ethical reasoning & contemporary medical ethics 2

Medical Ethics Year 1 1

Ethical Reasoning Ethical Reasoning & &

Contemporary Medical Contemporary Medical Ethics 2Ethics 2

Lecture 4Lecture 4

2828thth October 2009 October 2009Dr. Ruth PilkingtonDr. Ruth Pilkington

2Medical Ethics Year 1

‘The Four Principles’ in Medical Ethics

Beauchamp & Childress (2001)Beauchamp & Childress (2001)

The Four Principles in Medical Ethics

Respect for (Patient) Autonomy

Beneficence

Justice

Non-Maleficence


Respect for Patient AutonomyRespect for Patient Autonomy

AutonomyAutonomy literally means ‘ literally means ‘self-ruleself-rule’ or ‘’ or ‘self-self-governancegovernance’.’.

An individual’s capacity to make decisions about An individual’s capacity to make decisions about their health care needs and to consent to or their health care needs and to consent to or refuse treatment depends on their ability to refuse treatment depends on their ability to think, decide and act, freely, on the basis of think, decide and act, freely, on the basis of

such thought and decision.such thought and decision.

Two essential conditions for autonomy:Two essential conditions for autonomy:

LibertyLiberty

AgencyAgency



‘‘The autonomous individual acts freely in The autonomous individual acts freely in accordance with a self chosen plan,...A accordance with a self chosen plan,...A person with diminished autonomy, by person with diminished autonomy, by contrast, is in some respect controlled by contrast, is in some respect controlled by others or incapable of deliberating or others or incapable of deliberating or acting on the basis of his or her desires and acting on the basis of his or her desires and plansplans’, ’, (Beauchamp & Childress (2001))(Beauchamp & Childress (2001))

c.f. c.f. Those with diminished autonomy Those with diminished autonomy e.g.e.g. prisoners, prisoners, learning disabled persons, patient with dementia.learning disabled persons, patient with dementia.



Look at Autonomous Look at Autonomous ChoiceChoice rather than rather than Generally Autonomous Generally Autonomous CapacityCapacity, , i.e. i.e. a a

generally autonomous person may not be generally autonomous person may not be able to act autonomously in certain able to act autonomously in certain

situations.situations.

Respect for patient autonomy requires doctors Respect for patient autonomy requires doctors (+ family) to help patients make their own (+ family) to help patients make their own decisions and to respect those decisions decisions and to respect those decisions

(irrespective of whether one believes those (irrespective of whether one believes those decisions to be wrong).decisions to be wrong).






Beneficence

Justice

Non-Maleficence


Non-MaleficenceNon-Maleficence

We should avoid doing harming to others.We should avoid doing harming to others.‘‘Primum non nocere’Primum non nocere’ – [ – [transtrans. first (or above all) . first (or above all)

do no harm] – this would make medicine a very do no harm] – this would make medicine a very difficult pursuit! difficult pursuit!

It is an extremely important principle to avoid It is an extremely important principle to avoid harming others, but cannot take priority and be harming others, but cannot take priority and be

expressed as an absolute principle. Must be expressed as an absolute principle. Must be considered in the context of the obligation in considered in the context of the obligation in medicine of the principle to do good for our medicine of the principle to do good for our patients (beneficence), patients (beneficence), e.ge.g cancer surgery. cancer surgery.

Also balance required with the principles of Also balance required with the principles of autonomy and justice, autonomy and justice, e.g.e.g. involuntary isolation. involuntary isolation.






Beneficence

Justice

Non-Maleficence


BeneficenceBeneficence

The obligation to do good / promote what The obligation to do good / promote what is best for the patient.is best for the patient.

Sometimes conflict may arise between Sometimes conflict may arise between doctor's judgement of what is in the doctor's judgement of what is in the

patient’s patient’s best interestsbest interests and his desire to and his desire to respect the patient’s different but respect the patient’s different but

autonomousautonomous decision. decision.Must be balanced with the principles of Must be balanced with the principles of respect for autonomy, non-maleficence respect for autonomy, non-maleficence and justice (and justice (e.g.e.g.. rights and needs of . rights and needs of

others).others).






Beneficence

Justice

Non-Maleficence


JusticeJustice

Distributive JusticeDistributive Justice: Decisions re the allocation of scarce : Decisions re the allocation of scarce health resources (e.g. outpatient time, drugs, money, health resources (e.g. outpatient time, drugs, money,

ICU beds,...)ICU beds,...)

