Lecture 1 - Introduction to Bioethics

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SCOPE OF BIOETHICS I I. Definition of ethics, Postulates of ethics II. Various ethical schools of thought and how III. IV.

V. VI. VII.

they gave rise to the different ethical theories Development of Bioethics (History) Hippocratic Oath Human person, human act, needs and values Ethical Decision-Making Different Ethical Principles

INTRODUCTION There is controversy/conflict in any profession or discipline mainly because of differences in views or opinions of the parties involved. ETHICS is concerned and interested in human behaviors. It is subject to the determination of right (virtue) or wrong (vice), wherein right actions are rewarded and wrong ones are punished. Any human behavior performed under or with KNOWLEDGE, FREEDOM, and VOLUNTARINESS is within the ambit of moral or ethical judgment. The years 2003 and 2004 are controversial years in the history of modern medicine in the Philippines due to the increasing number of medico-legal cases. Thus, the House Bill No. 4955 (“An Act Punishing the Malpractice of any Medical Practitioner in the Philippines and for Other Purposes”) was passed in response to this. However, this bill threatens to destroy the patientdoctor relationship anchored on mutual trust. Why do we have legal problems in the practice of medicine? Malpractice due to: • Negligence – probably due to values that were not imbibed during medical training • Ignorance – insufficient knowledge of basic and biological sciences • Arrogant doctors • Objective to get rich faster – medicine is a profession of service and not profit A legal problem in medical practice usually begins with an ethical or moral problem. No medico-legal problem starts on a purely legal angle. It always has at its root some ethical or moral basis.

THE NEED FOR BIOETHICS IN MEDICAL PRACTICE The medical profession today is confronted with so many complex and challenging issues: • personal • interpersonal • professional • institutional • social Appropriate responses are not clear. The medical professional is sensitive; responses to the different dilemmas depend on so many variables: • professional status Christian · Hannah · Jacq · James · Monique · Wine

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social, economic, institutional & political climate patient and family values relationships religious beliefs cultural orientation legal constraints

In many instances when health care matters require ethical approach, we cannot follow the principle: “Everything than can be done ought to be done”. There are various ethical limitations in medical practice: • Right of a woman to have an abortion • Should children with serious birth defects put to death? • Do people have a right to die? • Right to medical care • Physicians lying to their patients • Should people suffering from genetic disease be allowed to have children? • Should parents agree to allow their children to be used as experimental subjects? • Is there full reporting of reportable diseases to proper authority (e.g. SARS, H1N1, AIDS)? Solutions for these different dilemmas can be formulated by applying the different ethical principles. Basic principles medical practitioners must know in the practice of the medical profession: • Care of the patient • Alleviate pain and cure the disease • Safeguard the patient’s life and health In this technological age in an artificial environment, we view the world through scientific eyes. To cope with this type of environment, we must be equipped with: • Scientific knowledge and skills to make technical decisions • Ethical knowledge (involves human needs and human value) to make ethical decisions. Hence, there is a need to know human needs and human values. Bioethics cannot be discussed thoroughly without knowledge of health care and responsibility. In this course, therefore, we will try to explain some fundamental questions which concern HEALTH (particularly the last two ones, since the first question is the focus of Family and Community Medicine): 1. What is health and who is responsible for it? 2. What are the ethical principles of health care? 3. How would these principles be applied to ethical issues? To understand human health and to make ethical decisions about how to care for human health in a way that protects human values, we must be aware of the true worth and dignity of human persons.

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Who & what is the human person whose health is to be cared for? Since every ethical decision ought to be based on good reasons that are not merely subjective and arbitrary but that can be rationally defended, there is a need to study PHILOSOPHY. Two branches of Philosophy (Raphael): 1. Philosophy of knowledge – attentive to critical examination of assumptions about matters of fact and argument. • Epistemology – study of knowledge • Metaphysics – study of ultimate reality • Philosophy of science • Philosophy of the mind • Philosophical logic 2. Philosophy of practice – focuses on the critical examination of assumptions about norms or values: • Ethics (moral philosophy) • Social and political philosophy • Philosophy of the law

