A Brief History and Overview Of Biomedical Ethics

1. A Brief History and Overview Of Biomedical Ethics Dr. Ruth Pilkington 7th October 2009 Med Yr 1

2. What is Biomedical Ethics? Med Yr 1

3. Medical Ethics • Ethics expresses the ways in which we examine, explore and attempt to understand the moral life. • What are the moral obligations of health professionals in a world of advancing technology and promise. • Allows us to reflect on the relationship between the professional and the patient. Med Yr 1

4. Medical Ethics • Ethics : a generic term for the various ways of understanding and examining the moral life • Moral Choices: • what values, what reasons and what language Med Yr 1

5. Medical Ethics • Applied Ethics : a practical discipline • Investigates ethical issues which arise in medicine and healthcare by applying the principles and methods of moral philosophy to these problems Med Yr 1

6. Medical Ethics • The doctor patient relationship • What makes a good doctor / professional? • What choices, values and traits Med Yr 1

7. How Should One Live?(Socrates) • How doctors should treat patients rests on general moral principles about how a person should treat another person • Thus • Biomedical ethics grounded firmly in the study of moral philosophy Med Yr 1

8. What is Biomedical Ethics? • Species of practical normative ethics • Norms = standards of right and wrong action & behaviour • Normative ethics = is concerned with how people ought to act, what sort of person one ought to be or what sort of policies ought tot be implemented. Med Yr 1

9. What is Biomedical Ethics? • Species of practical normative ethics • What one is obligated or permitted to do, or prohibited from doing, in different contexts of biotechnology, medical practice and research. • So we employ principles and theories of normative ethics to motivate and justify actions and policies in biomedicine. Med Yr 1

10. What is Biomedical Ethics? • Species of practical normative ethics • Objectivity • Impartiality Med Yr 1

11. What is Biomedical Ethics? • Descriptive ethics • Descriptive ethics is concerned with how people actually behave, not how they ought to behave. Med Yr 1

12. What is Biomedical Ethics? • Metaethics • Metaethics is focussed on the nature of morality; concerned with the point of ethics, i.e. what do the terms ‘good’, ‘bad’, ‘wrong’, right mean.. Med Yr 1

13. Contemporary Medical Ethics • ‘...the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools...’ • Sir William Osler, Canadian Physician(1906) • As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics (2008) Med Yr 1

14. Ethical Reasoning • Clinical Ethics is learnt in the same way as clinical medicine is learnt, ‘at the coalface’, through meeting patients and their families, being involved in their cases. It is a practical discipline. • The doctor must learn to recognise the ethical aspects of his/her clinical (and scientific research work), and to make reasoned decisions about this work within the framework of the law and medical council guidelines. Med Yr 1

15. Contemporary Medical Ethics • ‘Society allows doctors a degree of personal freedom in making decisions and in their interactions with patients. But in giving doctors that freedom society expects them to be able to defend their decisions and actions with reasons...Doctors must be able to show how their decisions and actions relate to the law and to the relevant guidelines.’1 • 1Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Med Yr 1

16. Scientific Reasoning The skill of evaluating the scientific evidence available and applying it, using clinical judgement to the clinical scenario at hand. This is a fundamental part of your medical education and later practice. Ethical Reasoning In the same way, ethical reasoning is a skill required to allow you to identify and negotiate ethical problems, using an organized framework of ethical methods or tools in the clinical setting. Ethical ReasoningLearning to Reason Ethical reasoning must stand up to scrutiny, (in court if necessary) in the same way as the scientific aspects of decision-making. Med Yr 1

17. Traditional Medical Ethics Med Yr 1

18. 2500 Years of Medical EthicsA brief history • Timeline 460 BC 2009 AD Hippocrates Med Yr 1

19. The School of Hippocrates5th century BC • Hippocrates – ‘The Father of Medicine’ • Medical School (Greek Island of Cos) 460 – 377 BC Med Yr 1

20. The Hippocratic Oath c.1595 Med Yr 1

21. Hippocratic Oath I • I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: • To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; • To look upon his children as my own brothers, to teach them this art. Med Yr 1

22. Hippocratic Oath II • I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. • I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion • But I will preserve the purity of my life and my arts. Med Yr 1

23. Hippocratic Oath III • I will not cut for stone, even for patients in whom the disease ismanifest; I will leave this operation to be performed by practitioners, specialists in this art. • In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. Med Yr 1

24. Hippocratic Oath IV • All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. • If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot. Med Yr 1

25. Beneficence and Nonmaleficence • Hippocratic Oath: • Established the principles of Beneficence and Non-maleficence • Prohibited poisons and potions for abortion or euthanasia • Maintain confidentiality • Avoid exploitation • Pursue ‘best interests’ of patient Med Yr 1

26. The Hippocratic Oath • However no acknowledgement of the patient’s rights (e.g. truth telling or consent) • Does not deal with welfare of society or of others Med Yr 1

