Transcript MedEthics-Year-I-ContemporayEthicsPrintable09

Ethical Reasoning
&
Contemporary Medical
Ethics
Lecture 3
21st October 2009
Dr. Ruth Pilkington
Ethics Lectures to date
1. Historical Overview of Medical Ethics
2. Traditional Moral Theory
Find at :
www.medicine.tcd.ie/ethics/ethicsyrone/index.php
Traditional Moral Theory
Kantian
(Deontological)
Ethics
Utilitarianism
Virtue Ethics
Contemporary Medical Ethics
‘...the student begins with the patient,
continues with the patient, and ends
his studies with the patient, using
books and lectures as tools...’
Sir William Osler, Canadian Physician(1906)
As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics
(2008)
Ethical Reasoning
Clinical Ethics is learnt in the same way as clinical
medicine is learnt, ‘at the coalface’, through
meeting patients and their families, being
involved in their cases. It is a practical discipline.
The doctor must learn to recognise the ethical
aspects of his/her clinical (and scientific
research work), and to make reasoned decisions
about this work within the framework of the law
and Medical Council guidelines.
Ethical Reasoning
Learning to Reason
Many (most?) clinical situations, and
decisions involve a combination of
factual concerns and ethical issues.
Ethical Reasoning
Learning to Reason
Scientific Reasoning
The skill of evaluating the
scientific evidence available
and applying it, using
clinical judgement to the
clinical scenario at hand.
This is a fundamental part
of your medical education
and later practice.
Ethical Reasoning
In the same way, ethical
reasoning is a skill required
to allow you to identify and
negotiate ethical problems,
using an organized
framework of ethical
methods or tools in the
clinical setting.
Ethical reasoning must stand up to scrutiny, (in court if necessary) in the
same way as the scientific aspects of decision-making.
Ethical Reasoning
Learning to Reason
Judgement
Judgement is needed in making final
decisions – there is no ethical algorithm
that can be applied without judgement.
Tools of Ethical Reasoning
How should I act morally in this situation?
Methods or Tools in Bioethics –
to help determine how best to guide human action
Bioethical Methodologies
How should I act morally in this situation?
1. Practical or Applied Ethics Applied Philosophy of
Medicine (Theoretical Framework using various elements
of ethical theories, etc.)
2. Principlism (Fixed set of moral principles, e.g.
Beauchamp & Childress)
3. Case comparison (Case based approach – real
/paradigm cases but no clear method)
4. Combined technique to seek compromise (?fails to
achieve moral clarity)
Tools of Ethical Reasoning
1. Distinguish
Facts from
Values
2. Clarify the
logic of
the argument
6. Reason
from principles
& theories
Tools
5. Rational
Decision
Theory
3. Case
comparison
4. Thought
experiments
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Clarify the Logic of
the Argument
Syllogisms – deductive argument expressed in the form
of two propositions called premises, and a conclusion that results logically.
P1
P2
C
P1
is
P2
C
If p then q
p
q
e.g.
If a foetus is a person it
wrong to kill it
A foetus is a person
It is wrong to kill a
foetus
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
P1
P2
C
P1
is
P2
C
If p then q
Not q
Not p
e.g.
If a foetus is a person it
wrong to kill it
It is not wrong to kill a
foetus
A foetus is not a person
Clarify the Logic of
the Argument II
An Invalid argument
P1
P2
C
If p then q
Not p
Not q
e.g.
P1
If a foetus is a person it
is wrong to kill it
P2
A foetus is not a
person
[C]
[It is not wrong to kill a
foetus]
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Clarify the Logic of
the Argument III
An Invalid argument
P1
P2
C
If p then q
Not p
Not q
e.g.
