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- the study of moral issues, or what is right and wrong, in the medical context
- (medical context = biomedical research, clinical medicine, and public health)
General methodologies for resolving bioethical issues include:
- Moral theory
Sources of bioethical problems
- Technologic innovations
- Human relationships
- Societal changes
Challenges to Ethical Theory
- Moral Nihilism
- Ethical/cultural relativism
Utilitarianism states that...
the right actions are those that maximize happiness for the greatest number of people
Characteristics of Utilitarianism:
- Consequentialist theory
- It epitomizes impartiality
- It considers [short and] long-term consequences
Objections to Utilitarianism:
- Why should happiness be the greatest consideration?
- Difficult to perform the utilitarian calculus (e.g. consequences of every action)
- Because it doesn't focus on intentions, it has a counter-intuitive approach to responsibility
- Conflicts with some of our more basic intuitions (justifies inhumane treatment)
Although we should aim to bring about good consequences, we must never do so at the expense of going against our duty (which we're obligated to fulfill)
Objections to Kantianism:
- Yields two outcomes that are totally different
- Problems in definitions for rationality (no emotions in rationality, no motivation to do the right thing)
- ...despite all this, Kantianism still emphasizes respect for people.
refers to a family of moral theories that insist that the right action is directed by certain values
refers to the methodology of having a religious tradition direct ethical decision-making int he medical context.
Some religious traditions have been more influential in Bioethics than others because...
- They have well-written guidelines for bioethical behavior
- Other religions have too many sub-divisions
- It has Natural Law Theories, which provide principles for interpreting the general ethical difficulties of the christian faith
Natural Law states...
- We come to know the good (not defined by us)
- Things are externally good
Doctrine of Double Effect
- States that it is better to merely foresee a bad effect than it is to intend it
- The act must not be intrinsically wrong
- The good effect must be directly produced by the person's action and not by the bad effect
- The goodness of the effect outweighs the badness of it
Respect for people's rights dictates ethical behavior
Two general types of rights
- Negative - right to non-interference
- Positive - right to assistance
Two rights-based theories:
- Libertarianism - advocate liberty rights (non-interference)
- Egalitarianism - call for respecting pos. and neg. rights; equal shares for all
Problems with rights-based approaches:
- People's rights will overlap and violate each other because we have so many
- Cross-cultural differences
Communitarian ethics states
- the right action is determined by the values, beliefs and norms of one's society/community
- the common good dictates the right
Overarching question that communitarians ask:
- Which policy will uphold the community beliefs?
- or, Which policies will promote the king of community in which we want to live?
Problems with Communitarian Ethics:
- Community is tough to define as borders blur
- What's popular =/= what's right
- What about the people on the periphery (marginalized)
Began with the concern over women and has expanded to encompass concerns over all vulnerable or oppressed populations
Objections to relying on moral theory to guide bioethical behavior:
- So many theories, it's unclear which is best
- Ethical theory is so broad and general, it gives contradictory answers to messy bioethics
- Even if we agree on one theory, it's not enough to guide all the complex bioethical issues
Bioethical behavior should be guided by mid-level principles that are derived from common morality
Four ethical principles work together to resolve bioethical issues:
- Principle of autonomy - respect for an individual's capability to make self-governed choices about medical treatments/research participation
- Principle of beneficence - foster the well-being of other people and the society at large
- Principle of non-maleficence - do not harm others
- Principle of justice - act fairly, distribute benefits and burdens in an equitable fashion, and resolve disputes by means of fair procedures
Aspects of principlism
- No one principle is necessarily more important than any other (look at issue first, see which should be emphasized)
- The principles are intentionally broad so that they're cross-cultural and widely applicable
- The principles gain specificity through rules that come into play in a particular context
Objections to principlism:
- Too simplistic to deal with the complexities of bioethical issues
- No guidance in how to combine and prioritize different principles
- Overlooks the complex and reciprocal relationship between principles, rules, and cases
- Case-based reasoning, i.e. bottom-up approach
- Begin with a grouping of less-complex cases that reflect a paradigmatic instance of a moral rule or principle
- Then, branch out to analogous cases of greater complexity
Moderate vs. Extreme Causist
- Extreme - reject principles entirely
- Moderate - make room for principles, theories, and cultural norms
The five models of physician-patient relationship
In the paternalistic model...
- The physician assesses the patient's condition, determines the best treatment, and informs the patient that it's best
- Soft = persuade and sway
- Hard = You have X, so we're treating with Y
- Good for emergencies
In the informative model...
