Transcript Introduction to medical ethics and bioethics.

Med HUM III
Introduction to Ethics, Medical
ethics, Bioethics
Main ethical approaches
Prof. Marija Definis-Gojanović
October 2016
ETHICS / MORAL
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The oldest scientific and philosophical discipline
? Demarcation: science / subject
ethics
moral
(gr. ethos = custom,
(lat. mos = character,
practice)
nature)
- Ethics – discipline about moral or philosophy
on moral
- Moral – system of norms or rules, written or not,
about human behavior
Ethics is a philosophical
discipline about moral
problems, deals with art of
living
What is Ethics?
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The formal study of:
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What is right and wrong.
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The study of the bases or principles
for deciding right and wrong.
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The analyses of the processes by
which we decide what is right and
wrong.
Ethics is not:
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Merely obeying the law
Compliance
Although in many instances laws are
statements of considered ethical
positions and most of the time
obeying the law is an element of
ethical behavior.
Relation between moral and other
regulative norms
Moral norm – specific individual system of personal
values with validity of genesis, development and
adoption
 Other regulative norms (close to moral):
- Of primitive society
- Of customs
- Of religion
- Of law
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Religious vs. Moral norms:
- religious norms are characterized by concept
“sanctity”
(moral ones by term “good”)
- religious norms are more absolute, without
conditions and inevitable that moral ones
- when broke religious norm, a man committed sin
(when violated moral norm, a man felt he
committed mistake against his dignity)
Traditional arrangements
of the field of ethics:

Meta-ethics (nature of right or good, nature
and justification of ethical issues)
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Normative ethics ( standards, principles)
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Applied ethics (actual application of ethical
principles to particular situation)
Three Broad Types of
Ethical Theory:
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1) Consequentialist theories (primarily
concerned with the ethical consequences of
particular actions)
2) Non-consequentialist theories (broadly
concerned with the intentions of the person
making ethical decisions about particular
actions)
3) Agent-centered theories (more concerned
with the overall ethical status of individuals)
Consequentialist Theories:
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The Utilitarian Approach
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The Egoistic Approach
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The Common Good Approach
Consequentialist Theories:
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The Utilitarian Approach
Epicurus (341-270 BCE) - the best life is one that
produces the least pain and distress
Jeremy Bentham (1748-1832) - actions could be
described as good or bad depending upon the
amount and degree of pleasure and/or pain they
would produce
John Stuart Mill (1806-1873) - modified this system
/subjective concept of “happiness” opposed to the
more materialist idea of “pleasure”/
Consequentialist Theories:
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The Egoistic Approach
variation of the utilitarian approach - known as
ethical egoism, or the ethics of self- interest: an
individual often uses utilitarian calculation to
produce the greatest amount of good for him or
herself
proponents: Thrasymacus (c. 459-400 BCE),
Thomas Hobbes (1588-1679), Ayn Rand (19051982)
Consequentialist Theories:
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The Common Good Approach
Plato (427-347 BCE) and Aristotle (384-322 BCE)
promoted the perspective that our actions should
contribute to ethical communal life
Jean-Jacques Rousseau (1712-1778): the best
society should be guided by the “general will” of
the people which would then produce what is best
for the people as a whole
Non-consequentialist Theories:
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The Duty-Based Approach
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The Rights Approach
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The Fairness or Justice Approach
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The Divine Command Approach
Non-consequentialist Theories:
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The Duty-Based Approach
sometimes called deontological ethics
associated with Immanuel Kant (1724-1804): doing
what is right is not about the consequences of our
actions but about having the proper intention in
performing the action
Kant’s formula for discovering our ethical duty:
“categorical imperative.” The most basic form: “Act
only according to that maxim by which you can at
the same time will that it should become a
universal law.”
Non-consequentialist Theories:
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The Rights Approach
history that dates back to the Stoics of Ancient
Greece and Rome, John Locke (1632-1704)
stipulates that the best ethical action is that which
protects the ethical rights of those who are affected
by the action
it emphasizes the belief that all humans have a
right to dignity
many now argue that animals and other nonhumans such as robots also have rights
Non-consequentialist Theories:
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The Fairness or Justice Approach
the Law Code of Hammurabi in Ancient
Mesopotamia (c. 1750 BCE) held that all free men
should be treated alike, just as all slaves should be
treated alike
today: John Rawls (1921-2002), who argued,
along Kantian lines, that just ethical principles are
those that would be chosen by free and rational
people in an initial situation of equality
Non-consequentialist Theories:
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The Divine Command Approach
sees what is right as the same as what God
commands; ethical standards are the creation of
God’s will
following God’s will is seen as the very definition
what is ethical
because God is seen as omnipotent and
possessed of free will, God could change what is
now considered ethical
Agent-centered Theories:
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The Virtue Approach
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The Feminist Approach
Agent-centered Theories:
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The Virtue Approach
argues that ethical actions should be consistent
with ideal human virtues
Aristotle: ethics should be concerned with the
whole of a person’s life, not with the individual
discrete actions a person may perform in any given
situation
approach prominent in non-Western contexts,
especially in East Asia (Confucius (551-479 BCE):
to act virtuously (in an appropriate manner)
Agent-centered Theories:
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The Feminist Approach
virtue approach to ethics supplemented and
sometimes revised by thinkers in the feminist
tradition, who often emphasize the importance of
the experiences of women and other marginalized
groups to ethical deliberation
the most important contributions of this approach:
the principle of care as a legitimately primary
ethical concern, often in opposition to the cold and
impersonal justice approach
Applied Ethics
Terms Used in Ethical Judgments
- Obligatory: it is not only right to do it, but that it is
wrong not to do it (ethical obligation to perform the
action)
- Impermissible: it is wrong to do it and right not to
do it
- Permissible: or ethically “neutral,” because it is
neither right nor wrong to do
 Supererogatory: types of actions are seen as going
“above and beyond the call of duty (they are right
to do, but it is not wrong not to do them)
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Types of Ethics
Professional Ethics: Obligations of the
profession
- Self-regulation
- Education of self and others
 Medical Ethics:
- human: medical (in narrow sense) and dental
- veterinarian
Knowledge, deliberation, understanding of medical
practice that should be in perspective of right,
honorable, accurate behavior
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Medical Ethics
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a field of applied ethics, the study of moral
values and judgments as they apply to
medicine. As a scholarly discipline, medical
ethics encompasses its practical application in
clinical settings as well as work on its history,
philosophy, theology, sociology, and
anthropology.