Patients in similar situations (Patients in similar situations (e.ge.g same diseases) should same diseases) should normally have access to the same health care (normally have access to the same health care (e.g.e.g. same same diagnostic technologies/pharmaceutical interventions).diagnostic technologies/pharmaceutical interventions).

But attempt to distribute our limited resources fairly, so But attempt to distribute our limited resources fairly, so that in providing for some, others are not left wanting.that in providing for some, others are not left wanting.

Justice also applies to Justice also applies to Forensic MedicineForensic Medicine (psychiatrists (psychiatrists assessment of sanity for court), assessment of sanity for court), Employment JusticeEmployment Justice (fair (fair promotion in the workplace), promotion in the workplace), Prohibition of involvement Prohibition of involvement

in Torturein Torture (Declaration of Tokyo), etc. (Declaration of Tokyo), etc.


Distributive JusticeDistributive Justice

Health Resource AllocationHealth Resource Allocation

Justice requires that like cases be Justice requires that like cases be treated alike and that the benefits and treated alike and that the benefits and

burdens of health services be burdens of health services be allocated equitably across patients.allocated equitably across patients.

However what criteria?However what criteria?

Clinical factors, patient values, system Clinical factors, patient values, system goals...goals...


JusticeJustice

No consensus moral theory to help No consensus moral theory to help resolve differences between resolve differences between

conflicting values, conflicting values,

HoweverHowever

the goal the goal

is is

FairnessFairness..


Strict Egalitarianism

Advocates the allocation of equal Advocates the allocation of equal material goods (healthcare material goods (healthcare

resources) resources)

to all members of society.to all members of society.


John B. Rawls John B. Rawls (1921-2002)(1921-2002)

‘‘Justice as Fairness’Justice as Fairness’

envisions a society of free citizens envisions a society of free citizens holding equal basic rights holding equal basic rights

cooperating within an egalitarian cooperating within an egalitarian economic system. economic system.


Rawls : Needs TheoryRawls : Needs Theory

Rawls rejected Rawls rejected utilitarianutilitarian approaches approaches to maximizing total welfare and to maximizing total welfare and

libertarianlibertarian ‘free for all’. ‘free for all’.

Believed in a theory of social justice.Believed in a theory of social justice.


Rawls : Needs TheoryRawls : Needs Theory

‘‘The Difference Principle’The Difference Principle’Some patients have Some patients have a special claima special claim on on

resources that rests not on the resources that rests not on the maximization of overall welfare but maximization of overall welfare but on the greater on the greater needneed for treatment. for treatment.


The Veil Of Ignorance The Veil Of Ignorance (Rawls)(Rawls)

Imagine self in an ethereal place Imagine self in an ethereal place looking down on a world of different looking down on a world of different societies, each distributing wealth in societies, each distributing wealth in

different ways.different ways.

You must choose which society you You must choose which society you will belong to, will belong to, not knowingnot knowing what what position, gender, attributes (e.g. position, gender, attributes (e.g.

personality, IQ), etc. you will have.personality, IQ), etc. you will have.


The Veil Of Ignorance The Veil Of Ignorance (Rawls)(Rawls)

Rawls : Rawls :

What society would a rational person What society would a rational person choose?choose?


The ‘Difference Principle’The ‘Difference Principle’

The rational person would choose a society The rational person would choose a society where the worst-off are maximally well where the worst-off are maximally well

off, off, i.e.i.e. the idea that justice is best the idea that justice is best achieved by the worst off groups being achieved by the worst off groups being

maximally well off.maximally well off.

The intuitive idea is that the social order is The intuitive idea is that the social order is not to establish and secure the more not to establish and secure the more

attractive prospects of those better off attractive prospects of those better off unless doing so is to the advantage of unless doing so is to the advantage of those less fortunate.’ (Rawls, 1972)those less fortunate.’ (Rawls, 1972)11

11 as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)


The ‘Difference Principle’The ‘Difference Principle’However is However is needneed or or maximizing the welfare of maximizing the welfare of

the worst offthe worst off the only value? the only value?

With other values, should need be given With other values, should need be given priority?priority?

If one adheres strictly to the idea of need, If one adheres strictly to the idea of need, scarce resources of a society might be used to scarce resources of a society might be used to provide minimal help to the few very badly off provide minimal help to the few very badly off

rather than much help to many.rather than much help to many.

