Transcript Medical Ethics Year I

Ethical Reasoning
&
Contemporary Medical Ethics 2
Lecture 4
28th October 2009
Dr. Ruth Pilkington
Medical Ethics Year 1
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‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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Respect for Patient Autonomy
Autonomy literally means ‘self-rule’ or ‘self-governance’.
An individual’s capacity to make decisions about their
health care needs and to consent to or refuse treatment
depends on their ability to think, decide and act, freely,
on the basis of such thought and decision.
Two essential conditions for autonomy:
Liberty
Agency
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Respect for Patient Autonomy
‘The autonomous individual acts freely in accordance with a
self chosen plan,...A person with diminished autonomy,
by contrast, is in some respect controlled by others or
incapable of deliberating or acting on the basis of his or
her desires and plans’, (Beauchamp & Childress (2001))
c.f.
Those with diminished autonomy e.g. prisoners, learning
disabled persons, patient with dementia.
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Respect for Patient Autonomy
Look at Autonomous Choice rather than Generally
Autonomous Capacity, i.e. a generally autonomous
person may not be able to act autonomously in certain
situations.
Respect for patient autonomy requires doctors (+ family)
to help patients make their own decisions and to
respect those decisions (irrespective of whether one
believes those decisions to be wrong).
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‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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Non-Maleficence
We should avoid doing harming to others.
‘Primum non nocere’ – [trans. first (or above all) do no harm]
– this would make medicine a very difficult pursuit!
It is an extremely important principle to avoid harming
others, but cannot take priority and be expressed as an
absolute principle. Must be considered in the context
of the obligation in medicine of the principle to do
good for our patients (beneficence), e.g cancer surgery.
Also balance required with the principles of autonomy
and justice, e.g. involuntary isolation.
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‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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Beneficence
The obligation to do good / promote what is best
for the patient.
Sometimes conflict may arise between doctor's
judgement of what is in the patient’s best interests
and his desire to respect the patient’s different
but autonomous decision.
Must be balanced with the principles of respect
for autonomy, non-maleficence and justice (e.g..
rights and needs of others).
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‘The Four Principles’ in Medical Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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Justice
Distributive Justice: Decisions re the allocation of scarce health
resources (e.g. outpatient time, drugs, money, ICU beds,...)
Patients in similar situations (e.g same diseases) should normally
have access to the same health care (e.g. same diagnostic
technologies/pharmaceutical interventions).
But attempt to distribute our limited resources fairly, so that in
providing for some, others are not left wanting.
Justice also applies to Forensic Medicine (psychiatrists assessment of
sanity for court), Employment Justice (fair promotion in the
workplace), Prohibition of involvement in Torture (Declaration of
Tokyo), etc.
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Distributive Justice
Health Resource Allocation
Justice requires that like cases be treated alike and
that the benefits and burdens of health services
be allocated equitably across patients.
However what criteria?
Clinical factors, patient values, system goals...
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Justice
No consensus moral theory to help resolve
differences between conflicting values,
However
the goal
is
Fairness.
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Strict Egalitarianism
Advocates the allocation of equal material goods
(healthcare resources)
to all members of society.
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John B. Rawls
(1921-2002)
‘Justice as Fairness’
envisions a society of free citizens holding equal
basic rights cooperating within an egalitarian
economic system.
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Rawls : Needs Theory
Rawls rejected utilitarian approaches to maximizing
total welfare and libertarian ‘free for all’.
Believed in a theory of social justice.
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Rawls : Needs Theory
‘The Difference Principle’
Some patients have a special claim on resources that
rests not on the maximization of overall welfare
but on the greater need for treatment.
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The Veil Of Ignorance (Rawls)
Imagine self in an ethereal place looking down on
a world of different societies, each distributing
wealth in different ways.
You must choose which society you will belong to,
not knowing what position, gender, attributes (e.g.
personality, IQ), etc. you will have.
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The Veil Of Ignorance (Rawls)
Rawls :
What society would a rational person choose?
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The ‘Difference Principle’
The rational person would choose a society where
the worst-off are maximally well off, i.e. the idea
that justice is best achieved by the worst off
groups being maximally well off.