P1 If it is raining I will
wear a coat
P2
It is not raining
[C] [Therefore I will not
wear
a coat]
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Tools of Ethical Reasoning
1. Distinguish
Facts from
Values
2. Clarify the
logic of
the argument
6. Reason
from principles
& theories
Tools
5. Rational
Decision
Theory
3. Case
comparison
4. Thought
experiments
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Thought Experiments I
Absolute Argument :
‘It is never right to kill someone’
The Case Of The Trapped
Lorry Driver
The Case Of The Trapped Lorry
Driver1
A driver is trapped in a blazing lorry. There is no
way in which he can be saved. He will soon
burn to death. A friend of the driver is
standing by the lorry. This friend has a gun
and is a good shot. The driver asks his friend
to shoot him dead. It will be less painful for
him to be shot than to burn to death.
Should the friend shoot the driver dead?
1
As quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)
Thought Experiments II
Absolute Argument:
‘There is an absolute right to life’
The Case Of The Connected
Violinist
The Case Of The Connected Violinist
(JJ Thompson, A Defense of Abortion , 1971)
You wake up one morning with your circulatory
system connected to another person. It turns out
that you are connected to a famous violinist, with
a fatal kidney ailment. If he remains connected
to your circulatory system, he will eventually be
cured. The Society of Music Lovers have
kidnapped you and connected you up, as you
are the only person with a suitable blood type.
‘But, never mind’, his doctors say, ‘It is only for 9
months and then he will be fully recovered and
then you can be disconnected.’
Thought Experiments III
Acts and Omissions:
‘Is there a moral difference between killing
and letting die’
The Cases of Smith and Jones
(Rachels J, ‘Active and Passive Euthanasia’, NEJM (1975)
The Cases of Smith and Jones
Rachels J, ‘Active and Passive Euthanasia’, NEJM (1975)
Smith stands to gain a
huge inheritance should
anything happen to his 6
yr old cousin.
One evening, he sneaks in
while the child is having a
bath and drowns the boy.
Jones also stands to
inherit if anything
happens to his 6 yr old
cousin. He sneaks into the
bathroom, to drown his
cousin, but finds that the
child has slipped and is
drowning in the bath.
Jones does nothing and
allows him to drown.
Is there any moral difference between what Smith and Jones did?
Tools of Ethical Reasoning
1. Distinguish
Facts from
Values
2. Clarify the
logic of
the argument
6. Reason
from principles
& theories
Tools
5. Rational
Decision
Theory
3. Case
comparison
4. Thought
experiments
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Rational Decision Theory
Consequentialist approach
To determine / maximise the best outcome, e.g. in
the allocation of scarce health resources, etc.
Assign probabilities and values to outcomes to
calculate the best ‘expected utility’ and thus
make decision on this basis.
Rational Decision Theory
Clinical Scenario
A decision must be made on whether or not to
resuscitate Mr. O’Connor, in the event of cardiac arrest.
Possibilities
Resuscitation Outcome
10% (p=0.1) success
Future QoL (value)
Reasonable (+5)
40% (p=0.4) success
Poor (-10)
50% (p=0.5) death
0
No resuscitation (DNR) = Death = value of 0
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Rational Decision Theory
Clinical Scenario II
Whether or not to resuscitate Mr.
O’Connor?
DNR :
‘Expected Utility’ 1 x 0 = 0
Resuscitation:
‘Expected Utility’ (0.1 x 5) + (0.4 x -10) +(0.5 x 0) = -3.5
Hence on basis of ‘expected utilities’, it is better
not to attempt resuscitation.
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
Tools of Ethical Reasoning
1. Distinguish
Facts from
Values
2. Clarify the
logic of
the argument
6. Reason
from principles
& theories
Tools
5. Rational
Decision
Theory
3. Case
comparison
4. Thought
experiments
Adapted from Hope, Savulescu, Hendrik,
Medical Ethics and Law (2008)
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
Respect for Patient Autonomy
Autonomy literally means ‘self-rule’ or ‘selfgovernance’.
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
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
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).
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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.
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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).
‘The Four Principles’ in Medical
Ethics
Beauchamp & Childress (2001)
The Four Principles in Medical Ethics
Respect for (Patient) Autonomy
Non-Maleficence
Beneficence
Justice
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.