Perhaps giving the moderately badly off those Perhaps giving the moderately badly off those limited resources for more net benefit would limited resources for more net benefit would

be more equitable? be more equitable? 11 as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)


Ethical Reasoning Ethical Reasoning In PracticeIn Practice

Ethical Reasoning

Tools

AdditionallyJudgement is required

Usecomplementary

ways of reasoning

Ethical

Problem


Reflective EquilibriumReflective Equilibrium

Rawls (1921-2002)Rawls (1921-2002)

‘‘Reflective equilibrium’Reflective equilibrium’ (Rawls, 1972) (Rawls, 1972) - -

Reasoning about morality requires a Reasoning about morality requires a continual moving between our moral continual moving between our moral responses to specific situations and responses to specific situations and our moral theories, i.e. our beliefs our moral theories, i.e. our beliefs

about what is right in various about what is right in various individual situations, to achieve an individual situations, to achieve an

equilibrium.equilibrium.


Method of Reflective Equilibrium Method of Reflective Equilibrium In PracticeIn Practice

One’sMoral

Judgements


Moral Theories

CaseEthical

Reasoning

Ethical

Problem

Revision to gain coherence


Rational DialogueRational Dialogue

Aim to achieve Aim to achieve reflective equilibriumreflective equilibrium by discussion with others, by discussion with others,

particularly helpful to achieving particularly helpful to achieving convergence and consensus.convergence and consensus.


Rational DialogueRational Dialogue

Helps to: Helps to: 1.1. identify inconsistencies between our identify inconsistencies between our

moral views in one situation and moral views in one situation and another; and between our theories and another; and between our theories and our intuitionsour intuitions

2.2. ensure we are aware of the perspectives ensure we are aware of the perspectives of different moral theories.of different moral theories.

3.3. ensure we are aware of the perspectives ensure we are aware of the perspectives of different people – and in the medical of different people – and in the medical setting, this can be particularly setting, this can be particularly important.important.

‘‘Med. Ethics and Law – The core curriculum’, Med. Ethics and Law – The core curriculum’, Hope,Savulescu, Hendrick, 2008)Hope,Savulescu, Hendrick, 2008)


The Role of EmotionThe Role of Emotion

Learning the role of emotion (? moral Learning the role of emotion (? moral intuition) and how to assimilate it intuition) and how to assimilate it

into our reasoning. into our reasoning.

IntuitivelyIntuitively we may arrive at a place we we may arrive at a place we do not feel comfortable with morally do not feel comfortable with morally and we may need to challenge and and we may need to challenge and

readjust our reasoning, to bring our readjust our reasoning, to bring our intuitions and theories into line.intuitions and theories into line.



As doctors, our emotional responses need As doctors, our emotional responses need to be subject to rational analysis. to be subject to rational analysis.

Feelings of revulsion, pity or fear are not Feelings of revulsion, pity or fear are not helpful when trying to decide how best helpful when trying to decide how best

to help others. to help others.

And may lead us to make incorrect And may lead us to make incorrect decisions. decisions.



Nonetheless, our emotional responses Nonetheless, our emotional responses of humanity, compassion and caring of humanity, compassion and caring

for our patients are essential for our patients are essential components of our medical work.components of our medical work.

Without this sensitivity we may lack Without this sensitivity we may lack judgement and sacrifice basic ethical judgement and sacrifice basic ethical principles of principles of autonomy, beneficence, autonomy, beneficence,

non-maleficence and justicenon-maleficence and justice..



Integration of emotions with the Integration of emotions with the decisional factors of the process of decisional factors of the process of

retrospective thinkingretrospective thinking


Reflective Equilibrium Reflective Equilibrium In PracticeIn Practice

One’sMoral

Judgements

One’sEmotions

Moral Theories

CaseEthical

Reasoning


Ethical

Problem

Revision to gain coherence


The Slippery Slope ArgumentThe Slippery Slope Argument

RRuns as follows:uns as follows:If we allow society to take a certain step If we allow society to take a certain step

or allow a certain procedure now, the or allow a certain procedure now, the fear is expressed that this would lead fear is expressed that this would lead ((unavoidably, down the slippery slopeunavoidably, down the slippery slope) )

to some point in the future, where some to some point in the future, where some further development of or progression further development of or progression from that initial decision, not morally from that initial decision, not morally

permissible, would come about.permissible, would come about.


The Slippery Slope The Slippery Slope ArgumentArgument

Example: Example: Banning effective contraception because we Banning effective contraception because we

fear that to practise population control is fear that to practise population control is to step on to a slope that leads inexorably to step on to a slope that leads inexorably

to the extinction of the human race.to the extinction of the human race.11

1 John Harris, The Value of Life



Example: Example: An opponent of voluntary active euthanasia An opponent of voluntary active euthanasia

(VAE) might argue that allowing such a (VAE) might argue that allowing such a practice would lead to non-voluntary practice would lead to non-voluntary

euthanasia, euthanasia,

such as the killing of all people over 80 such as the killing of all people over 80 years of age, years of age, etc.etc.


