them all the time
with our soaps and bleaches and scourers.
 Vegetables are alive too, and they make good salads.
 So we need to ask whether individual fetuses have lives
that are valuable in a way that individual bacterial and
vegetable lives are not.
 Do fetuses, in other words, have lives that are deserving
of ethical concern?
 Abortion – The Status of the Fetus

 The opponent of abortion would answer that they

do have such lives, since the lives they have are
human lives, and surely if any lives are worthy of
ethical concern then human lives are.
 A defender of abortion might respond as follows:
Let’s admit that the fetus is alive; let’s admit that
the life it has is in some sense human.
 But exactly the same could be said of my appendix.
That’s alive isn’t it? After all, it’s not dead.
 Abortion – The Status of the Fetus

 And given its role as a part of my body, the life it

has is surely in some sense human (it doesn’t have a
vegetable life, or a fox life, does it?).
 Yet my appendix is not deserving of any particular
ethical concern: indeed it may perfectly justifiably
be removed from my body whenever I choose.
 Thus, if appendectomies justifiably cause the death
of appendixes, why can we not say on the same
grounds that abortions justifiably cause the death of
fetuses?
 Abortion – The Status of the Fetus

 The defender of abortion claims, plausibly,

that fetuses have a live which is no more than
genetically human – and that this puts them
in the same boats as, for instance,
appendixes.
 Abortion - Personhood

 The position taken by the defender of

abortion – while fetuses are genetically
human, they are not human in the same
(ethically significant) sense that you and I are
human – is certainly quite persuasive.
 Abortion - Potential
Personhood…
 Persons are ethically valuable (let’s agree, in other
words, that properties like autonomy and higher
mental functioning are ethically essential).
 Potentially a person also has ethical value.
 If this second claim is accepted, then the abortion
becomes morally wrong because fetuses, even if
they are not persons now, surely will become
persons if they are not aborted.
 Abortion - Potential
Personhood…
 Their potential personhood, in other words,
puts them on a par ethically with actual
persons.
 This idea is meant to be that if fetuses are
potential persons, and if persons must not be
killed, then fetuses must not be killed either.
But the conclusion does not follow.
 Some highlights of fetal
development
 At 20 weeks the baby is viable
 At 6 weeks we can measure brain waves
 At 6 weeks he begins to move his arms and
legs
 At 3 weeks his heart begins to beat
 Scientifically, biologically, and medically,
life begins at conception