Transcript How does bioethics, or modern medical ethics, differ from traditional

Medical Ethics I
Dr Martin Dyar
Large Chemistry Theatre, 10am
20th October, 2008
Lecture One of Five:
Bioethics: Introduction and Historical Overview
What are we doing when we are engaged in
philosophy?
• ‘The role of the philosopher is to remain
obstinately curious about what is usually
taken for granted …’ (Evans, 2001)
• Clarity, depth, and consistency of
statement and perception.
What are we doing when we are involved in ethics?
•
•
•
•
•
•
•
Ethical issues emerge when certain actions ought or ought not to be performed
because of the impact these actions can be expected to have on the interests of
others.
As we grow up, we come to understand morality as a set of normative standards
about doing good, avoiding harm, respecting others, keeping promises, and acting
fairly, as well as standards of character and moral excellence.
Our moral life has traditionally been examined from three perspectives: virtue, duty,
and the consequences of our actions.
Emmanuel Levinas: The ‘Face to Face’ relationship. The role of the ego. The Other.
Conversation. Medicine and technology deflecting the Face to Face?
George Eliot. ‘The other side of silence.’ Ted Hughes’ Crow: ‘Ought I to stop eating
and try to become the light?’ A vegetarian vision. An agony of Kinship.
The internal, unreflective and sometimes blind nature of ethical responses and ideas,
and of course, the endurance of the unethical
A medical ethics course: the effort to be systematic, to enter a discourse, to pursue
clarity and depth, with the aim of developing the ability to negotiate the complex, the
dramatic, but also the more everyday moral concerns in medicine.
What are we doing when we are engaged in medical
ethics?
• ‘Medical ethics is the application of ethical reasoning to medical
decision making’ (BMA)
• We assume that there is a set of tools, concepts, principles,
resources, methods, practices and habits that we can master, then
apply.
• A search for morally acceptable and reasoned answers in situations
where different moral concerns, interests or priorities conflict …
involving
– critical scrutiny of the issues
– and careful consideration of various options
• The process through which a decision is made is often as important
as the decision itself, and the ability to justify is always central.
Clarity and Depth: explaining your position.
• If this class was merely a reading of the medical council code, what
would be missing? What is insufficient about conformity to
professional standards in terms of the new medical ethics?
Early and traditional medical ethics
• The medicine man is an age old figure, representing
what Levinas has termed the primordial category of
analgesia
• Many examples of medical ethics before Hippocrates (c.
500BC)
• Code of Harrumabi (c. 1750BC) set penalties for failed
procedures
• Hinduism: Ayur Veda: warns against injuring or
abandoning the patient, and against treating the king’s
enemies
The Hippocratic Oath
•
•
•
‘I will use dietetic measures to the use and profit of the sick according to my
capacity and understanding.’
Honour one’s teacher like a parent, ‘share his fate and if the occasion arise
supply him with the necessaries of life’
Twofold significance of the Oath:
– it establishes the principles of beneficence and non-maleficence
– prohibition of potions and poisons for abortion and euthanasia affirms
the view of the sanctity of life
The Hippocratic Oath and its successors
emphasised the following medical duties
– to pursue patients’ best medical interests
– to avoid harming or exploiting them
– and to maintain their confidences
The essence of the Hippocratic tradition
• The definitive feature of [the Hippocratic Oath] is
the commitment of the physician to benefiting
the patient without any acknowledgment of
patients’ rights, such as the right to be told the
truth or to give consent before being treated.
The more purely Hippocratic codes also pay no
attention to the welfare of society or other
individuals (Veatch)
Critical analysis of issues is not part of traditional
medical ethics
• Ethical norms were imparted and enforced
in the process of medical socialisation,
and reinforced by written codes, typically
based on the H.O., without explicit
analysis of the issues involved.
• Percival’s influential 1803 code was
originally composed to meet the needs of
a group of overworked and quarrelling
doctors in Manchester.
Medical ethics can be understood both in traditional
terms and as a new analytical practice, bioethics
• Traditional medical ethics: ‘the standards
of professional competence that the
profession expects of its members’ (Boyd
1997)
• Until the middle of the twentieth century,
paternalism was the norm and traditional
medical ethics was less concerned with
respect for patients’ autonomy or with
justice.
What is the new medical ethics?
• A critical process through which substantive ethical claims are
justified (or criticised) in the light of argument and counterargument.
• Informed by a wide variety of perspectives, including multicultural
insight, and various academic disciplines such as moral philosophy,
law, the social sciences, history and theology, including more
recently literature and the arts.
