MEDICAL ETHICS

1. MEDICAL ETHICS A Brief Introductory Lecture Ms Shirley Chan / EL Dept / JJC. 2010.

2. What is ethics? • Ethics is a system of moral principles • They affect how people make decisions and lead their lives • Ethics is concerned with what is good for individuals and society • Ethics covers the following dilemmas: • how to live a good life • our rights and responsibilities • moral decisions - what is good and bad?

3. Ethics is used to… • Provide a moral map • Most moral issues get us pretty worked up - think of abortion and euthanasia – hence, we use our hearts rather than our minds to argue • Philosophers can come in to offer us ethical rules and principles that enable us to take a cooler view of moral problems • Ethics provides us with a moral map, a framework that we can use to find our way through difficult issues

4. However… • Ethics doesn't give the right answers • For many ethical issues, there isn't a single right answer - just a set of principles that can be applied to particular cases to give those involved some clear choices • Some philosophers go further and say that all ethics can do is eliminate confusion and clarify the issues. After that it's up to each individual to come to their own conclusions

5. And… • Ethics can give several answers • Many people want there to be a single right answer to ethical questions. • There may be several right answers, or just some least worst answers - and the individual must choose between them • We have to take responsibility for their own choices and actions, rather than falling back on convenient rules and customs

6. Where does ethics come from? • Philosophers have several answers to this question: • God and religion • Human conscience and intuition • A rational moral cost-benefit analysis of actions and their effects • The example of good human beings • A desire for the best for people in each unique situation • Political power

7. Where does ethics come from? • God-based ethics - supernaturalism • Supernaturalism makes ethics inseparable from religion. • It teaches that the only source of moral rules is God • So, something is good because God says it is, and the way to lead a good life is to do what God wants

8. Where does ethics come from? • Intuitionism • Intuitionists think that good and bad are real objective properties that can't be broken down into component parts • Something is good because it's good; its goodness doesn't need justifying or proving • They believe human beings have an intuitive moral sense that enables them to detect real moral truths • So good things are the things that a sensible person realises are good if they spend some time pondering the subject

9. Where does ethics come from? • Consequentialism • It bases morality on the consequences of human actions and not on the actions themselves • Consequentialism teaches that people should do whatever produces the greatest amount of good consequences • One famous way of putting this is 'the greatest good for the greatest number of people' • The most common forms of consequentialism are the various versions of utilitarianism, which favour actions that produce the greatest amount of happiness • Despite its obvious common-sense appeal, consequentialism turns out to be a complicated theory, and doesn't provide a complete solution to all ethical problems • Two problems with consequentialism are: • it can lead to the conclusion that some quite dreadful acts are good • predicting and evaluating the consequences of actions is often very difficult

10. Where does ethics come from? • Non-consequentialism or deontological ethics • Non-consequentialism is concerned with the actions themselves and not with the consequences. It's the theory that people are using when they refer to "the principle of the thing" • It teaches that some acts are right or wrong in themselves, whatever the consequences, and people should act accordingly

11. Where does ethics come from? • Virtue ethics • Virtue ethics looks at virtue or moral character • Virtue ethics is particularly concerned with the way individuals live their lives, and less concerned in assessing particular actions • Virtue ethics teaches that an action is right if and only if it is an action that a virtuous person would do in the same circumstances, and that a virtuous person is someone who has a particularly good character

12. Where does ethics come from? • Situation ethics • Situation ethics rejects prescriptive rules and argues that individual ethical decisions should be made according to the unique situation • Rather than following rules the decision maker should follow a desire to seek the best for the people involved • There are no moral rules or rights - each case is unique and deserves a unique solution

13. Where does ethics come from? • Ethics and ideology • Some philosophers teach that ethics is the codification of political ideology, and that the function of ethics is to state, enforce and preserve particular political beliefs • They usually go on to say that ethics is used by the dominant political elite as a tool to control everyone else