DEFINITION OF ETHICS, POSTULATES OF ETHICS Ethics – moral philosophy – the study of social morality and philosophical reflection on its norms and practices (basic human behaviors that are specifically and inherently human) Etiology: • Greek: ethika – having to do with character • “ethos” – behavior or custom that is permanent • Latin: “mos” or “moris” – moral, morality Scope of Ethics: • As a science – deals with the study of the morality, or the rightness and wrongness of the human act; • As a discipline – meant for the exercise of human conduct that is good or evil; • As a philosophical study – guides both the speculative and practical intellect in the acquisition and application of ethical principles in concrete human conduct. Moral duty and obligation Ethics is a practical and normative science. It is based on reason, which studies human acts, and provides norms for their goodness or badness. • As a practical science – deals with a systematized body of knowledge that can be used, practiced, and applied to human action. • As a normative science – establishes norms or standards for the direction and regulation of human actions. It deals only with human acts insofar as they are performed with intellectual deliberation and volition. How is Ethics distinguished from VALUES or MORES? Christian · Hannah · Jacq · James · Monique · Wine

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MORES – behavior which a society determines to be acceptable behavior. They are set in time and place. VALUES – ideals or principles, as of a given society.

Medical Ethics – concerned with value choices in medical practice Bioethics – a more recent discipline, an outgrowth of philosophy focusing on man as the center of reality and of human life; it is a philosophy of life. It centers on the happiness of man. It is very comprehensive and treats of human life and society. Bioethics – the systematic study of human conduct in the area of life science and health care in the light of moral values and principles – the branch of applied ethics which investigates practices & developments in the life science and/or biomedical fields (Beauchamp & Childress) Bioethics involves: • obtaining relevant factual information • assessing its reliability • identifying moral problems • mapping out alternative solutions problems

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Importance/Significance of Bioethics: 1. The health care procedures done by health professionals and their corresponding right conduct in the practice of health care: • preventive • curative • rehabilitative 2. The possession of health or wholeness of the health seekers or patients is entrusted to health professionals. Medical practice is an integrally technical and ethical profession. The doctor is a physician, not a technician. 3. The world of health profession and life can only be possibly practised and lived by recognizing the ethical dimension in them through which they can regulate human actions and relations. 4. The study of Bioethics deserves careful recognition especially by those who have not been well-versed in the complexities of the medical or health care professions. The rationale in the study of bioethics: 1. To address the perennial ethical problems, issues and dilemmas confronting health and pastoral workers; 2. To address legal problems in health care with ethical concerns. 3. To address the challenge of modern technology.

VARIOUS ETHICAL SCHOOLS OF THOUGHT AND HOW THEY GAVE RISE TO THE DIFFERENT ETHICAL THEORIES Naturalism

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A view of moral judgment that regards ethics as dependent upon human nature and psychology.

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Attributes differences in moral codes to social conditions. c. Suggests basic congruence related to the possession, by nearly all people, of similar underlying psychological tendencies – universality in moral judgment. d. Allows each group or person to make judgments based upon feelings about particular actions in particular situations. e. Raphael points to sympathy as a motivating factor in moral decision making. This entails imagining ourselves in the shoes of the other and consequently sharing their feelings. Rationalism

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Argue that feelings and perceptions, though they may seem similar in many people, may not actually be similar. b. Believe there are absolute truths that are not dependent upon human nature; ethical values have an independent origin in the nature of the universe or in the nature of God, and can be known to humans through the process of reasoning. c. Believe there are truths about the world that are necessary and universal, and that these truths are superior to the information that we receive from our senses. Plato (founder of the Academy in Athens) and Aristotle (Western Philosophy; 384-322 BC) have disagreed over a lot of things, but they have agreed on this one thing: “That the life of VIRTUE is rewarding for the virtuous, as well as beneficial for the community…That the highest and most satisfying form of human existence is that in which man exercises his rational faculties to the fullest extent.” The ultimate goal of humans is to develop their reasoning powers, therefore, the life of the intellect is the highest form of life. According to ST. THOMAS AQUINAS (13th century), ethics is an organized type of KNOWLEDGE leading to certain general judgments about what is RIGHT or WRONG in HUMAN ACTIVITY. Basic Characteristics: Emphasizes on ENDS or GOALS of human activity, enabling it to judge various types of actions in term of end-directed character of HUMAN NATURE. • Prior ATTITUDE of moral agents (influenced by habits): o intelligent thinking o reasonable willing o controlled emotions • MEANS • ACTUAL EXPERIENCE • CONSEQUENCES of one’s moral actions to self and society ARISTOTELEAN ETHICS has been influenced by Aquinas: Aristotle believes that “goodness of character is produced by the practice of virtuous behavior rather than virtuous acts being the end result of a good character.” Ethics is identified with five distinct habits:

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Hexeis – the ability to grasp the starting points (principles, definitions) of reasoning. 2. Episteme, scientia (scientific thinking) – the skill to reason step-by-step to well-established conclusions. 3. Sophia (wisdom) – the ability to evaluate experience in terms of the highest standards. 4. Phronesis (prudence, practical wisdom) – the acquired ability to reason to good practical conclusions concerning one’s free actions. 5. Poeisis (art) – the acquired ability to make things reasonably well. Virtues Theories Character Ethics – an individual’s actions are based upon a certain degree of INNATE MORAL VALUE. Cardinal Values (Homer, Plato, Aristotle, Aquinas & early Christian thinkers) 4 C’s: CARING – concerned or attentive CHARITY – benevolent feeling COMPASSION – ability to imagine oneself in the situation of another COURAGE – ability to face difficulty or danger with firmness and without fear DISCERNMENT – sensitive insight involving acute judgment and understanding and eventuates in decisive action FAITH – complete confidence or trust GENEROSITY – liberality in giving or sharing HONESTY – trustworthiness HOPE – feeling that events will turn out for the best INTEGRITY – soundness, reliability, wholeness, and an integration of moral character JUSTICE – rightfulness or lawfulness PRUDENCE – having caution and good judgment RESPONSIBILITY – accountability 2T’s: TEMPERANCE – self-restraint in action or statement. TRUSTWORTHINESS – having a confident belief in and reliance upon the ability and moral character of another person. WISDOM – knowledge of what is true or right coupled with good judgment; enlightened understanding Doctrine of Ethical Relativism a. There are no universal or absolute moral principles. Standards of RIGHT or WRONG are always relative to a particular culture. b. Strength: Every culture has its own form of moral action. c. Criticism: • Hitler killing 6 million Jews • Hippocratic Oath • In the medical context, religious practice against medical interventions: Jehovah’s witness Situation Ethics a. Proponent: Joseph Fletcher b. The moral norm depends upon a given situation, but whatever this situation

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maybe, one must always act in the name of Christian love. c. 3 types of love: • Eros – sexual love, relates man to a woman; refers to heterosexual relationship. • Philia – brotherly/sisterly love • Agape – refers to one’s care and concern and kindness towards others. Christian love; love of one’s neighbor. d. Propositions: • Only one thing is intrinsically good, namely LOVE, nothing else. (Agape) • The ultimate norm of Christian decision is LOVE, nothing else. Love for human being, irrespective of race, creed or culture. (e.g. A physician who extends medical assistance to an NPA rebel or to a MLNF rebel.) • Love & justice are the same, for justice is love distributed. To love someone is to be just to that person as well. • Love wills the neighbor’s good whether we like him or not. • Only the end justifies the means, nothing else. • Decisions ought to be made situationally, not prescriptively. e. In the medical context: • A patient who needs medical treatment should be extended help to irrespective of creed, race, color or ideology. • Medical assistance should not be motivated by kinship, favoritism, friendship, utang na loob, pakikisama, comradeship or camaraderie, and monetary gains. • Difficulties: confidentiality, veracity, medical abuse & misuse, mercy killing

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Deontological Theories a. Affirm principles regarding the inherent or intrinsic rightness or wrongness of actions.

