Medical Ethics Lecture

Outline prepared and written by:

Dr. Jason J. Campbell: http://jasonjcampbell.org/home.php

Youtube Playlist Link:
http://www.youtube.com/playlist?list=PL6F19C2BC7EE8383A&feature=view_all

--------------------------------------------------------------------------------------Pence, Gregory E. Classic Works in Medical Ethics: McGraw-Hill, 1998, John M. Freeman, Kevin McDonnel. Tough Decisions: Cases in Medical Ethics Second Edition. New York: Oxford University Press, 2001.

--------------------------------------------------------------------------------------1.0: General Introduction to Ethical Theories: Virtue Based Ethics

Pence, Gregory E. Classic Works in Medical Ethics: McGraw-Hill, 1998, p. 1-18. Ethical Theories and Medical Ethics

Virtue Ethics: 1. the ethical theory that emphasizes acquiring good traits of character. (p. 1). 2. the ethical act was a performative act. To be ethical meant one acted in accordance with one having a virtuous character [Explain]. 3. Role identification, then, i.e., what one did became the conceptual grounds for initially accessing ethics and an ethic of behavior. 4. Within Platonic dialogues, the interlocutor serves as the means with which one is trained in the ways of being ethical. a. The interlocutor probed a personas archetypetypically an expert, with a specific social role and inquired into the nature of that role. b. The response from the expert shed light on how ethical actions are accomplished. This is based in an apprentice/master relationship, where the apprentice comes to know through the relationship with a master in the field.

5. Thus, in terms of medicine the question the ancients struggled with was what is the object of medicine? What is its purpose? 6. In Plato's Symposium Eryximachus, the physician, discuss the purpose of medicine: [From my Masters Thesis] a. First is the nature of opposites 1 and its relation to health (186b2-186d5); second, the reconciliation of these opposites in maintaining physical harmony (186d6-187e8); and finally, the cosmological nature of medicine and its relationship with the divine (188a-188e4). 7. Thus, as an example, from (6) if it was assumed during antiquity that these three factors were the purpose of medicine then the physician would always have to act in accordance with this purpose. 8. Attaining harmony and balance, then, became paramount for the physician, who was also charged with aiding the patient in reconciling these opposites. 9. Love: was, at the time, assumed to be one of the factors necessary to aid in the process of reconciling imbalances within the body. the science of what the body loves, or desires, as regards repletion and evacuation (186c6-7)." 10. Though the physician could identify the imbalances within the body and prescribe a change in one's behaviors, the prescription mandated that the patient exert "self-control" (sphrosun). Thus, sphrosun aided in bring balance and reconciliation to the ill body.

"The body is, in fact, composed of opposites which are at strife with one another, the hot, the cold, the dry, the moist,etc.; medicine is the art which produces love and concord between these opposites." (my emphasis), Ref: Taylor, Alfred Edward. 1956. Plato: The Man and His Work. London, Methuen and Co. Ltd, pg. 217.

11. Since the ancients conceptualized ethics in terms of virtue and an ill body is a consequence of excessive imbalances within the body, it follows that a physically attractive body exhibits both health and, more importantly, virtue, as the physically attractive body serves as a representation of sphrosun. The body represented virtue [KEY] For the ancients, a physically unhealthy body then served as a physical demonstration of one's vice, the beautiful body a demonstration of one's virtue. See Plato's Charmides (159d).2 [Explain]

--------------------------------------------------------------------------------------1.1: Four Principles and Medical Ethics 1. Autonomy: [patient centered] "refers to the right to make decisions about one's own life and body without coercion by others...to the extent that their decisions do not harm others, individuals should be left alone to make fundamental medical decisions that affect their own bodies and lives." (p.13). John
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"And in leaping and running and in bodily exercises generally, actions done quickly and with agility are good and noble; those done slowly and quietly are bad and unsightly...in all bodily actions, not quietness, the greatest agility and quickness, is noblest and best? Yes, certainly." Charmides (159d). 3