14. Are there universal moral rules? • Moral Absolutism • The belief that there are such universal rules that apply to everyone • There are some moral rules that are always true, that these rules can be discovered and that these rules apply to everyone • Immoral acts - acts that break these moral rules - are wrong in themselves, regardless of the circumstances or the consequences of those acts • Absolutism takes a universal view of humanity - there is one set of rules for everyone - which enables the drafting of universal rules - such as the Declaration of Human Rights • Religious views of ethics tend to be absolutist

15. Are there universal moral rules? • Moral Absolutism • Why people disagree: • Many of us feel that the consequences of an act or the circumstances surrounding it are relevant to whether that act is good or bad • Absolutism doesn't fit with respect for diversity and tradition of unique societies and countries, or religions and ethnic groups

16. Are there universal moral rules? • Moral Relativism • Moral relativists say that if you look at different cultures or different periods in history you'll find that they have different moral rules • Therefore it makes sense to say that "good" refers to the things that a particular group of people approve of • They believe that relativism respects the diversity of human societies and responds to the different circumstances surrounding human acts

17. Are there universal moral rules? • Moral Relativism • Why people disagree: • Many of us feel that moral rules have more to them than the general agreement of a group of people - that morality is more than a super-charged form of etiquette (E.g. the Universal Declaration of Human Rights make sense not just because many people agree to it. It is an intrinsic respect for the sanctity of life)

18. Are there universal moral rules? • Moral Somewhere-in-between-ism • Most non-philosophers think that both of the above theories have some good points and think that • there are a few absolute ethical rules • but a lot of ethical rules depend on the culture

19. Key distinctions • What’s the difference between ethics, morals, values, beliefs, principles, code of conduct? • What about RIGHTS?

20. Key distinctions • BELIEFS • Beliefs: convictions that we generally hold to be true, usually without actual proof or evidence • Assumptions that we make about the world and our values stem from those beliefs • Religious beliefs include: a belief that God created the earth in seven days, or that Jesus was the son of God • Non religious beliefs include: that all people are created equal, which would guide us to treat everyone regardless of sex, race, religion, age, education, status etc with equal respect • Our beliefs grow from what we see, hear, experience, read and think about. From these things we develop an opinion that we hold to be true and unmovable at that time • From our beliefs we derive our values, which can either be correct or incorrect when compared with evidence, but nonetheless hold true for us

21. Key distinctions • VALUES • Values: beliefs of a person or social group in which they have an emotional investment (either for or against something); "he has very conservatives values" • Values are about the worth an individual gives to a person, article or idea • Values include courage, respect, patriotism, honesty, honour, compassion etc • E.g.: We value family piety in our society, as we believe that the elderly are core to the foundations of our society. • Beliefs and values determine our attitudes and opinions

22. Key distinctions • MORALS • Morals: motivation based on ideas of right and wrong • Morals are concerned with the judgement of goodness or badness of human action • Both morals and values are a part of the behavioural aspect of a person

23. Key distinctions • ETHICS • Ethics: A theory or a system of moral values / The rules or standards governing the conduct of a person or the members of a profession • Ethics define the code that a society or group of people adhere to

24. Key distinctions • PRINCIPLES • Principles are general rules and guidelines, intended to be enduring and seldom amended, that inform and support the way in which an organization / profession sets about fulfilling its mission (method used etc) • CODE OF CONDUCT • A code of conduct is a set of rules outlining the responsibilities of or proper practices for an individual or organization

25. Key distinctions • RIGHTS • Rights are explained as legal, social, or moral freedoms to act or refrain from acting, or entitlements to be acted upon or not acted upon • Link between RIGHTS and ETHICS: • Our rights (which different societies may / may not recognise) are determined by our ethical system (which determines what is right or wrong) – informed by our values, morals and beliefs • Q: Is there such a thing as a universal right? Is it ABSOLUTE?

