Ethical Reasoning & Contemporary Medical Ethics 2

Ethical Reasoning & Contemporary Medical Ethics 2 Lecture 4 28th October 2009 Dr. Ruth Pilkington Medical Ethics Year 1

‘The Four Principles’ in Medical EthicsBeauchamp & Childress (2001) Medical Ethics Year 1

Respect for Patient Autonomy Autonomy literally means ‘self-rule’ or ‘self-governance’. An individual’s capacity to make decisions about their health care needs and to consent to or refuse treatment depends on their ability to think, decide and act, freely, on the basis of such thought and decision. Two essential conditions for autonomy: Liberty Agency Medical Ethics Year 1

Respect for Patient Autonomy ‘The autonomous individual acts freely in accordance with a self chosen plan,...A person with diminished autonomy, by contrast, is in some respect controlled by others or incapable of deliberating or acting on the basis of his or her desires and plans’, (Beauchamp & Childress (2001)) c.f. Those with diminished autonomy e.g. prisoners, learning disabled persons, patient with dementia. Medical Ethics Year 1

Respect for Patient Autonomy Look at Autonomous Choice rather than Generally Autonomous Capacity, i.e. a generally autonomous person may not be able to act autonomously in certain situations. Respect for patient autonomy requires doctors (+ family) to help patients make their own decisions and to respect those decisions (irrespective of whether one believes those decisions to be wrong). Medical Ethics Year 1

Non-Maleficence We should avoid doing harming to others. ‘Primum non nocere’ – [trans. first (or above all) do no harm] – this would make medicine a very difficult pursuit! It is an extremely important principle to avoid harming others, but cannot take priority and be expressed as an absolute principle. Must be considered in the context of the obligation in medicine of the principle to do good for our patients (beneficence), e.g cancer surgery. Also balance required with the principles of autonomy and justice, e.g. involuntary isolation. Medical Ethics Year 1

Beneficence The obligation to do good / promote what is best for the patient. Sometimes conflict may arise between doctor's judgement of what is in the patient’s best interests and his desire to respect the patient’s different but autonomous decision. Must be balanced with the principles of respect for autonomy, non-maleficence and justice (e.g.. rights and needs of others). Medical Ethics Year 1

Justice Distributive Justice: Decisions re the allocation of scarce health resources (e.g. outpatient time, drugs, money, ICU beds,...) Patients in similar situations (e.g same diseases) should normally have access to the same health care (e.g. same diagnostic technologies/pharmaceutical interventions). But attempt to distribute our limited resources fairly, so that in providing for some, others are not left wanting. Justice also applies to Forensic Medicine (psychiatrists assessment of sanity for court), Employment Justice (fair promotion in the workplace), Prohibition of involvement in Torture (Declaration of Tokyo), etc. Medical Ethics Year 1

Distributive Justice Health Resource Allocation Justice requires that like cases be treated alike and that the benefits and burdens of health services be allocated equitably across patients. However what criteria? Clinical factors, patient values, system goals... Medical Ethics Year 1

Justice No consensus moral theory to help resolve differences between conflicting values, However the goal is Fairness. Medical Ethics Year 1

Strict Egalitarianism Advocates the allocation of equal material goods (healthcare resources) to all members of society. Medical Ethics Year 1

John B. Rawls (1921-2002) ‘Justice as Fairness’ envisions a society of free citizens holding equal basic rights cooperating within an egalitarian economic system. Medical Ethics Year 1

Rawls : Needs Theory Rawls rejected utilitarian approaches to maximizing total welfare and libertarian ‘free for all’. Believed in a theory of social justice. Medical Ethics Year 1

Rawls : Needs Theory ‘The Difference Principle’ Some patients have a special claim on resources that rests not on the maximization of overall welfare but on the greater need for treatment. Medical Ethics Year 1

The Veil Of Ignorance (Rawls) Imagine self in an ethereal place looking down on a world of different societies, each distributing wealth in different ways. You must choose which society you will belong to, not knowing what position, gender, attributes (e.g. personality, IQ), etc. you will have. Medical Ethics Year 1

The Veil Of Ignorance (Rawls) Rawls : What society would a rational person choose? Medical Ethics Year 1