• Medical ethics has ceased to be the sole domain of doctors: ‘part of
the general moral and ethical order by which we live’ and
increasingly in practice ‘tested against the principles of society.’
(Kennedy, 1981)
How does bioethics, or modern medical ethics, differ
from traditional medical ethics?
• It is not limited to questioning the ethical dimensions of
doctor-patient and doctor-doctor relationships
• It’s goal is not the development of, or adherence to, a
code or set of precepts (professionalisation) but a better
understanding of the issues (Percival’s Role)
• It is prepared to ask deep philosophical questions about
the nature of ethics, the value of life, what it is to be a
person, what it means to be a doctor, the significance of
being human, and the experience of illness.
• It embraces issues of public policy and the direction and
control of science
• It is interdisciplinary, presupposing the broad social and
cultural significance of medicine
• In Levinasian terms: a wider realm of others has been
granted moral significance. Bioethics attempts to
respond more profoundly.
What factors prompted the emergence of the new medical
ethics? 1
• Medical atrocities of the Nazi doctors: Nuremburg Code, 1946: first
articulation of informed consent: The patient or subject has the right
to be informed of the relevant facts of what is being proposed and to
approve or disapprove before the doctor proceeds
• Changing social attitudes, including less deference to authority
• More assertive attitudes to individual rights and self determination
• A shift from the preoccupation of medical ethics with the individual
patient at the expense of the community
• The increasing plurality of cultural and religious norms
• The advent of human rights
• New, more powerful, more expensive medical technologies,
including those with the capacity to prolong life, alter psychological
states, impede and enhance reproductive capacity, and change our
genetic structure.
What factors prompted the emergence of bioethics, or
the new medical ethics? 2
•
Social and cultural change advanced the questioning spirit, less deference for
authority:
– Civil rights movement, focussing on justice and inequality
– Cuban Missile crisis and Vietnam war, renewed questioning of war and nuclear
weapons
– Student activism, calls for greater social relevance in university courses
– Feminism, contraception, abortion, reproductive rights
•
Growth in ‘patient rights’ movement: a growing concern about the power exercised by
doctors and scientists
•
Feminism gave a new self-consciousness and self-awareness to the nursing
profession. Nursing Code, 1965:
– ‘The nurse is under an obligation to carry out the physician’s orders intelligently
and loyally’
– ‘The first and most helpful criticism I ever received from a doctor was when he
told me that I was supposed to be simply an intelligent machine for the purpose
of carrying out his orders’ (Dock, 1917)
– 1973: The nurses ‘primary responsibility’ is no longer doctors but patients, ‘those
people who require nursing care.’
What factors prompted the emergence of bioethics, or
the new medical ethics? 3
• Bioethics began to take shape as a field of study in the 1960s. A
response to new developments in clinical medicine: dialysis, organ
transplants, artificial ventilators;
• and in medical science: IVF, related reproductive technologies,
contraceptives, prenatal testing.
• The new challenges and choices prompted a growth in academic
comment. Moral philosophy: shift from meta-ethics to applied ethics.
New structures emerged. Hastings Center and the Kennedy
Institute. Journal of medical ethics.
• The understanding that new developments within medicine and the
life sciences were raising ethical issues for society as a whole
• In the 1970s the term ‘bioethics’ came to refer to the growing interest
in the ethical issues arising from healthcare and the biomedical
sciences
What factors prompted the emergence of bioethics, or
the new medical ethics? 4
• ‘Outsider’ involvement in the previously largely closed
medical world, such as philosophers, theologians,
lawyers, sociologists and psychologists, looking in and
offering their views.
• The beginnings of acceptance that insights from these
varying perspectives could be helpful in the development
of medicine; The philosophically more critical, analytic,
and multidisciplinary approach to ethical issues arising
within the clinical practice of medicine
• Increasing realisation that medical ethics needed to
extend its sphere of interest beyond the clinical
encounter into broader social issues such as the fair and
beneficial distribution of healthcare facilities
What factors prompted the emergence of bioethics, or
the new medical ethics? 5
• A sense of the profession’s obligation to
become involved, as health care
professionals, in trying to remedy social
factors that impinged adversely on
people’s health. Lifestyle: unhealthy diet,
smoking, and lack of exercise;
environmental pollution; overpopulation;
even unemployment, poverty, crime, and
warfare.
The shift to the new medical ethics: summary
• As a result of major changes, medical
ethics had to develop a more analytical
approach. A clear shift from the previous
reliance on medical paternalism to a
doctor-patient partnership approach,
adding respect for patients’ autonomy and
an increasing awareness of justice to the
traditional Hippocratic concern to provide
health benefits with minimal harm.