26. Hippocratic Oath • An oath historically taken by doctors swearing to practice medicine ethically

27. Values in medical ethics • The common values that apply to medical ethics discussions are: • Autonomy • Beneficence • Non-maleficence • Justice • Dignity • Truthfulness and honesty • Confidentiality

28. Values in medical ethics • Autonomy • Respect for the individual and his ability to make decisions with regard to his own health and future • Actions that enhance autonomy are thought of as desirable and actions that 'dwarf' an individual and their autonomy are undesirable • Respect for autonomy is the basis for informed consent and advance directives (living will)

29. Values in medical ethics • Autonomy • Psychiatrists are often asked to evaluate a patient's competency for making life-and-death decisions at the end of life • Persons with a psychiatric condition such as delirium or clinical depression do not have the capacity to make end-of-life decisions. Therefore, for these persons, a request to refuse treatment should be ignored • Unless there is a clear advance directive to the contrary, persons who lack mental capacity should be treated according to their best interests • On the other hand, persons who have the mental capacity to make end-of-life decisions have the right to refuse treatment and choose an early death if that is what they truly want. In such cases, psychiatrists should be a part of protecting that right

30. CASE STUDY: EUTHANASIA Euthanasia is the practice of terminating the life of a person or an animal because they are perceived as living an intolerable life, in a painless or minimally painful way either by lethal injection, drug overdose, or by the withdrawal of life support Euthanasia is also known as mercy killing. In Singapore, the signing of the Advance Medical Directive (AMD), allows doctors to put an end to a patient’s sufferings under specific conditions only Medical experts cannot and should not defy the wishes of a dying person, because if this is so, he/she will be deemed as lacking in human compassion and empathy, a treasured quality which is implicit in all areas of science Q: What determines quality of life? How much suffering is truly unbearable?

31. CASE STUDY: EUTHANASIA Dignitas is a Swiss assisted dying group that helps those with terminal illness and severe physical and mental illnesses to die assisted by qualified doctors and nurses Additionally, they provide euthanasia for people with incurable mental illnesses provided that they are of sound judgment and submit to an in-depth medical report prepared by a psychiatrist that establishes the patient's condition as fulfilling the specifications of the Swiss courts Swiss laws on assisted suicide clearly state that people who assist in an assisted suicide can only be prosecuted if they are motivated by self-interest Approximately £7,000 is charged for an assisted suicide and funeral 21% of people receiving assisted dying in Dignitas do not have a terminal or progressive illness, but rather "weariness of life” Several countries (such as Netherlands and Belgium) allow assisted suicide, but only Switzerland allows foreigners – leading to the coining of the term “suicide tourism” EXIT is another Swiss organization providing assisted suicide. In 2008, it had 50,000 members. However, EXIT strictly denies suicide assistance for people from abroad

32. CASE STUDY: EUTHANASIA Chantal Sébire In 2000, she was diagnosed with a rare form of cancer which left her face severely disfigured. She also lost her senses of sight, taste, and smell and suffered severe pain  In 2008 she made a public appeal to the French president, Nicolas Sarkozy, to allow her to die through euthanasia, stating that "One would not allow an animal to go through what I have endured.” This was rejected, as the French courts allow only for removal of life-support equipment for terminally ill patients, it does not allow a doctor to take action to end a patient's life One month later, she died in her home, from a drug used commonly around the world for assisted suicide, though not found in France Q: What is the difference between ACTIVE and PASSIVE involvement of the doctor in assisted suicide? Does it make a difference?

33. CASE STUDY: EUTHANASIA Assisted suicide for HEALTHY people? Case 1: In July 2009, British music conductor Sir Edward Downes and his wife Joan died together at a suicide clinic outside Zürich "under circumstances of their own choosing." Sir Edward was not terminally ill (though he had near deafness and blindness), but his wife was diagnosed with rapidly developing cancer Case 2: Betty and George Coumbias were a Canadian married couple who sought to become the first husband and wife to complete simultaneous suicides with legal authorization. Although assisted suicide is illegal in Canada, they hoped to end their lives with the approval of the government of Switzerland The couple's request was unusual in that, while George Coumbias suffers from heart disease, Betty Coumbias was reported to be in excellent health This was ultimately rejected by the Swiss courts Q: Can a claim of inability to live with the death of a loved one be a valid reason for euthanasia? Q: Where are the limits? Physiological pain versus psychological / emotional suffering?