The ‘Difference Principle’ The rational person would choose a society where the worst-off are maximally well off, i.e. the idea that justice is best achieved by the worst off groups being maximally well off. The intuitive idea is that the social order is not to establish and secure the more attractive prospects of those better off unless doing so is to the advantage of those less fortunate.’ (Rawls, 1972)1 1 as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Medical Ethics Year 1

The ‘Difference Principle’ However is need or maximizing the welfare of the worst off the only value? With other values, should need be given priority? If one adheres strictly to the idea of need, scarce resources of a society might be used to provide minimal help to the few very badly off rather than much help to many. Perhaps giving the moderately badly off those limited resources for more net benefit would be more equitable? 1 as quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Medical Ethics Year 1

Ethical Reasoning In Practice Ethical Problem Medical Ethics Year 1

Reflective Equilibrium Rawls (1921-2002) ‘Reflective equilibrium’(Rawls, 1972) - Reasoning about morality requires a continual moving between our moral responses to specific situations and our moral theories, i.e. our beliefs about what is right in various individual situations, to achieve an equilibrium. Medical Ethics Year 1

Method of Reflective Equilibrium In Practice Ethical Problem Revision to gain coherence Medical Ethics Year 1

Rational Dialogue Aim to achieve reflective equilibrium by discussion with others, particularly helpful to achieving convergence and consensus. Medical Ethics Year 1

Rational Dialogue Helps to: • identify inconsistencies between our moral views in one situation and another; and between our theories and our intuitions • ensure we are aware of the perspectives of different moral theories. • ensure we are aware of the perspectives of different people – and in the medical setting, this can be particularly important. ‘Med. Ethics and Law – The core curriculum’, Hope,Savulescu, Hendrick, 2008) Medical Ethics Year 1

The Role of Emotion Learning the role of emotion (? moral intuition) and how to assimilate it into our reasoning. Intuitively we may arrive at a place we do not feel comfortable with morally and we may need to challenge and readjust our reasoning, to bring our intuitions and theories into line. Medical Ethics Year 1

The Role of Emotion As doctors, our emotional responses need to be subject to rational analysis. Feelings of revulsion, pity or fear are not helpful when trying to decide how best to help others. And may lead us to make incorrect decisions. Medical Ethics Year 1

The Role of Emotion Nonetheless, our emotional responses of humanity, compassion and caring for our patients are essential components of our medical work. Without this sensitivity we may lack judgement and sacrifice basic ethical principles of autonomy, beneficence, non-maleficence and justice. Medical Ethics Year 1

The Role of Emotion Integration of emotions with the decisional factors of the process of retrospective thinking Medical Ethics Year 1

Reflective Equilibrium In Practice Ethical Problem Revision to gain coherence Medical Ethics Year 1

The Slippery Slope Argument Runs as follows: If we allow society to take a certain step or allow a certain procedure now, the fear is expressed that this would lead (unavoidably, down the slippery slope) to some point in the future, where some further development of or progression from that initial decision, not morally permissible, would come about. Medical Ethics Year 1

The Slippery Slope Argument Example: Banning effective contraception because we fear that to practise population control is to step on to a slope that leads inexorably to the extinction of the human race.1 1John Harris, The Value of Life Medical Ethics Year 1

The Slippery Slope Argument Example: An opponent of voluntary active euthanasia (VAE) might argue that allowing such a practice would lead to non-voluntary euthanasia, such as the killing of all people over 80 years of age, etc. Medical Ethics Year 1

The Slippery Slope ‘The Principle Of The Dangerous Precedent’ [F.M.Cornford (1908)]1 ‘... is that you should not now do an admittedly right action for fear you, or your equally timid successors, should not have the courage to do right in some future case, which ex hypothesi is essentially different, but superficially resembles the present one. Every public action which is not customary, either is wrong, or, if it is right, is a dangerous precedent. It follows that nothing should ever be done for the first time.’ 1 As quoted in J. Harris, The Value of Life (1985) p. 127 Medical Ethics Year 1

The Slippery Slope Argument We would be both irrational and immoral if we cut ourselves off from options that we clearly perceive to be the beneficial products of the procedures now being developed because we fear that we will be insufficiently resolute to resist the dangers.1 1John Harris, The Value of Life, p.127 Medical Ethics Year 1