Based on definition of “Medical Ethics” http://en.wikipedia.org/wiki/Medical_ethics
Medical Ethics
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Long history
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Third Dynasty (Egypt) 2700 BCE
Code of Hammurabi (Babylon) 1750 BCE
Oath of the Hindu Physician (Vaidya’s Oath) 15th cy. BCE
Hippocratic oath (Hippocrates, ca 460-370 BCE)
The Oath of Asaph and Yohanan (ca 6th cy. CE)
Advice to a Physician (Persia) 10th cy. CE
Oath of Maimonides 12th cy. CE
Ming Dynasty (China) 14th cy. CE
Seventeen Rules of Enjun (Japanese Buddhist Physicians) 16th
cy. CE)
Drawn from Codes of Medical and Human Experimentation Ethics by Victoria Berdon
and Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html
History cont.
Percival's Code (England), 1803: basis for first AMA
Code of Medical Ethics.
 Beaumont's Code (United States), 1833: experimental treatments,
voluntary, informed consent.
 American Medical Association (AMA) - Code of Medical Ethics,
1847.
 Claude Bernard (France), 1865.
 Walter Reed (United States), 1898: introduces written consent
“contracts”. Allows healthy human subjects in medical experiments.
 Berlin Code or Prussian Code (Germany), 1900: no medical
experiments when subject not competent to give informed consent, in
the absence of unambiguous consent, or when information not properly
explained to subject.
 Reich Circular (Germany), 1932: concerned with consent and wellbeing of the subjects.
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Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and
Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html
Modern issues and statements
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Nuremberg Code (1947)
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Medical research
Declaration of Geneva, W.M.A. (1948, 1968, 1984, 1994, 2005, 2006)
World Medical Association International Code of Medical
Ethics
AMA revision (1957)
Declaration of Helsinki, application to medical research (1964,
rev. 1975, 1983, 1989, 1996, 2000)
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Belmont Report (1979)
AMA revision (2001)
Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and
Jennifer Flavin viewable at http://wisdomtools.com/poynter/codes.html
Why study medical ethics?
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“As long as the physician is a knowledgeable and
skilful clinician, ethics doesn’t matter.”
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“Ethics is learned in the family, not in medical
school.”
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“Medical ethics is learned by observing how senior
physicians act, not from books or lectures.”
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“Ethics is important, but our curriculum is already too
crowded and there is no room for ethics teaching.”
Why study medical ethics?
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ethics is and always has been an essential
component of medical practice
some ethical principles are basic to the physicianpatient relationship, but application in specific
situations is often problematic due to disagreement
about what is the right way to act)
study of ethics prepares medical students to
recognize difficult situations and to deal with them in
a rational and principled manner
Why study medical ethics?
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integral part of medicine at least since the time of Hippocrates
concept of medicine as a profession
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in recent times - influence by developments in human rights
(e.g., violations of human rights, such as forced migration and
torture; whether healthcare is a human right)
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closely related to law (e.g., medical licensing and regulatory
officials), but
ethics prescribes higher standards; occasionally requires that
physicians disobey laws that demand unethical behaviour;
laws differ significantly from one country to another while
ethics is applicable across national boundaries
Bioethics
Medical ethics closely related to bioethics
(biomedical ethics), but
not identical
- medical ethics focuses primarily on issues arising
out of the practice of medicine
- bioethics: very broad subject, concerned with the
moral issues raised by developments in the
biological sciences
- bioethics does not require the acceptance of certain
traditional values that are fundamental to medical
ethics
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Bioethics
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branch of applied ethics that studies the
philosophical, social, and legal issues arising in
medicine and the life sciences
it is chiefly concerned with human life and wellbeing, though it sometimes also treats ethical
questions relating to the nonhuman biological
environment
Bioethics
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era of replacing human organs and their functions
began with chronic dialysis and renal
transplantation in the 1960s.