Stuart Mill in On Liberty notes, "...Over himself, over his own body and mind, the individual is sovereign." a. The ethics of autonomy is set in opposition to a virtue based ethic, which is characterized as paternalistic in nature. b. Contemporary medical ethics is more of an ethic of autonomy and less of a virtue based ethic. c. "...competent adults [have the right] to end their lives when they choose and to decline to participate in dangerous experiments." (p.14). 2. Beneficence: [physician centered] "doing good to others" if an ethic of beneficence requires a physician to act in accordance with those means used to benefit a patient's health, then by contrast, those means used to intentionally destroy, hamper or suppress a patient's health are unethical. [note: unconcerned with legality]. a. Therapeutic Experiments: Human-subject experimentation specifically designed to benefit the patient's health/wellbeing. Example: "If a physician means to help diabetic patients, an experiment on diabetic patients (with their consent) is justified." (p.14) b. Non-Therapeutic Experiments: Human-subject experimentation that does not benefit the patient's health/wellbeing. [This form of medical experimentation can either be moral/ethical or immoral/unethical given patient consent, full disclosure and physician intent.] Example Moral/Ethical: "The aim of a nontherapeutic trial is to obtain knowledge which may contribute towards the future development of new forms of treatment or procedure," [Ref] where the patient is fully informed of the risks and has consented to participation. Example Immoral/Unethical: "The aim of a nontherapeutic trial is to obtain knowledge which may contribute towards the future development of new forms of treatment or procedure," [Ref] where the patient is intentionally misinformed of the risks and has not consented to participation or consent
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was based on misinformation and/or the physician incorporates methods into the research design that intentionally destroy, hamper or suppress a patient's health. c. Immoral Experimentation: Human-subject experimentation specifically designed to harm the patient's health/wellbeing. [even if the justification is "for the greater good"][Explain], Example: Japanese experimentation in Unit 731 Ex1 Ex2]. 3. Nonmaleficence: [patient centered] "not harming others" "Above all, this maxim implies that if a physician is not technically competent to do something, he shouldn't do it." (p. 14). Duty to Prevent Harm Potentially Beneficial Treatment is: Physician Duties 1. Likely to save patient from great Strongest duty to provide treatment harm 2. Likely to save patient from some Strong duty to provide treatment harm 3. Likely not to prevent harm, but Weak duty to provide treatment; to confer some benefit. discuss with patient 4. Likely not to prevent harm, but Duty to provide treatment to confer great benefit. [Ref]3 4. Justice: "...has both a social and a political interpretation. Socially, it means treating similar kinds of people similarily...A just physician treat each patient the same...Politically, the principle amounts to distributive justice...At the very least, it would mean a guarantee of equal access to medical care for every citizen, such that insurance coverage would not be a factor..." (p. 15). [Explain] "...justice requires physicians to treat patients impartially, without bias on account of gender, race, sexuality, or wealth." (p.15).
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Wolf, Susan M. "Health Care Reform and the Future of Physician Ethics." The Hastings Center Report 24, no. 2 (1994): 28-41.

2.0: James Rachels' "Active and Passive Euthanasia" Classic Works in

Medical Ethics: McGraw-Hill, 1998, p. 21-34. ---------------------------------------------------------------------------------------------

I have uploaded a brief 50min discussion on Euthanasia here [Background] See the Karen Ann Quinlan case of 1975, for context. The thesis of this article: "Rachels challenges the claim that "passive" euthanasis (or letting die) is always more humane than "active" euthanasia (or direct killing). In some situations, he argues, it may be more humane to kill" (p.21). Assumptions Letting/Allowing Death Passive Humane Permissible "Natural Death" Withholding "treatment" Acceptable Moral

Direct Killing

Active Inhumane Impermissible "Mercy Killing" Participating in Killing Reprehensible "Immoral"

