Biomedical Ethics

• An overview of ethics in health care

Applied Ethics

• Applied Ethics attempts to deal with specific realms of human action and to craft criteria for discussing issues that might arise in those realms (e.g., Business Ethics, Medical Ethics, Engineering Ethics)

• Ethics Updates: ethics.acusd.edu/index.html• Bioethics Links:

www.ethics.ubc.ca/resources/biomed/• Bioethics Center: www.med.upenn.edu/bioethics/

Motivated Guide to the Rise of Medical Ethics - Euthanasia

• The term ‘euthanasia’ (or ‘mercy killing’) comes from the Greek word meaning ‘good death’

• The History of Euthanasia– Greek and Roman Times

• Hippocrates vs. Stoicism

– Christian Perspectives• Natural Law and the Preservation of Life

– Modern Secular Perspectives• Utilitarianism (Bentham, Mill)

– The Nazi Era (involuntary euthanasia)– Medical Advances in the 1960’s and 1970’s

The Rise of Medical Ethics

• Technology is rapidly changing the context in which medicine is practiced

• In dealing with life and death situations, doctors have certain ‘duties’ to uphold

• A need to clarify these duties through a set of principles– Beauchamp and Childress, Principles of

Biomedical Ethics

The Principle of Autonomy

• A person is autonomous if and only if that person is self-governing

• All things being equal, autonomous actions and choices should not be constrained by others

• The Principle of Autonomy lies behind Informed Consent and Refusal of Treatment– The issue of informed decision-making implies that

subjects and patients with the capacity to ‘consent’ may likewise opt to refuse

The Principle of Nonmaleficence

• As a principle, it has become associated with the dictum, above all, do no harm

• As a prima facie rule, it includes the following: “Don’t kill”, “Don’t cause pain”, and “Don’t disable”

• The AMA holds that cessation of treatment is morally justifiable when the patient and/or immediate family, in consultation with medical staff decide to withhold or stop the use of “extraordinary means to prolong life when there is irrefutable evidence that biological death is imminent”

• But while the physician is always morally prohibited from killing, he or she is not morally bound to preserve life in all cases. Thus, in certain circumstances, the physician is morally permitted to allow a patient to die

The Principle of Beneficence

• The Principle of Beneficence asserts the duty to help others

• In the medical context, failure to benefit others when in a position to do so violates the professional relationship that is institutionally established between health care professionals and patients

• Paternalism– Weak Paternalism

– Strong Paternalism

Hospital Ethics Committees

• Functions: Education, policy formation, consultation, prospective and retrospective review

• Make up: doctor, lawyer, social worker (patient advocate), administrator, chaplain, ethicist

• A ‘weak ethic’: In general, committees do not embody an ‘organic view of society’ and so they try to remain neutral with regard to religion, etc…

Minogue’s Methodology:The Hospital Ethics Committee Approach

• Achieving Consensus– Cooperative thinking about ethics can improve the quality of

ethical decision making

• Cases and Policies– Cases point beyond themselves toward policy development

• Developing policy adds another level of ethical decision making

• The Place of Ethical Theory– “Ethical theory travels alongside medical practice, and each

fertilizes the other”

• Committee Dialogue and Decision Making– ‘Dialogical Reason’ (Habermas), with its multiple perspectives,

it integral to the development of “practical wisdom”• Unlike the arguments of philosophy, decisions about cases and

policies must be made in the context of committee dialog (though decisions can always be made the object of further discussion and critique)

Two Types of Ethical Theory

• Utilitarianism (Consequentialism)– Act Utilitarianism– Rule Utilitarianism

• Deontology– Kant’s Theory– Multi-Rule Deontology (e.g., Ross)

Forgoing Treatment – Hospital Policy

• Concerns the Scope and Limits of ‘Rescuing Patients’

• Competent Patients– Forcing treatment upon a patient against his or her will is,

in most cases, unethical– Do not have to provide futile treatment, even if requested– Scarcity of resources can limit ability to meet requests

• Incompetent Patients– Attempt to ascertain patient’s value history– Surrogate decision maker and ‘substituted decisions’– PVS patients, scarce resources, and futility of treatment

The Case of Dax Cowart

An unmarried, 25 year-old man named Dax Cowart was in a terrible accident and received second and third degree burns over two-thirds of his body. Now, one year after the accident, Dax is blind in both eyes, though with delicate surgery, partial vision may be restored to one eye. The burns have not healed completely, and Dax must be immersed daily in an antiseptic solution to keep the burns from getting infected. Each day after the bath the burns must be bandaged; both procedures are extremely painful to Dax.

Dax has had several operations on his hands and arms, but has recently begun to refuse any additional surgery o them. Dax’s hands are, as of now, useless. The doctor’s feel, however, that further surgery could restore some useful function to Dax’s hands. Dax’s upper torso – particularly his arms, face, and neck – is severely scarred.

Dax is very intelligent and articulate, and before the accident he led a very active life. He has repeatedly asked that his treatment be discontinued and that he be allowed to go home and die. Doctors attending Dax say that if his treatment were discontinued he would most certainly die from infections to his open wounds.

Euthanasia –Hospital Policy

• Intervention with the solitary intent of causing death is prohibited

• It is ethically permissible to provide pain medications to a terminally ill patient, even if such medications may hasten the death of a terminally ill, consenting patient– Does not apply to a non-terminally ill patient

– Does not effect the right of a competent patient to refuse medical treatment (forgoing treatment)

• Neither merciful intent nor autonomous request by a patient form a justifiable basis

• There are ethical differences between active euthanasia and physician assisted suicide