- The physician provides the patient with all of the relevant information
- The patient selects the medical interventions he/she wants
- The physician executes said interventions
- Good for walk-in clinics
In the interpretive model...
- The physician elucidates the patient's values and what he/she actually wants, and helps the patient select the available medical interventions that realize these values
- Good for on-going physician/patient relationship
In the deliberative model...
Te physician helps the patient determine and choose the best health-related values that can be realized in the clinical situation
In the instrumental model...
The patient's values are irrelevant (e.g. Tuskegee, Nazis, etc.)
Of the five physician-patient relationship models, the authors prefer the ____________ model. Why?
- It reflects the ideal of autonomy, includes caring, doesn't lapse to paternalism, the doc does bring in personal judgements, doc should promote certain health-related values, we can correct for a lack of training by modifying curriculum
Non-disclosure is only justified when...
the doctor's obligation not to harm overrides the patient's right to know the full truth
Three reasons why patients should be free to make their medical decisions:
- The patient is the best judge of his values and best interest
- You're the one who is being affected
- When we respect people's ability to make their own decision, we foster diversity
Paternalism is justified when...
- Individuals are unable to determine which actions align with their values due to ignorance
- An individual would be harmed by his actions AND that person would change their mind if they were informed
The authors reject paternalism when...
- The harm of disclosing a mistake in prognosis outweighs the harm of not
- Considering that disclosure of information could be (1) depressing, (2) detrimental for the patient, and (3) if you put yourself under a doctor's care, you're prioritizing your health
Problems with the argument FOR paternalism
- Not everyone prioritizes their health as #1 (if this were true, we'd spend ALL of our $$ on health)
- Prolonged life isn't always the best life
- Pain is necessary to achieve our goals
Key features of autonomy
- Self-governed behavior follows choices that one has critically reflected on
- Self-governed choices are voluntary and stem from people's life plans (what they value most; how the define themselves and their lives)
Impediments to autonomy due to illness:
- Inability to fulfill life plans
- Cognitive restraints - patient is unable to understand medical info
- Psychological restraints - anxiety, fear, denial, depression
- Social restraints - unjustly limited options (poor, can't afford) and social/cultural expectations (patient will follow the doctor's guidance)
Doctors should intervene when...
a patient can't comprehend what's going on due to psychological restraints
Doctors can intervene by...
- Repeating crucial information
- Altering the tone of the conversation (emphasize a positive attitude)
- Working to alter the attitudes of family members, friends, when applicable
- Emphasizing critical reflection
- This maps on to the interpretive model (addressing life values) and deliberative model (doc has a strong role)
- Doctors need to adopt a therapeutic approach to respecting autonomy when patients are severely ill
- Non-interference is not always the best policy for respecting autonomy in the medical context
According to Baylis, an "error" is defined as:
planned act or omission fails to achieve its intended outcome AND this failure has nothing to do with chance or risk
According to Baylis, it is difficult to identify an error because
- whether an act or omission constitutes an error is contextually relevant
- not all harms that result from medical intervention are errors (e.g. obesity makes operations difficult)
Why is it common for physicians not to disclose their errors with patients?
- Uncertainty regarding what constitutes an error
- Belief that it is in the patient's best interest not to know when practitioners make an error (inc anxiety, dec trust? not really)
- Fear of litigation (failure to admit error AND apologize = lawsuit)
- Socialization of doctors
The socialization of doctors involves
- Medical practitioners are thought not to make errors because of all the schooling
- Doctors have a tendency to dismiss smaller errors and blame others for large errors
- Entrenched practice of non-disclosure (whose who disclose get pressure from colleagues)
Proposed solutions for attending to errors:
- Attend to the larger social context
- Provide a supportive professional environment for disclosing errors
- Remind physicians that patients will experience emotions (negative) if they discover they've been lied to
- Revise medical liability (no-fault insurance?), tort reform
- Create a professional environment in which truthfulness with patients in the norm
High Context vs. Low Context culture
- High context - people infer things without being told; many things are left unsaid, letting the culture explain
- Low context - direct verbal communication; the communicator needs to be much more explicit and the value of a single word is less important.
Hyodo & Nunchi
- Hyodo - filial piety; refers to the duties that family members owe each other (take care of sick relatives, protect them from the truth, check with family firs to see if he should give bad news
- Nunchi - hunch, nonverbal communication; People know when something is wrong (they would like to know, but not be told. they'll figure it out with nunchi)
The different tongue study teaches us that...
