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Introduction to Bioethics

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Introduction to Bioethics

What is Bioethics?

Now often known as medical ethics or clinical ethics – hospital based issues

Philosophical study of ethical issues brought about by advances in scientific and medical technologies

Bioethical dilemmas arise when different parties, albeit all well-meaning, hold divergent values that lead to opposing viewpoints on appropriate actions

Common Bioethical Issues Disagreements between family and clinicians

regarding the patient/resident’s best interest Living at risk (eating, wandering, falling) Deciding appropriate forms of care Determining legitimate level of restraint Determining patient preferences without

clear instructions (Terri Schiavo) Providing services that take up tremendous

resource (e.g., multiple transplants)

History of Bioethics Started as concerns regarding research ethics Nuremberg Doctors’ Trial -- 23 German

physicians who either participated in the Nazi program to euthanize persons deemed "unworthy of life“ or who conducted experiments on concentration camp prisoners without their consent were tried.  The trial lasted 140 days.  85 witnesses testified and almost 1,500 documents were introduced.  16 of the doctors charged were found guilty.  7 were executed.

Nazi Experiments

The Nuremberg Code (1947) Voluntary consent Anticipate scientific benefits Benefits outweigh risks Animal experiments first Avoid suffering No intentional death or disability Protection from harm Subject free to stop / withdraw Qualified investigators Investigator will stop if harm occurs

History of Bioethics The distinct academic field began in the

1960s in the United States Philosophers and theologians were later

joined by physician-ethicists and lawyers Scientific advances coupled with cultural

changes New emphasis on individual autonomy and

rights – suspicion of medical paternalism Focused on individual research participant

and patient

What Were Founding Bioethicists Studying?

Normative ethics – formulation and defense of basic principles, values, virtues, and ideals governing moral behaviour

Descriptive ethics – factual descriptions of moral behaviour and belief systems

Analytic approach – discerning meanings of life, concepts of rights/justice/fairness, etc.

Balancing ethical principles Shift from the greatest good to

individual rights

Major Principles in Bioethics Tom Beauchamp and James Childress’s

Principles of Biomedical Ethics: Non-maleficence and Beneficence

Utilitarian – harm-benefit analysisdo no harmbest interest standard

Autonomyrespect for one’s rights and dignityinformed and voluntary consent

Justicefairnesscaring for the most vulnerable

As the Story Goes...

Suppose a trolley is running out of control down a track. In its path are 5 people who have been tied to the track. Fortunately, you can flip a switch, which will lead the trolley down a different track to safety. Unfortunately, there is a single person tied to that track.

Should you flip the switch?

Another Story... A physician has five patients, each in need of

a different organ and will die without that organ. Unfortunately, there are no organs available to perform any of these five transplant operations. A young man who just got hit by a trolley is brought into the ER. In the course of assessing his injuries, which are not life-threatening if treated immediately, the doctor discovers that his organs are compatible with all five of his dying patients.

Would it be justified for the physician to let the patient die to harvest his organs to save the other five patients?

How Bioethics Have Evolved

Feminist critique Social structure and power hierarchy Concerns of medicalization Significance of social relationships Multiculturalism and perceived

homogeneity among bioethicists Care ethics -- justice reconfigured Relational autonomy

How Bioethics Have Evolved (Continued)

Disability critique Vulnerability and dependency as human

conditions Meanings of “normal” and a “good” life Medical vs social model Cure vs social acceptance Social contexts affect individual

decisions Meaning of autonomy challenged

Current Focus in Bioethics

Branches – biomedical/clinical ethics, research ethics, organizational ethics

Genetics Brain imaging technologies Multiculturalism End-of-life care Aging Health-care resource allocation

Systematic Approach in Resolving Dilemmas

Finding thoughtful and rational justification for our beliefs and decisions

More than intuitive responses – ask why we may have certain intuitions, and how to manage conflicting intuitions

Systematic approach can help to identify essential elements to ethical decision-making, ease pressure, and promote consistency in resolving dilemmas

Issues to Consider in Approaching Dilemmas

Define and identify the ethical dilemma Clarify the facts and identify stakeholders –

what’s known and what’s not? Medical indications

Diagnosis, prognosis, treatments or medication history, other clinical options, etc.

Patient/Resident/Family (PRF) preferences Advance directives, code status, goals of care, etc.

Quality of life The PR’s subjective evaluation of his or her situation

Contextual factors Social contexts, family situation, cultural/religious values, financial

situation, etc.

Issues to Consider (Continued) Analyze and balance the values involved

Various principles may help – autonomy, beneficence, non-maleficence, justice

What do various available options and our prioritization of certain values/principles over others say about who we are?

Make a recommendation Involve relevant stakeholders – shared decision making

Follow up and evaluation ensures accountability, consistency, and

transparency, thereby promoting trust and integrity

Case Discussion

As a result of an automobile explosion, 25 year-old Dax Cowart was badly burned over 65% of his body. Both eyes, both ears and both hands were damaged beyond repair. Large doses of narcotics were required for minimal pain relief. To control the many infected areas on his body, Cowart had to be submerged daily in a tank of highly chlorinated water to disinfect his wounds. The experience was excruciatingly painful, and Cowart protested and refused the “tankings.” He pleaded with his caregivers to be allowed to die, and stated several times that he wanted to kill himself. The physicians turned to his mother to obtain consent for all his treatments.

What Should the Clinicians Do?

Moral Considerations

Factual Considerations

Non-Maleficence Medical Indication

Beneficence PF Preference

Autonomy Quality of Life

Justice Contextual Factors

Care