b. Deontology (also called Kantian Ethics, by

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Pragmatism

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Proponents: Charles Peirce (18391814) and William James (1840-1910) b. Holds that the true and valid form of knowledge is one which is: • PRACTICAL – sensible results • WORKABLE – can be put to work • BENEFICIAL – helps or does people good • USEFUL – can aid in attaining good results c. Application to Medicine: Truth must be verified and tested through: • Experimentation • Instrumentalism • Reconstructionism – reconstruct human experience and relate to one’s own. • Progressism – an individual progresses through his experience & self-activity. d. Examples: Drug testing and Family Planning Methods e. Difficulties of Pragmatism: Christian · Hannah · Jacq · James · Monique · Wine

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Materialistic Individualistic

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German philosopher Immanuel Kant), came from the Greek word “deontos,” meaning duty Immanuel Kant (1724-1804) was a brilliant German thinker influenced by Spinoza & Rousseau, and heightened by Judaeo Christian Ethics “Actions possess moral worth only when we do our duty for its own sake.” Based upon rationalist view: the rightness or wrongness of an act depends upon the nature of the act rather than its consequences. An action is right when it conforms to laws or rules laid down by legitimate authority and wrong when it violates these laws. Kant’s philosophy is called formalism or Kantianism: “Moral rules are absolute and apply to all people, for all times in all situations”. It asserts that: • All people are equal, irrespective of gender, race, creed, social or financial status; • All people are equally competent to make universally legislative decisions. Kant maintains that an act is moral if and only if one does whatever one is obliged to do. Categorical Imperative vs. Hypothetical Imperative: • Categorical imperative (essence of Kant’s ethics):  Mandates an action without any condition whatsoever, and without regard to the consequences that such an action may yield;  Enjoins a person to do such and such an act without qualification;  Lays a universal rule, which if followed, will ensure that the person is acting from a sense of duty, such an act is morally legitimate and just. • Hypothetical imperative: a command with a corresponding condition or limitation Two types of duties: • Perfect duty – one which we must always observe, irrespective of time and place or circumstance • Imperfect duty – must be observed only on some occasions Ross’ Ethics (1877) – William David Ross, a British Aristotelian scholar and moral philosopher. Rule Deontological Theory: The rightness or wrongness of an act is brought about by motive, circumstances, and end result of the action.

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m. Ross distinguished between actual duty and prima facie duty: • Actual Duty – an absolute obligation that one has to do the right thing at all times; a duty that one has to do at all times, no matter what. • Prima Facie Duty – a conditional moral duty, where one's obligation to fulfill that moral duty depends on the situation one is in (e.g. keeping promises, loyalty). n. Ross Ethics – Intuitionism: • Learn & discern the facts in the case; • Consider the possible consequences of our actions; • Reflect on our prima facie duties; • Decide on the best course of action under the circumstances. o. Types of Prima Facie Duties: • Fidelity – faithful to our duties, obligations, vows, or pledges-telling the truth to the patient • Reparation – a duty to make amends for injury that we have inflicted on others; duty of compensation. • Gratitude – a duty to appreciate and recognize the services others have done for us, which may be either a favor, kindness, good fortune, a great help, or saving one’s life. • Justice – proper distribution of social benefits and burdens; distribution of scarce medical resources. • Beneficence – duty to bring about what is good for others, but also to help them better their conditions with respect to virtue, intelligence and comfort. • Self-improvement – improving ourselves with respect to virtue, intelligence and happiness. • Non-maleficence – avoid inflicting evil, injury or harm upon others as we would avoid doing so to ourselves. p. In the medical context, prima facie duties provide moral guidelines for health care professionals. Teleological-Consequentialist Theories a. Comes from the Greek word “teleos” – goal, end b. The weakness of any deontological system is that it does not give any ultimate reason why the will of the authority itself is right or wrong. c. Laws are useful and necessary guides for our ethical decisions, but still we cannot help questioning whether some laws are just. Teleological methodologies seek to answer this question. d. Teleology: • Seeks to justify or reject an action by determining whether it is an effective or self-defeating means to the goal of true human fulfillment in the community. Christian · Hannah · Jacq · James · Monique · Wine

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Affirms principles regarding the production of good and the avoidance of bad consequences.