The intuitive idea is that the social order is not to establish
and secure the more attractive prospects of those better
off unless doing so is to the advantage of those less
fortunate.’ (Rawls, 1972)1
1
as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)
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The ‘Difference Principle’
However is need or maximizing the welfare of the worst off the
only value?
With other values, should need be given priority?
If one adheres strictly to the idea of need, scarce
resources of a society might be used to provide
minimal help to the few very badly off rather than
much help to many.
Perhaps giving the moderately badly off those limited
resources for more net benefit would be more
equitable?
1
as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)
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Ethical Reasoning
In Practice
Use
complementary
ways of
reasoning
Ethical
Reasoning
Tools
Ethical
Problem
Additionally
Judgement
is required
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Reflective Equilibrium
Rawls (1921-2002)
‘Reflective equilibrium’ (Rawls, 1972) Reasoning about morality requires a continual
moving between our moral responses to specific
situations and our moral theories, i.e. our beliefs
about what is right in various individual
situations, to achieve an equilibrium.
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Method of Reflective Equilibrium
In Practice
Moral
Theories
Case
Ethical
Reasoning
Ethical
Problem
One’s
Moral
Judgements
Additionally
Judgement
is required
Revision to gain coherence
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Rational Dialogue
Aim to achieve reflective equilibrium by discussion
with others, particularly helpful to achieving
convergence and consensus.
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Rational Dialogue
Helps to:
1. identify inconsistencies between our moral
views in one situation and another; and
between our theories and our intuitions
2. ensure we are aware of the perspectives of
different moral theories.
3. ensure we are aware of the perspectives of
different people – and in the medical setting,
this can be particularly important.
‘Med. Ethics and Law – The core curriculum’, Hope,Savulescu, Hendrick, 2008)
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The Role of Emotion
Learning the role of emotion (? moral intuition)
and how to assimilate it into our reasoning.
Intuitively we may arrive at a place we do not feel
comfortable with morally and we may need to
challenge and readjust our reasoning, to bring
our intuitions and theories into line.
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The Role of Emotion
As doctors, our emotional responses need to be
subject to rational analysis.
Feelings of revulsion, pity or fear are not helpful
when trying to decide how best to help others.
And may lead us to make incorrect decisions.
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The Role of Emotion
Nonetheless, our emotional responses of
humanity, compassion and caring for our
patients are essential components of our
medical work.
Without this sensitivity we may lack judgement
and sacrifice basic ethical principles of autonomy,
beneficence, non-maleficence and justice.
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The Role of Emotion
Integration of emotions with the decisional
factors of the process of retrospective thinking
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Reflective Equilibrium
In Practice
Case
Ethical
Reasoning
One’s
Moral
Judgements
Moral
Theories
Ethical
Problem
One’s
Emotions
Additionally
Judgement
is required
Revision to gain coherence
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The Slippery Slope Argument
Runs as follows:
If we allow society to take a certain step or
allow a certain procedure now, the fear is
expressed that this would lead (unavoidably, down
the slippery slope) to some point in the future,
where some further development of or
progression from that initial decision, not
morally permissible, would come about.
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The Slippery Slope Argument
Example:
Banning effective contraception because we fear that to
practise population control is to step on to a slope that
leads inexorably to the extinction of the human race.1
1 John Harris, The Value of Life
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The Slippery Slope Argument
Example:
An opponent of voluntary active euthanasia (VAE) might
argue that allowing such a practice would lead to nonvoluntary euthanasia,
such as the killing of all people over 80 years of age, etc.
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The Slippery Slope
‘The Principle Of The Dangerous Precedent’
[F.M.Cornford (1908)] 1
‘... is that you should not now do an admittedly right action for
fear you, or your equally timid successors, should not have the
courage to do right in some future case, which ex hypothesi is
essentially different, but superficially resembles the present one.
Every public action which is not customary, either is wrong, or, if
it is right, is a dangerous precedent. It follows that nothing should
ever be done for the first time.’
1
As quoted in J. Harris, The Value of Life (1985) p. 127
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The Slippery Slope Argument
We would be both irrational and immoral if we cut
ourselves off from options that we clearly perceive to be
the beneficial products of the procedures now being
developed because we fear that we will be insufficiently
resolute to resist the dangers.1
1 John Harris, The Value of Life, p.127
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Feminist Ethics
Feminist ethics
based on feminist belief system that:
Gender Inequality exists
2.