Bioethics infrastructures: a global field of inquiry
• The first institutions and centres of bioethics: 1969, the Institute of
Society, Ethics and Life Sciences (the Hastings Centre). Daniel
Callahan. Hastings Centre Report.
• 1971, Kennedy Institute of Human Reproduction and Bioethics at
Georgetown University. First use of the term bioethics.
• UK: 1963 London Medical Group. 1975, Journal of Medical Ethics.
Similarly: Nordic, Netherlands and Benelux. Germany slower.
• Interdisciplinary aspect: a field of learning and inquiry defined by its
movement across subjects: Moral philosophy, moral theology, law
(the big three), history, psychology, economics, philosophy,
literature, anthropology, sociology.
• Subject also includes: politicians, the media, and the general public.
• Undergraduate and postgraduate bioethics teaching now
commonplace, and nursing and medical schools see it as integral to
their curricula
• Policy and Consultation: Irish Council for Bioethics
New advances: new moral questions
Dialysis Machines
• Dialysis Machines: it was now possible to
sustain kidney failure patients who previously
would have died. More renal disease patients
than machines, too expensive to make
universally available.
• 1962, Artificial Kidney Centre in Seattle, set up a
committee to select patients for treatment, the
god committee. A bias was found in its
decisions, towards those of the same social
class and ethnic background as its members
New advances: new moral questions
Heart transplants and respirators
• Christiaan Barnard, 1967, first heart transplant: ‘a new era of
medicine’
• Linked to the development of ventilators and the introduction of the
concept of brain death
• Respirators could save many lives, but not all those whose hearts
kept beating ever recovered any other significant functions. In some
cases, their brains had ceased to function altogether. The realisation
that such patients could be a source of organs for transplantation led
to the setting up of the Harvard Brain Death Committee, and its
recommendation that the absence of all ‘discernible central nervous
activity’ should be ‘a new criterion for death.’
• The recommendation has subsequently been adopted almost
everywhere
• New question: when should a patient be declared dead: the
boundaries of life had been pushed. Should a transplant be part of
normal medical care? Should medical science do what medical
science can do?
New advances: new moral questions
Saving and prolonging the lives of incompetent
patients
• The unclear status of the incompetent patient: if a patient
is unable to say ‘no’, does this mean that his or her life
must always be prolonged for as a long as possible,
even if the patient’s prospects are very poor? Can we
talk about proper limits?
• Duff and Campbell, NEJM, 1973: non-treatment
decisions in the special care nursery. Attempt to break
‘the public and professional silence on a major taboo.’
Out of 299 infants, 49 had died as a result of a nontreatment decision. Were these decisions sound? Is
either more important: sanctity or quality of life?
• What are the proper limits to the provision of care,
saving and prolonging life, when care is available?
• Medical futility?
New advances: new ethical questions
Karen Ann Quinlan
• Feeding tube and respirator coming to symbolise an ‘oppressive
medical technology’ (Pence)
• Details of Karen’s condition: PVS (although term was not in use),
with dramatic movements, suggesting resistance and pain.
• Hospital gave her ‘1 in a million’ chance of recovery, a chance some
felt the hospital must offer.
• Eventually moved from ICU to ER, because she was not in need of
a heart monitor
• Parents reassured by their parish priest, that according to Pope Pius
XII, extraordinary means (like the MA-1 respirator) are not morally
required of catholics.
• Family requested that treatment be withdrawn, hospital refused.
• A lawyer for Karen’s doctor said that turning off the respirator would
be ‘like turning on the gas chamber’
Quinlan
• Implications of the case: the moral and legal
difference between so-called ordinary and
extraordinary means of treatment, the role of
parents or guardians in medical end-of-life
decisions, the validity of an incompetent
patient’s previously expressed wishes regarding
life-sustaining treatment.
• New Jersey Supreme Court decided that life
support could be discontinued without the
treating doctor being deemed to have committed
an unlawful homicide.
Controversies that intensified the scrutiny of the ethics
of research
• The Brooklyn Jewish Chronic Disease
Hospital (injection with live cancer cells, no
consent)
• Willowbrook State Hospital NY, 1954.
(children with learning disabilities
inoculated with hepatitis)
• Tuskegee, Alabama (1930-1970, a study
of the ‘natural history’ of syphilis in
untreated African-American men)
Landmark in the promotion and articulation of research
ethics
• 1973, US National Commission for the
Protection of Human Subjects of Biomedical and
Behavioural Research: regulations to protect the
rights and interests of subjects of research.
Hugely influential.
• The Belmont Report: early articulation of ethical
principles: respect for persons, beneficence,
justice. Later embraced by Beauchamp and
Childress, Principles of Biomedical Ethics.