Feminist Ethics Feminist ethics based on feminist belief system that: • Gender Inequality exists • It is unjust • Social and political actions can help correct existing inequities Medical Ethics Year 1

Feminist Ethics Hence an approach to ethics that places a very high priority on exploring and addressing questions of social justice, particularly gender injustice. Belief that gender and other forms of injustice (race, disability, socioeconomic class, age, sexual orientation) have been largely invisible in the work of mainstream ethical theorists. Challenging gender assumptions, race assumptions, age assumptions, etc. Medical Ethics Year 1

Feminist Ethics Traditional Ethics Focuses on the Male : i.e. questions and methods regarding interactions in the public sphere Ignores the Female: i.e. questions and methods pertaining to the private sphere of families and communities Medical Ethics Year 1

Feminist Ethics • Liberal Feminism • Ethics of Care • Oppression Theorists • Continental & Post Modern Feminists Medical Ethics Year 1

Feminist Ethics Affirms the general right of women to control their own bodies and lives. Aims to redress the balance of power between the sexes and to put them on equal terms. Incorporates both men and women in its model of care. The concept of the moral agent being relational rather than independent. c.f. Roe vs. Wade (1973) US Medical Ethics Year 1

Ethics of Care Resists the concept of gender equality Moral Reasoning : Women vs. Men (Gilligan, 1982) • Women have tendency to concentrate on narratives, contexts, and relationships of care, i.e. interpersonal relationships and human connectedness. • Men tend to emphasize ‘an ethics of justice’, involving tiers of general moral principles and employing a logic of hierarchical justification Medical Ethics Year 1

Ethics of Care Moral Reasoning : (Gilligan, 1982) A competent moral agent should be capable of both approaches, i.e. an ethics of care and an ethics of justice approach Medical Ethics Year 1

Ethics of Care Similar to Virtue ethics ‘What would the caring person do’? Nurturing Values such as Care, Love, Trust, Responsibility are virtues A question of responsibility to those who are dependent on others; The moral importance in preserving relationships Medical Ethics Year 1

Ethics of Care Joan Tronto (1994) : Questions regarding the responsibility for attending to the human needs among us should be central to our thinking in ethics. 4 phases of Caring: Attentiveness (Recognising Need of Care) Responsibility (Taking Care of) Competence (Care giving) Responsiveness (Evaluating Care Received) Particularly welcomed in Nursing profession where the needs of individual patients are central Medical Ethics Year 1

Contemporary Virtue Ethics Aristotle – a virtue is the mean between excess and deficiency, e.g. Courage mean between Cowardice and Foolhardiness. Resurgence in modern ethics since, ‘[t]he bankruptcy of modern moral philosophy.’ 1 The Qualities of A Good Doctor, e.g. compassionate, humane, courteous, hard-working The Qualities of A Good Patient, e.g. self-control, moderation, reasonable expectations 1 Anscombe, E, MacIntyre, A, as quoted in Glannon, W. ‘Biomedical Ethics’ OUP(2005) Medical Ethics Year 1

Contemporary Virtue Ethics Contemporary focus on the action An Action is right if and only if it is what an agent with a virtuous character would do in the circumstances. Keep a death bed promise : virtue of justice Save a wounded stranger by a roadside : virtue of benevolence Medical Ethics Year 1

Contemporary Virtue Ethics Aristotle ‘It is not merely the state in accordance with the right rule, but the state that implies the presence of the right rule, that is virtue.’ i.e. Acting as someone with the virtue of benevolence would act not only involves providing assistance to another but also includes having and acting from a genuine concern for the well-being of that person and a disposition to have and act from that concern in particular types of situations. Strong connection between Motive & Rightness has a considerable intuitive plausibility Medical Ethics Year 1

Communitarianism Aristotle – ‘humans are essentially social beings’. A reaction to the modern focus on individual rights and freedoms. Emphasis on an individual’s responsibilities to their community and also the responsibility of that community for the welfare of the vulnerable therein. Public pursuit of the common good may take precedence over an individual’s personal objectives. e.g participation in research ‘is a moral duty’ (see Harris, J) Medical Ethics Year 1

Ethical Reasoning & Contemporary Medical Ethics 2