- not all patients consider truth-telling to be of #1 importance
- Truth can be seen as an essential tool that allows the patient to maintain a sense of personal agency and control
- Or, it can be seen as a traumatic and demoralizing, sapping the patient of hope and the will to live
- Also, the truth can be more than told or withheld. It can be told vaguely, partially, understood without telling, known by nunchi.
Benchmarks, Comparative vs. Non-comparative
Three central questions to Justice, Health, and Healthcare.
- Is healthcare special? (Yes, b/c of its impact on opportunity)
- When are healthcare inequalities unjust?
- How can we meet competing healthcare needs under reasonable resource restraints?
- FINAL QUESTION: Are the inequalities that remain after applying Rawls principles unjust?
Social determinants of health
- GDP: Higher GDP per capita = higher life expectancy (levels off at $8-10k)
- Dist. of Income: The fairer the distribution of income = the fairer the distribution of health/well-being
- Education spending: The less spent on education, the lower its overall health
- Government public policies that allow grave income inequalities erode social cohesion
Which health inequalities are unjust?
Those that don't align with Rawls' theory of the just distribution of social goods
- Represents Kantian contractarianism
- Weigh each person's interests equally from that, derive principles
How can we met competing healthcare needs under reasonable resource restraints?
- Apply Rawls theory to the allocation of healthcare and the social goods that bear on health (social determinants of health)
- This will drastically reduce the socioeconomic gradient, & therefore increase overall health of population
Is healthcare special?
- Daniels: yes, b/c health is special and it has a direct link to opportunity
- Screenivasan: healthcare isn't special, HEALTH is special.
Which health inequalities are unjust?
- Daniels: We must structure equal opportunity to the social determinants of health in order to ensure health.
- Screenivasan: Daniels assumes that people must have an equal opportunity to healthcare in order to arrive at a fair share of health.
- (If health is what is important, then should we focus on social determinates of heath or on healthcare?)
- Daniels needs to provide further arguments: about why healthcare is special, and to support his conclusion that the just allocation of healthcare requires equal opportunity of healthcare
Kidney sales are needed because...
- Dialysis is expensive
- People are suffering
- Shortage of donors (run out of altruistic ones)
Radcliffe-Richards conclusion about kidney sales:
- Current arguments against kidney sales do no work
- Given the need for kidneys, the burden of proof rests on those who argue we shouldn't allow kidney sales
- Until we find a good argument against kidney sales, we should allow this practice
- It exploits the poor (why not give 'em an option to make $$)
- Subjects don't really consent b/c they don't understand (not sufficient to ban a practice, use a guardian)
- Risks are greater for the poor b/c they don't get proper care (same problems in other activities, regulate)
- It provides one more advantage for the rich (this already exists; try and level the playing field instead, remove multiple listing)
- Motivation should be altruistic not monetary (altruism doesn't distinguish donors from vendors; dad example)
- Undermines the requisite trust in medical profession, money making docs (if this is true, ban private practice; have doc perform surgery and someone else handles the money)
- Opens the door for coercion (banning doesn't fix this, implement regulation)
- Slippery slope to sell vital organs (there's a distinction)
AMA position on organ selling:
- Utilitarian: greatest amount of good for the greatest amount of people. Push for non-coercive inducements
- **Author disagrees, says keep the cash out of donation
Three common objections to organ donation
- Commodification (objectifies people)
- Reason & Rescues (hypocrisy: you'd do it if needed / burden of proof)
- Science & Superstition (We already sell fluids & other parts)
Conclusion of those against organ selling:
When considering whether organ selling is ethically acceptable, we need to realize that the real issue extends beyond organs to whether such practices align with moral intuitions, cultural definitions & subsequent practices dealing with the body and the self.
Global Economic Order
- "Global" = 1 cohesive society that has resulted from the spread of EU control since 15th century
- "Economic" = Bretton Woods institutions were a framework for economic cooperation; shape the economic order; not reducible to states
Benchmarks for measuring harm:
- Historical - examining the effects of the GEO over time (life exp, income, etc all inc)
- Counterfactual - compares the way things currently are with the way they would have been
- Fairness - the measure of whether people in a country have been harmed is whether there is an unfair distribution of social goods
Which benchmark is feasible?
- Counterfactual is impossible, how would we know for sure what would have been?
- Fairness is also impossible, what IS the natural distribution of goods?