Willowbrook State School, NY
• The number of residents with severe learning disability
increased from 200 in 1949 to more than 6000 in 1963.
Susceptible children were constantly admitted.
Contagious hepatitis was persistent and endemic
• Dr. Krugman, 1971: ‘Viral hepatitis is so prevalent that
newly admitted susceptible children become infected
within 6 to 12 months. These children are a source of
infection for the personnel who care for them and for
their families if they visit with them. We were convinced
that the solution of the hepatitis problem in this institution
was dependent on the acquisition of new knowledge
leading to the development of an effective immunizing
agent.’
The justification of the Willowbrook study
• ‘Our proposal to expose a small number of newly admitted children
(750-800 in total) to the Willowbrook strains of hepatitis virus was
justified for the following reasons:
• 1) they were bound to be exposed to the same strains under the
natural conditions existing in the institution
• 2) They would be admitted to a special, well-equipped, and well
staffed unit where they would be isolated from exposure to other
infectious diseases which were prevalent in the institution –namely,
shigellosis, parasitic infections, and respiratory infections– thus, their
exposure in the hepatitis unit would be associated with less risk than
the type of institutional exposure where multiple infections could
occur.
• 3) They were likely to have subclinical infection followed by
immunity to particular hepatitis virus
• 4) Only children with parents who gave informed consent would be
included.’ (Krugman, 1971)
Some criticisms of the ethics of the Willowbrook study
• Did the study offer some therapeutic benefit to the
subjects, or only to others? Some have argued that there
was no benefit to the children.
• The aim of the study was to determine the period of
infectivity of hepatitis. It produced positive results. But it
can be argued that an experiment is not justified by its
results but is ‘ethical or not at its inception.’ Immunization
was not the purpose, but merely a by-product,
incidentally beneficial.
• There were alternative ways to control hepatitis. ‘The
paediatricians duty is to improve the situation, not to take
advantage of it for experimental purposes.’
• Informed consent and the parents: questions around
coercion and information
Some foundational assumptions in bioethics/schools
of thought
•
•
•
•
•
•
•
•
•
The foundation of respect for autonomy
Utilitarian welfare maximisation
Social justice
The four principles
Casuistry
Virtue ethics
Narrative ethics
Feminist ethics
Geocultural bioethics
What are the major areas of study in the new medical
ethics?
•
•
•
•
•
•
Issues stemming from health care relationships
Issues of life and death
The patient’s interests vs. the interests of others
Issues of distributive justice
Conceptual analysis
Ethical issues in the practice of medical science
– the impetus of Nuremburg
• Bioethics, Science, Technology and Society
• Environmental Ethics
• Medical Education, Medical Humanities
William Carlos Williams: ‘The Use of Force’
•
•
•
•
•
•
•
•
•
•
•
How does the story read: traditional or modern?
Connotations of the title? Official procedure: Continuum of force
Could it be written now? Blind to paternalism?
Is there anything objectionable in the actions portrayed in this short
story?
What might have been done differently?
Does the speaker reveal a sense of self-awareness?
Is there ethical reasoning involved?
Narrative ethics: what kind of effort or understanding?
Is there a philosophy, a principled approach, evident here?
The account is very candid. Is this part of an effort to be
provocative? Does this create ethical ambiguity?
What do you think motivates this character to be a doctor?
• Political and Media interest: recent headlines?
• Saturday and Thursday’s papers
– ‘Psychiatric Patient Takes Case Against involuntary
detention in hospital’
– ‘Legal Basis urged for end of life treatment’
– ‘Combative Exchanges over medical cards means
testing’ (The Irish Times, Thursday, October 16th,
2008)
• The role of religion
• Must every doctor be a bioethicist?
Aims of the ethics course
•
To provide students with training in the knowledge, skills and attitudes relevant to the
development of ethical competence for medical practice, with particular emphasis on
the role of patient-centred care.
•
To promote the tools of ethical engagement, including ethical reasoning, information
gathering, communication and debate, critical thought, compassionate response, and
reflection.
•
To ensure that students know the main professional obligations of doctors as
endorsed by the institutions which regulate and influence medical practice.
•
To equip students with a knowledge and understanding of the legal process and the
legal obligations of medical practitioners, sufficient to enable them to practice
medicine effectively and with minimal risk.
•
To enable students to enjoy the intellectual satisfaction of debates within medical
ethics and law, while appreciating that ethical and legal reasoning and critical
reflection are integral aspects of their clinical decision-making and practice.
•
To promote an appreciation of the convergence between medicine and the
humanities, with particular emphasis on the contributions of philosophy, literature and
film, to medical education.