34. CASE STUDY: IRANIAN CONJOINED TWINS

35. CASE STUDY: IRANIAN CONJOINED TWINS The adult twins came to Singapore in July 2003 for a highly controversial operation to separate them into two individuals but they died on the operating table The twins read up widely on the risks of the surgery and decided to take a chance even though they knew of the possibility of a high failure rate. Also, they were the ones who wanted to have the operation carried out on them, not the doctors. They knew there is always a risk involved in all operations, including simpler ones like Lasik Q: Because of the high risk involved, should doctors have agreed to this operation? Q: How important are the rights of the twins to a meaningful life?

36. CASE STUDY: OTHER CONJOINED TWINS Well – known case of conjoined twins Jodie and Mary: the twins were born in 2000 in UK. Mary was totally dependent on Jodie for survival. Medical reports showed that Jodie was mentally alert, but not Mary. Mary was sapping Jodie’s strength. Jodie would soon die. Their parents refused to separate the two, for religious reasons. The doctors / hospital brought this to the courts. The courts decreed to go ahead with the operation. Mary died immediately. Jodie survived, but required extensive operations and surgeries. She is now a normal child. Q: Can parents make decisions for their children? Q: Should 1 child be sacrificed for another? Q: Can courts interfere in family affairs? • The Siamese twins from Iraq were separated recently in early July 2010. One of the twins had an abnormal growth and was endangering the other. Their father agreed to take the risk even though the mentioned twin had a poor chance of survival upon separation.

37. Case study: Ashley X – “Pillow Angel” • Ashley X was born in 1997 (United States) with severe and permanent brain damage • Her parents argue that keeping her "frozen" as a girl rather than letting her go through puberty and growing into a woman will give her a better life

38. Case study: Ashley X – “Pillow Angel” • When she was 9, they authorised doctors to remove her uterus to prevent menstruation, to limit her breast growth through the removal of breast buds so that she would not experience discomfort when lying down, and give her doses of hormones to stop her growing taller • The parents argue this would ease them in looking after Ashley, and she would have less discomforts from puberty • Opponents have accused Ashley's parents of "Frankenstein-esque" behaviour - of maiming the child for the sake of convenience • After a year of surgery, Ashley reached her adult height of 53 inches and weight of 63 pounds, an estimated reduction of her potential height and weight of 20% and 40%, respectively • Q: Whose rights are more important? The patient or the caregivers? • Q: Who can protect the right of the disabled child?

39. Values in medical ethics • Beneficence • Actions intended to benefit the patient or others • Some argue that beneficence is the only fundamental principle of medical ethics • They argue that healing should be the sole purpose of medicine, and that endeavours like cosmetic surgery, contraception and euthanasia fall beyond its purview

40. CASE STUDY: Isabelle Dinoire Dr Bernard Devauchelle, the French doctor who performed the world’s first face-transplant was accused of self-glorification and fame-seeking The doctor was merely doing his best to serve a patient’s need (in the case of the French woman, Isabelle Dinoire, who underwent the face-transplant, she had been mauled by her dog and lost her nose, lips and chin), knowing that such needs stems from the basic desire of human beings to look their best. In doing so, he contributed to the knowledge of medical transplant surgeries worldwide too. It takes time for medical science to be fully developed and mature and carrying out the face transplant before such techniques were recognised by the medical community. This reflects a disregard for the rest of the researchers as well as to the nature of science for methods to be tested and proven Q: Should doctors take risks? Should the RIGHTS of the patient matter, or is it outweighed by the potential harm if the operation did not take place? Q: Can someone live without a FACE?