The Slippery SlopeThe Slippery Slope

‘‘The Principle Of The Dangerous Precedent’ The Principle Of The Dangerous Precedent’ [F.M.Cornford (1908)][F.M.Cornford (1908)] 11

‘‘... is that you should not now do an admittedly ... is that you should not now do an admittedly right action for fear you, or your equally timid right action for fear you, or your equally timid successors, should not have the courage to do successors, should not have the courage to do

right in some future case, which ex hypothesi is right in some future case, which ex hypothesi is essentially different, but superficially essentially different, but superficially

resembles the present one. Every public action resembles the present one. Every public action which is not customary, either is wrong, or, if it which is not customary, either is wrong, or, if it

is right, is a dangerous precedent. It follows is right, is a dangerous precedent. It follows that nothing should ever be done for the first that nothing should ever be done for the first

time.’time.’11 As quoted in J. Harris, The Value of Life (1985) p. 127 As quoted in J. Harris, The Value of Life (1985) p. 127



We would be both irrational and immoral We would be both irrational and immoral if we cut ourselves off from options that if we cut ourselves off from options that we clearly perceive to be the beneficial we clearly perceive to be the beneficial products of the procedures now being products of the procedures now being

developed because we fear that we will developed because we fear that we will be insufficiently resolute to resist the be insufficiently resolute to resist the

dangers.dangers.11

1 John Harris, The Value of Life, p.127


Feminist EthicsFeminist Ethics

Feminist ethics Feminist ethics based on feminist belief system that:based on feminist belief system that:

1.1. Gender Inequality existsGender Inequality exists

2.2. It is unjustIt is unjust3.3. Social and political actions can help Social and political actions can help

correct existing inequitiescorrect existing inequities



Hence an approach to ethics that places a very Hence an approach to ethics that places a very high priority on exploring and addressing high priority on exploring and addressing

questions of social justice, particularly questions of social justice, particularly gender injustice.gender injustice.

Belief that gender and other forms of injustice Belief that gender and other forms of injustice (race, disability, socioeconomic class, age, (race, disability, socioeconomic class, age,

sexual orientation) have been largely invisible sexual orientation) have been largely invisible in the work of mainstream ethical theorists.in the work of mainstream ethical theorists.Challenging gender assumptions, race Challenging gender assumptions, race

assumptions, age assumptions, etc.assumptions, age assumptions, etc.



Traditional EthicsTraditional Ethics Focuses on the Male : Focuses on the Male : i.e.i.e. questions questions

and methods regarding interactions and methods regarding interactions in the public spherein the public sphere

Ignores the Female: Ignores the Female: i.e.i.e. questions and questions and methods pertaining to the private methods pertaining to the private

sphere of families and communitiessphere of families and communities



1.1. Liberal FeminismLiberal Feminism

2.2. Ethics of CareEthics of Care

3.3. Oppression TheoristsOppression Theorists

4.4. Continental & Post Modern Continental & Post Modern FeministsFeminists



Affirms the general right of women to Affirms the general right of women to control their own bodies and lives.control their own bodies and lives.

Aims to redress the balance of power Aims to redress the balance of power between the sexes and to put them on between the sexes and to put them on

equal terms.equal terms.

Incorporates both men and women in its Incorporates both men and women in its model of care. The concept of the moral model of care. The concept of the moral

agent being relational rather than agent being relational rather than independent.independent.

c.f. c.f. Roe vs. WadeRoe vs. Wade (1973) US (1973) US


Ethics of CareEthics of Care

Resists the concept of gender equalityResists the concept of gender equalityMoral Reasoning : Women vs. Men (Moral Reasoning : Women vs. Men (Gilligan, 1982Gilligan, 1982))

1.1. Women have tendency to concentrate on Women have tendency to concentrate on narratives, contexts, and relationships of care, narratives, contexts, and relationships of care,

i.e.i.e. interpersonal relationships and human interpersonal relationships and human connectedness.connectedness.

2.2. Men tend to emphasize Men tend to emphasize ‘an ethics of justice’,‘an ethics of justice’, involving tiers of general moral principles and involving tiers of general moral principles and employing a logic of hierarchical justificationemploying a logic of hierarchical justification



Moral Reasoning : (Moral Reasoning : (Gilligan, 1982Gilligan, 1982))

A competent moral agentA competent moral agent should be capable should be capable of both approaches, i.e. of both approaches, i.e.

an ethics of carean ethics of care and and an ethics of justicean ethics of justice approachapproach



Similar to Virtue ethicsSimilar to Virtue ethics

‘‘What would the caring person do’?What would the caring person do’?