unprecedented
problems (selection of patients; "God Committee“)
origin: Potter’s “Bioethics, the Science of Survival”
(1970), which suggests viewing bioethics as a
global movement; Callahan’s “Bioethics as a
Discipline” (1973), in which he argues for the
establishment of a new academic discipline;
creation of institute in which researchers should
examine and analyze medical dilemmas
Bioethics
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repeated story about the origin of the term
bioethics is incorrect
German theologian Fritz Jahr published articles
(1927, 1928, 1934) using the German term “BioEthik” (which translates as “Bio-Ethics”) and
forcefully argued more civilized, ethical approach
to issues concerning human beings and the
environment
his bioethical imperative: “Respect every living
being, in principle, as an end in itself and treat it
accordingly wherever it is possible.”
As Practical Ethics, Medical Ethics
focuses on:
The process of deciding what is the most
appropriate (right) course of action in a particular
situation:
 given these facts
 given my skills and abilities
 operating with finite knowledge
 in real time
 and then effecting that course of action.
Ethical Problems
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Problems caused by fact of having to
choose between goods or things to which
we owe an obligation
Bad rankings of goods
Failure to grasp facts
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Ignorance
Incompetence
Willful blindness
Bad factual analysis
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Often caused by personal or institutional
distortion
Organizational Problems
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General organizational culture
Ego and narcissism
Overly punitive responses
Lack of a culture of responsibility
Failure to acknowledge information
distortion
Bad communication flows
High transaction costs for doing the
“right” thing
Process of making ethical decisions
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Awareness—Is there a moral issue here?
 What is its nature? How important?
What are the facts?
What are the issues?
What rules or values apply here?
To whom or what do I owe a duty?
How should they be applied?
Who needs to decide and act? Who ought to?
To what am I obligated because of role/position?
What are the consequences?
What are the options?!
Duties to whom or what?
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Individuals
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Groups
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Patients
Patients’ families/guardians
Colleagues
Co-workers
Self
Profession
Society
The weak
Ideas/Principles
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The Law
Truth
Justice
Individual value
Duties—Sources
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Legal Obligations
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Institutional Obligations
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Health insurance
Emergency treatment
Reporting duties
Practices of hospital
Professional norms and
obligations
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Inhere with being a physician
How do individuals decide what is ethical?
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Two different ways of approaching ethical issues:
1.
Non-rational (not irrational)
2.
Rational
How do individuals decide what is ethical?
1.
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Non-rational (not irrational) approaches:
Obedience - following the rules or instructions of
those in authority, whether or not you agree with
them (common way: children and those who work
with authorities)
Imitation - following the example of the role model
Feeling or desire (subjective approach)
Intuition - location in the mind (rather than the will)
Habit – there is no need to repeat a systematic
process each time a moral issue arises similar to
one that has been dealt with previously
How do individuals decide what is ethical?
1.
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Rational approaches:
Deontology (search for well-founded rules)
Consequentialism (the right action is the one that
produces the best outcomes; the best known is
utilitarianism uses “utility” as a measure: “the
greatest good for the greatest number”)
Principalism (often clash of principles)
Virtue ethics (a type of moral excellence; important
virtues: compassion, honesty, prudence, dedication)
Framework for ethical decision-making
IN PRACTICE
1.
2.
Four steps problem-solving process:
Problem identification (identify: technical facts,
moral parameters, legal constraints, relevant
human values)
Develop alternative curses action (identify: relevant
ethical principles for each alternative, recognize
ethical assumptions for each alternative, determine
additional emerging ethical problems)
Framework for ethical decision-making
IN PRACTICE
Four steps problem-solving process:
3. Select one alternative course of action (justify the
selection of your alternative, defend your selection
upon ethical grounds)
4. Consider objections to alternative selected
(objections arising from: factual errors, faulty
reasoning, conflicting values)
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Framework for ethical decision-making
IN PRACTICE
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Determine whether the issue at hand is an ethical
one.
Consult authoritative sources to see how
physicians generally deal with such issues.
Consider alternative solutions.
Discuss your proposed solution with those whom it
will affect.
Make your decision and act on it.
Evaluate your decision and be prepared to act
differently in future.
Factors in ethical decision-making in
health-care
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2.
3.
Ethical theories
Ethical principles
Ethical rules
ETHICAL MAXIM (principles)
General guidelines that site what is forbidden,
desirable or permissible (often base for rules)
1.
2.
3.
4.
Respecting autonomy
Doing no harm (nonmaleficence)
Benefiting others (beneficence)
Being just (justice)
- Being faithful (fidelity)
ETHICAL RULES (codes)
manners developed by professional organizations
Structure of codes:
1.
regulative
2.
protective (for public opinion)
3.
specific (regarding membership)
4.
obligated
Professional codes as a framework for
decision making
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Over centuries medical profession has developed
its own standards of behavior for its members –
expressed in codes of ethics and related policy
documents
Global level: WMA, UN Principles of medical ethics
Ethical directives of medical associations are
general in nature but
“in making decisions, it is helpful to know what other
physicians would do in similar situations”