It is unjust
Social and political actions can help correct existing
inequities
1.
3.
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Feminist Ethics
Hence an approach to ethics that places a very high
priority on exploring and addressing questions of
social justice, particularly gender injustice.
Belief that gender and other forms of injustice (race,
disability, socioeconomic class, age, sexual
orientation) have been largely invisible in the work of
mainstream ethical theorists.
Challenging gender assumptions, race assumptions, age assumptions,
etc.
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Feminist Ethics
Traditional Ethics
Focuses on the Male : i.e. questions and methods
regarding interactions in the public sphere
Ignores the Female: i.e. questions and methods
pertaining to the private sphere of families and
communities
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Feminist Ethics
Liberal Feminism
2. Ethics of Care
3. Oppression Theorists
Continental & Post Modern Feminists
1.
4.
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Feminist Ethics
Affirms the general right of women to control
their own bodies and lives.
Aims to redress the balance of power between the
sexes and to put them on equal terms.
Incorporates both men and women in its model
of care. The concept of the moral agent being
relational rather than independent.
c.f. Roe vs. Wade (1973) US
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Ethics of Care
Resists the concept of gender equality
Moral Reasoning : Women vs. Men (Gilligan, 1982)
1.
Women have tendency to concentrate on narratives,
contexts, and relationships of care, i.e. interpersonal
relationships and human connectedness.
2.
Men tend to emphasize ‘an ethics of justice’, involving
tiers of general moral principles and employing a
logic of hierarchical justification
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Ethics of Care
Moral Reasoning : (Gilligan, 1982)
A competent moral agent should be capable of both
approaches, i.e.
an ethics of care and an ethics of justice approach
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Ethics of Care
Similar to Virtue ethics
‘What would the caring person do’?
Nurturing Values such as Care, Love, Trust,
Responsibility are virtues
A question of responsibility to those who are
dependent on others;
The moral importance in preserving relationships
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Ethics of Care
Joan Tronto (1994) : Questions regarding the responsibility
for attending to the human needs among us should be
central to our thinking in ethics.
4 phases of Caring:
Attentiveness (Recognising Need of Care)
Responsibility (Taking Care of)
Competence (Care giving)
Responsiveness (Evaluating Care Received)
Particularly welcomed in Nursing profession where the needs of individual
patients are central
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Contemporary Virtue Ethics
Aristotle – a virtue is the mean between excess and deficiency,
e.g. Courage mean between Cowardice and Foolhardiness.
Resurgence in modern ethics since, ‘[t]he bankruptcy of modern moral
philosophy.’ 1
The Qualities of A Good Doctor, e.g. compassionate, humane,
courteous, hard-working
The Qualities of A Good Patient, e.g. self-control, moderation,
reasonable expectations
1 Anscombe,
E, MacIntyre, A, as quoted in Glannon, W. ‘Biomedical Ethics’ OUP(2005)
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Contemporary Virtue Ethics
Contemporary focus on the action
An Action is right if and only if it is what an agent with a
virtuous character would do in the circumstances.
Keep a death bed promise : virtue of justice
Save a wounded stranger by a roadside : virtue of
benevolence
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Contemporary Virtue Ethics
Aristotle
‘It is not merely the state in accordance with the right rule, but the
state that implies the presence of the right rule, that is virtue.’
i.e.
Acting as someone with the virtue of benevolence would act
not only involves providing assistance to another but
also includes having and acting from a genuine concern
for the well-being of that person and a disposition to
have and act from that concern in particular types of
situations.
Strong connection between Motive & Rightness has a considerable
intuitive plausibility
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Communitarianism
Aristotle – ‘humans are essentially social beings’.
A reaction to the modern focus on individual rights and
freedoms.
Emphasis on an individual’s responsibilities to their
community and also the responsibility of that
community for the welfare of the vulnerable therein.
Public pursuit of the common good may take precedence
over an individual’s personal objectives.
e.g participation in research ‘is a moral duty’ (see Harris, J)
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