Suppose, "a patient who is dying of incurable cancer of the throat is in terrible pain, which can no longer be satisfactorily alleviated. He is certain to die within a few days...but he does not want to go on living...since the pain is unbearable. Suppose the doctor agrees to withhold treatment...the justification for his doing so is that the patient is in terrible agony, and since he is going to die anyway, it would be wrong to prolong his suffering needlessly." (p.22). [Explain] "But know notice this. If one simply witholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given." (p.22). [Read all of the Down's Syndrome Example] extended quote.
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[Read all of the Smith/Jones Example] [Explain role of motive/intent] "...the bare difference between killing and letting die does not, in itself, make a moral difference" (p.24). [Precise Identification of Contradiction]: "The American Medical Association, [December 4, 1973]: stated, "the intentional termination of the life of one human being by another...[BUT]...what is the cessation of treatment [letting/allowing to die], in these circumstances if not the intentional termination of the life of one human being by another"? (p.25). [KEY]: "...one learn to think of killing in a much worse light than of letting to die"] (p.25). [Question]: in the case of the children with Down's Syndrome, is "allowing them to die" ethically more justifiable than actively taking their lives? [hint: trick question]. [Problem]: The ethical system of justification, which legitimizes "allowing to die" and de-legitimizes active killing, is unjustly biased. "...for any purpose of moral assessment...the decision to let a patient die is subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right or wrong" (p.25). Important Rachaels is not concerned with the legal implication of this distinction, he is clear about that, only the moral/ethical implications. See my fictional example from a creative piece I wrote in 2005 demonstrating this point here. [pg. 123-125]. [General Explanation of example in Book]. (inaction as action).
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3.0 Jerome A. Motto, "The Right to Suicide: A Psychiatrist's View" Classic Works in Medical Ethics: McGraw-Hill, 1998, pg. 67-72 The Right to Suicide "...the question as to whether a person has the right to cope with pain in his world by killing himself can be answered without hesitation. He does have that right" (p.68).

 [KEY]: "It is only when philosophical and theological questions are raised that one can find room for argument about the right to suicide, as only in these areas can restrictions on behavior be institutionalized without requiring social or legal support." (p.68). 2 Dilemmas Stemming from the Right to Suicide: 1. "What is the extent to which the exercise of that right should be subject to limitations?" (p.68). [Explain] 2. "When the right is exercised, how can we eliminate the social stigma attached to it." (p.68). [Explain] 2 Psychological Criteria for Limiting a Person's Right to Suicide: 1. "The act must be based on a realistic assessment of his life situation" (p.68). 2. "The degree of ambivalence regarding the act must be minimal," (p.68). [KEY]: "Every person's perception is reality to him, and the degree of pain experienced by one can never be fully appreciated by another, no matter how empathic he is. Differences in capacity to tolerate pain add still another crucial yet unmeasurable element" (emphasis in original), (p.68). To, then, limit the patient's right to suicide, the medical professional, "he is constantly working with his patients on the process of differentiating between what is realistic and what is distorted." (p.68). [Implication]: It would be a clear violation of professional standards for a medical practitioner to exacerbate a patients delusions, knowing that his delusions are not real, which could then lead to suicidal drives. The physician must be "aware of his own tendency to distort and realize that the entire issue is one of degree." (p.69). Meta: [Limitation of the attempt to Limit a Patient's Right]: The perception of the medical practitioner becomes the standard by which a patient's realistic assessment is itself based. (1) The inherent problem becomes demonstrating how the medical practitioner gained this privileged perception. [what it simply because of education?, what ascribes this privileged perceptive abilities to the practitioner?]

"Thus if I am working with a person...one limitation I would put on his right to suicide would be that his assessment of his life situation be realistic as I see it." (p.69). [Critique]: There is a huge conceptual obligation, which requires a very precise justification for a medical practitioner's ability to limit a right they themselves acknowledge and recognize. Is a self referential appeal meaningful? [Read pg. 69]: Explain the distinctions between "Rational Suicide" and a "Realistic Assessment of one's Life Situations" [Read pg 70] (emphasis on "modification"). Reducing the Stigma of Suicide: "...the suicidal act is not considered respectable in our society. It can be maintained that granting a right but stigmatizing the exercise of that right is tantamount to not having granted it in the first place." (p.71) Step1: "Talk about it freely". Loses the "taboo" stigma with open discussion. [KEY] Step 2: Continued institutionalized support for suicidal persons. Educational Outreach: "...Every person who completes the equivalent of a high school education would be provided with an orientation toward the problem of suicide...." (p.71). [Read p.72 and 72.1]
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4.1: On Eugenics, Genetic Manipulation and Chimeras:

(1): Camporesi, S., and G. Boniolo. "Fearing a Non-Existing Minotaur? The Ethical Challenges of Research on Cytoplasmic Hybrid Embryos." Journal of Medical Ethics 34, no. 11 (2008): 821-25. (2) Dixon, Bernard. "Engineering Chimeras for Noah's Ark." The Hastings Center Report 14, no. 2 (1984): 10-12. (3) English, Darrel S. "Genetic Manipulation and Man." The American Biology Teacher 34, no. 9 (1972): 507-26. (4) Motulsky, Arno G. "Impact of Genetic Manipulation on Society and Medicine." Science 219, no. 4581 (1983): 135-40.c ---------------------------------------------------------------------------------------------

1. English writes: "The science of improving human beings by applying the principles of inheritance to obtain a desirable combination of physical characteristics and mental traits is called eugenics" (507).
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a. the motivation for any eugenics program is always attaining optimal geno/pheno types and/or eliminating "inferior" geno/pheno types. b. The value attributed to these traits, as desirable or undesirable, are determined by those capable of implementing the eugenics program. Two Type of Eugenics: Historical Account 1. Negative Eugenics: "...concerned with the elimination of alleles that produce undesirable phenotypes" (508). a. Examples include: "dissuasion from procreation, voluntary sterilization, medically induced abortions... and the encouragement of birth-control practices by persons possessing un-desirable traits" (508). May "target" 'a' in a sci-fi example for elimination from population. Example: 0% A A A AA AA A AA AA Discuss social interpretation of "breeding" @ this level. Example: 50% Carrier A A A AA AA a Aa Aa Discuss social interpretations on "mixing" at this level. Example: 50% Carrier 25% Expressed A a A AA Aa a Aa aa Discuss social interpretation of "contamination" at this level. Example: 100% Expressed a a a aa aa a aa aa Discuss social interpretation of "destruction" at this level. Discuss pseudoscientific notion of "purification" [bottom up] and "degradation" [top down] in relation to the above diagrams.
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2. Positive Eugenics: "furthering the increase of alleles that produce desirable phenotypes or at least with guarding against the decrease of these alleles" (508). a. aims at "the reproduction of persons of presumedly superior genotypes" (507). [Explain Social Implication] a. Important note for social scientists: manipulation for individual and social "improvements" [Explain Ethical Complications]. i. paternalism, social determinism, social engineering etc. 4.2: On Eugenics, Genetic Manipulation and Chimeras: Genetic Engineering: "The ability to manipulate, in a purposeful manner, the genetic constitution of human beings" (510). "Genetic engineering is the process of using recombinant DNA (rDNA) technology to alter the genetic makeup of an organism... genetic engineering involves the direct manipulation of one or more genes. Most often, a gene from another species is added to an organism's genome to give it a desired phenotype." [REF]. [Social Implications]: 1. Misinformation and Equivocation: Laypersons often conflate scientific terms and in so doing misrepresent scientific methodologies. E.g., the problem may be one of public opinion, influencing government policy and ultimately hampering viable scientific research: "a vivid public debate on a number of issues, ranging from purely scientific ones to much broader societal issues, such as the role of public and scientific opinion in influencing regulation and government policy." (S. Camporesi and G. Boniolo, p. 822). Q: How do we find that balance, socially? 2. "Sometimes incomplete knowledge and lack of understanding of various issues in this rapidly evolving subject have led to unwarranted emotional reactions and illadvised resolutions designed to block the progress of investigative activity" (Motulsky, p.135).

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Socioethical Considerations for Chimeras and Hybrids:

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