Utilitarianism a. Consequentialism b. An action is judged as good or bad in relation to the consequence, outcome, or end that is derived from it; based on Naturalism (Burkhardt & Nathaniel). c. Goal of human life is maximum satisfaction, or, one who produces more satisfactory consequences than unsatisfactory ones (Ashley & O’Rourke). d. Right action is that which has the greatest utility or usefulness (Burkhardt). e. Proponents: • Epicurus (Roman philosopher, 200300 B.C.) – Both good and evil lie in sensation, pleasure being good and pain being evil. Pleasure can be gained by living a life of moderation, courage and justice and by cultivating friendship. • Jeremy Bentham (English philosopher, 1748-1832) – Leading political philosopher, father of modern utilitarianism; Actions can be considered to be right when they increase happiness and diminish misery, and can be considered to be wrong when they have the opposite effect. f. Principle of Utility – by utility is meant that property in any object, whereby it tends to produce benefit, advantage, pleasure, good, or happiness or to prevent the happening of mischief, pain, evil, or unhappiness to the party whose interest is considered. g. Principle of the Greatest Happiness – an action is good (right) in so far as it produces the greatest happiness for the greatest number of people; bad (wrong) insofar as it produces more harm than benefit for the greatest number of individuals. h. Act Utilitarianism (situational) suggests that people choose actions that will, in any given circumstance, increase the overall good. • It recognizes that tenets should be used as rough guidelines rather than strict rules. There are no universal rules but that every action must be judged in its unique context. (Beauchamp & Childress) • Proponent: Joseph Fletcher whose general ethical rule is “Do what is most loving in the circumstances.” i. Rule Utilitarianism (absolute) accepts general ethical rules as prima facie rules that are generally obliging but admit exceptions in some circumstances. • It suggests that people should act according to rules that tend to maximize happiness and diminish unhappiness. • “Greatest good for the greatest number.”

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Requires that people tell the truth. Rule utilitarianism sacrifices rights of individuals in favor of the overall good. It gives little recognition to the principle of autonomy. • “Thou shalt not kill.” The supreme principle of ethics is the greatest good for the greatest number. • The argument of this rule-utilitarian was that even though the patient’s health is sometimes maximized through the use of deception, a widespread use of deception will eventually cause more harm than good. Thus, though rule-utilitarians recognize that in some instances good might result from a particular act, in the end, the overall good is maximized by the following of strict rules in all situations. • Examples:  Population control resulting to  an old population  Telling the truth about the patient’s illness  Severely damaged newborn: ordinary treatment or extraordinary treatment? • In the medical context: Provides a system of formulating testing and evaluating hospital policies and/or regulations for the enactment of laws, directives, guidelines and codes of conduct. • Examples:  Hospital visits: time; age of visitors; length of visits  Vaccine testing  Drug testing Weakness of Utilitarianism: It can be used to justify almost any action because it provides no objective way of measuring the good and bad consequences of an action.

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Proportionalism a. Popular in the Catholic Church b. Seeks to reduce ethical decisions to a single fundamental principle of proportion, as follows: “An action is morally good if the pre-moral values that it promotes outweigh the pre-moral disvalues it promotes; otherwise, it is morally evil. Physical Pre-moral Values Psychological Social c. Proportionalists argue that the criterion in making such legitimate exceptions is the principle of proportion. • Principle of Proportion – if the values achieved by the act outweigh the disvalues or harm caused, then the act is moral. Prudential Personalism a. Consistent with the teaching of the Catholic Church b. Based on moral discrimination and not on the principle of proportion.

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c. Agrees with Proportionalism that in every moral decision we must take into account not only prima facie concrete moral norms but also the circumstances and the purposes of the actors; d. But contrary to Proportionalism, it maintains that some basic human values, corresponding to the basic needs of the human person, are non-negotiable and can never be violated. e. Prudential because it takes full account of the circumstances and purposes of human actions, but also considered as Personalism because it protects the dignity and basic rights of the person against violation by anyone or by society (Ashley & O’Rourke, p. 83). f. There are, however, some concrete moral norms are valid in all circumstances and for any purpose: • Examples: It is always wrong to kill innocent human beings; It is always wrong to commit incest or rape; It is always wrong to perjure oneself. g. Such actions strike at the nonnegotiable values of human life on which all human society is based, and they are contradictory to our love of neighbor and therefore our love of God.