Nurturing ValuesNurturing Values such as Care, Love, such as Care, Love, Trust, Responsibility are virtues Trust, Responsibility are virtues

A question of responsibility to those A question of responsibility to those who are dependent on others; who are dependent on others;

The moral importance in preserving The moral importance in preserving relationshipsrelationships



Joan Tronto (1994)Joan Tronto (1994) : Questions regarding the : Questions regarding the responsibility for attending to the human responsibility for attending to the human needs among us should be central to our needs among us should be central to our

thinking in ethics.thinking in ethics.

4 phases of Caring:4 phases of Caring:Attentiveness (Recognising Need of Care)Attentiveness (Recognising Need of Care)

Responsibility (Taking Care of)Responsibility (Taking Care of)

Competence (Care giving)Competence (Care giving)

Responsiveness (Evaluating Care Received)Responsiveness (Evaluating Care Received)

Particularly welcomed in Nursing profession where Particularly welcomed in Nursing profession where the needs of individual patients are centralthe needs of individual patients are central


Contemporary Virtue EthicsContemporary Virtue EthicsAristotle Aristotle – – a virtuea virtue is the mean between is the mean between excessexcess and and

deficiencydeficiency, , e.g. e.g. Courage mean between Cowardice and Courage mean between Cowardice and

Foolhardiness. Foolhardiness.

Resurgence in modern ethics sinceResurgence in modern ethics since,, ‘[t]he bankruptcy of ‘[t]he bankruptcy of modern moral philosophy.’ modern moral philosophy.’ 11

The Qualities of The Qualities of A Good DoctorA Good Doctor, e.g. compassionate, , e.g. compassionate, humane, courteous, hard-workinghumane, courteous, hard-working

The Qualities of The Qualities of A Good PatientA Good Patient, e.g. self-control, , e.g. self-control, moderation, reasonable expectationsmoderation, reasonable expectations

1 1 Anscombe, E, MacIntyre, A, as quoted in Glannon, W. ‘Biomedical Ethics’ OUP(2005)Anscombe, E, MacIntyre, A, as quoted in Glannon, W. ‘Biomedical Ethics’ OUP(2005)


Contemporary Virtue EthicsContemporary Virtue EthicsContemporary Contemporary focus on the actionfocus on the action

An Action is right if and only if it is what an An Action is right if and only if it is what an agent with a virtuous character would do in agent with a virtuous character would do in

the circumstances. the circumstances.

Keep a death bed promise : Keep a death bed promise : virtue of justicevirtue of justiceSave a wounded stranger by a roadside : Save a wounded stranger by a roadside :

virtue of benevolencevirtue of benevolence


Contemporary Virtue EthicsContemporary Virtue EthicsAristotleAristotle

‘‘It is not merely the state in accordance with the right It is not merely the state in accordance with the right rule, but the state that implies the presence of the rule, but the state that implies the presence of the

right rule, that is virtue.’right rule, that is virtue.’i.e.i.e.

Acting as someone with the Acting as someone with the virtue of benevolencevirtue of benevolence would act not only involves providing assistance to would act not only involves providing assistance to another but also includes having and acting from a another but also includes having and acting from a genuine concern for the well-being of that person genuine concern for the well-being of that person

and a disposition to have and act from that concern and a disposition to have and act from that concern in particular types of situations.in particular types of situations.

Strong connection between Motive & Rightness has a Strong connection between Motive & Rightness has a considerable intuitive plausibilityconsiderable intuitive plausibility


CommunitarianismCommunitarianism

Aristotle – Aristotle – ‘humans are essentially social beings’.‘humans are essentially social beings’.

A reaction to the modern focus on individual rights A reaction to the modern focus on individual rights and freedoms.and freedoms.

Emphasis on an individual’s responsibilities to their Emphasis on an individual’s responsibilities to their community and also the responsibility of that community and also the responsibility of that community for the welfare of the vulnerable community for the welfare of the vulnerable

therein.therein.

Public pursuit of the common good may take Public pursuit of the common good may take precedence over an individual’s personal precedence over an individual’s personal

objectives.objectives.

e.ge.g participation in research ‘ participation in research ‘is a moral dutyis a moral duty’ (’ (see see Harris, JHarris, J))

ethical reasoning & contemporary medical ethics 2

Documents

principles of respect

principles of autonomy

diminished autonomy

patient autonomyautonomy

patient autonomylook

autonomous capacity

autonomous person

autonomous decision