27. The Hippocratic Oath • The Oath of ‘a closed, self-protecting guild’1 ; • an ‘old boy’s club’? • ‘Tradition of altruistic doctors practising paternalistic medicine...’? Med Yr 1 1Harris, J, Bioethics (2001) OUP

28. Thomas Percival, English Physician • Beginning of modern professional ethics • First used the term ‘Medical Ethics’ in his book on the subject (1803) • Somewhat of a misnomer at this point; conflicts between practitioners were endemic at this time • c.f. Manchester doctors dispute • Tripartite structure of medicine at the time: • Physicians, Surgeons and Apothecaries Med Yr 1

29. Thomas Percival • Expanded the Hippocratic focus on the doctor-patient relationship to a broader social ethic of medicine emphasizing the professional responsibility of the physician. • Influenced the early ethical codes of AMA, BMA and the WMA up until 1940’s Med Yr 1

30. Medico-ethical Assoc. 1800s • Manchester Medico-ethical Assoc. • BMA medico-ethical committee 1853 • The attempt to produce codes of professional ethics to deal with certain recurrent problems they faced in the practice of their profession. • ‘Colleague control’ Med Yr 1

31. AMA Code of Medical Ethics 1849 • Revised to AMA Principles of Medical Ethics 1903 • Leading with revised editions to a code embodying a set of principles that in the spirit of Percival, emphasize not only nonmaleficence and beneficence but also doctors’ responsibility to the medical profession and to society at large. Med Yr 1

32. Medical EthicsFoundations I • Traditional codes of ethics: • Doctors ‘as independent, self-sufficient philanthropists, whose beneficence is analogous to generous acts of giving.’ Med Yr 1

33. Modern /Biomedical Ethics Med Yr 1

34. 20th C : Nazi Germany and US • Experimentation on Humans • Without their consent • ‘Perverse extension of the authoritarian nature of paternalism’ (Glannon) Med Yr 1

35. Nuremberg Code (1947) • The judgment by the war crimes tribunal at Nuremberg laid down 10 standards to which physicians must conform when carrying out experiments on human subjects. • 1. ‘The voluntary consent of the human subject is absolutely essential…’ Med Yr 1

36. Nuremburg Code (1947) • Informed Consent enshrined in Medical Ethics Code • Patient oriented approach for the first time • Medical ethics ceased to be the sole domain of doctors; now tested against the principles of society (Kennedy, 1981) Med Yr 1

37. Changing Society 1960s • Less deference to authority • Anti-war movements, Vietnam, Cuban Missile crisis, CND, hippies, public demonstrations for ‘rights’, civil rights movements, feminism • Generally more assertive attitudes to individual rights and self-determination Med Yr 1

38. Changing Medicine • Technology progressing to offer more expensive treatments, life-prolonging, scarcity of resources with increasing costs (Dialysis, Organ transplant, Artificial ventilation) • Reproductive control with contraception and abortion – concept of reproductive rights Med Yr 1

39. ‘Bioethics’ (1971) • ‘a new discipline that combines biological knowledge with knowledge of human value systems’ (Potter, 1971) • The study of the ethical dimensions of medicine and the biological sciences Medicine Ethics * Science Med Yr 1

40. ‘Bioethics’ • A growth in Academic comment with a shift in Moral philosophy increasingly from metaethics to applied ethics • Increasing ethical issues for society as a whole, prompted by the new technologies (IVF, Genetics, Stem cell technologies, etc.) • Non-medical commentary (philosopher, sociologist, ...) on how medicine and science should be regulated and how doctors and scientists should behave Med Yr 1

41. Modern Medical EthicsFoundations II • Moral Philosophy • Contemporary Medical ethics: • 1960s Moral problems of modern society • CND, Vietnam, ... • Personal and public responsibility for happens to the world • Patients have rights and entitlements Med Yr 1

42. Beneficence and Nonmaleficence • Early interpretations • excessively paternalistic • Now tempered with the recognition of other principles Med Yr 1

43. Autonomy • Gradual shift in decisional authority from doctor to patient • Introduced the patient based principle of • AUTONOMY • To sit alongside and complement physician based principles of beneficence and non-maleficence Med Yr 1

44. AUTONOMY • auto = ‘self’ • nomos = ‘law’ • Moral Self Rule • Having the capacity and the right to self-determination; to formulate and follow a life plan of one’s own making Med Yr 1

45. Sovereign over own mind and body Individual freedom can be restricted only if risk of harm to others Respect for persons as autonomous ends-in-themselves Capacity to Reason Apply the moral law unto ourselves Med Yr 1

46. Justice • In context of a changing society, • ‘equality’ involves the concept of equal access to society's ‘goods’, • i.e. scarce and expensive healthcare resources • How can these be justly allocated? Med Yr 1

47. Modern Biomedical Ethics • Modern bioethics reformulates the fundamental moral problems as a problems for society, rather than merely ones of professional self-regulation. • Takes the patient’s perspective as it’s starting point.1 1 Gillick, M., NEJM 2000; 342 (19) 1458-59 Med Yr 1