41. CASE STUDY: Baby Fae Baby Fae was born premature on October 14 1984 in California with a fatal heart condition Her mother requested aid from Dr. Leonard Bailey, a heart surgeon On October 26, Bailey successfully transplanted a baboon heart into Fae, an astonishing medical and scientific achievement. The baby was in good health for two weeks, when her organs began to falter. She ultimately dies of kidney failure The surgery was widely condemned on moral grounds, from the Vatican to People for the Ethical Treatment of Animals (PETA) Baby Fae would be the first and last human to receive a cross-species heart transplant her surgery taught doctors around the world an incredible amount about organ transplantation Dr. Bailey and his team have performed more than 500 organ transplants in very young children, saving their lives and the lives of countless others through what they learned from Baby Fae Q: Should surgeons embark on potentially threatening procedures to save their patient?

42. Values in medical ethics • Non-maleficence • Actions intended not to harm or bring harm to the patient and others • The concept of non-maleficence is embodied by the phrase “first, do no harm” • In practice, many treatments carry some risk of harm. In some circumstances, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm • The principle of non-maleficence is not absolute, and must be balanced against the principle of beneficence (doing good)

43. Values in medical ethics • Non-maleficence • Doctrine of double effect • This doctrine says that if doing something morally good has a morally bad side-effect, it's ethically OK to do it providing the bad side-effect wasn't intended. This is true even if you foresaw that the bad effect would probably happen • A commonly cited example of this phenomenon is the use of morphine in the dying patient, where use can ease the pain and suffering of the patient, yet simultaneously hastening the demise of the patient through suppression of the respiratory system • Q: Think about the issue of the conjoined twins – where 1 twin may die as a result of a “good” to be accomplished. Is this ethically acceptable?

44. Values in medical ethics • Justice • Distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality) • Actions are consistent, accountable and transparent • not to discriminate on age, sex, religion, race, position or rank • greater good of society • respect of the Law

45. Case study: pricing drugs • Pharmaceutical companies have a duty to uphold an ethical relationship within the marketplace. • There is a duty of care to the health and safety of all. • Issues are raised that as pharmaceutical companies have a large investment to protect and stakeholders to please - how do we ensure that an ethical standard is upheld. • Despite the pharmaceutical industry's notable contributions to human progress, including the development of miracle drugs for treating cancer, AIDS, and heart disease, there is a growing tension between the industry and the public. • Government officials and social critics have questioned whether the multibillion-dollar industry is fulfilling its social responsibilities. This doubt has been fueled by the national debate over drug pricing and affordable healthcare, and internationally by the battles against epidemic diseases, such as AIDS, in the developing world. • Q: Should such firms offer affordable prices for their medication? What implications will this have on innovation and research?

46. Values in medical ethics • Dignity • Innate right to respectful and ethical treatment

47. Case study: conducting drug research in india • Transnational drug companies are moving their clinical trials business to India, giving a new urgency to clinical trials registry reform there • Drug companies are drawn to India for several reasons, including a technically competent workforce, patient availability, low costs and a friendly drug-control system. • While good news for India’s economy, the booming clinical trial industry is raising concerns because of a lack of regulation of private trials and the uneven application of requirements for informed consent and proper ethics review • Q: Should we allow for dubious clinical trials, if the world at large benefits?

48. Values in medical ethics • Truthfulness and honesty • Obligation to full and honest disclosure • Informed consent: • A person must be fully-informed about and understand the potential benefits and risks of their choice of treatment • An uninformed person is at risk of mistakenly making a choice not reflective of his or her values or wishes • If the patient is incapacitated (bedridden, crippled etc) , laws around the world designate different processes for obtaining informed consent, typically by having a person appointed by the patient or their next of kin make decisions for them • The value of informed consent is closely related to the values of autonomy and truth telling

49. Values in medical ethics • Confidentiality • Based on loyalty and trust • Maintain the confidentiality of all personal, medical and treatment information • Information to be revealed with consent and for the benefit of the patient, except when ethically and legally required • Disclosure should not be beyond what is required

50. Values in medical ethics • Confidentiality • Confidentiality is challenged in cases involving the diagnosis of a sexually transmitted disease in a patient who refuses to reveal the diagnosis to a spouse; and • In the termination of a pregnancy in an underage patient, without the knowledge of the patient's parents