ethical reasoning & contemporary medical ethics lecture 3 21 st october 2009 dr. ruth pilkington

Ethical Reasoning &

Contemporary Medical EthicsLecture 3

21st October 2009Dr. Ruth Pilkington

Ethics Lectures to date

1. Historical Overview of Medical Ethics

2. Traditional Moral Theory

Find at :www.medicine.tcd.ie/ethics/ethicsyrone/index.php

Traditional Moral TheoryKantian

(Deontological)Ethics

Virtue EthicsUtilitarianism

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)

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.

Ethical Reasoning

Learning to Reason

Many (most?) clinical situations, and decisions involve a combination of

factual concerns and ethical issues.

Ethical Reasoning

Learning to Reason

Ethical reasoning must stand up to scrutiny, (in Ethical reasoning must stand up to scrutiny, (in court if necessary) in the same way as the court if necessary) in the same way as the

scientific aspects of decision-making.scientific aspects of decision-making.

Scientific ReasoningThe 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 ReasoningIn 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 Reasoning

Learning to Reason

Judgement

Judgement is needed in making final decisions – there is no ethical algorithm that can be applied without judgement.

Tools of Ethical Reasoning

Methods or Tools in Bioethics –

to help determine how best to guide human action

How should I act morally in this situation?How should I act morally in this situation?

Bioethical Methodologies

How should I act morally in this situation?How should I act morally in this situation?

1. Practical or Applied Ethics Applied Philosophy of Medicine (Theoretical Framework using various elements of ethical theories, etc.)

2. Principlism (Fixed set of moral principles, e.g. Beauchamp & Childress)

3. Case comparison (Case based approach – real /paradigm cases but no clear method)

4. Combined technique to seek compromise (?fails to achieve moral clarity)


6. Reasonfrom principles

& theories

5. Rational Decision Theory

4. Thought experiments

3. Case comparison

2. Clarify the logic of

the argument

1. DistinguishFacts from

Values

Tools

Adapted from Hope, Savulescu, Hope, Savulescu, Hendrik, Hendrik, Medical Ethics and LawMedical Ethics and Law (2008) (2008)

Clarify the Logic of the Argument

Adapted from Hope, Savulescu, Hendrik, Hope, Savulescu, Hendrik, Medical Ethics and LawMedical Ethics and Law (2008) (2008)

Syllogisms – deductive argument expressed in the form of two propositions called premises, and a conclusion that results logically.P1 If p then q

P2 p

C q

e.g.

P1 If a foetus is a person it is wrong to kill it

P2 A foetus is a person

C It is wrong to kill a foetus

P1 If p then q

P2 Not q

C Not p

e.g.


P2 It is not wrong to kill a foetus

C A foetus is not a person

Clarify the Logic of the Argument II


An Invalid argument

P1 If p then q

P2 Not p

C Not q

e.g.


P2 A foetus is not a person

[C] [It is not wrong to kill a foetus]

Clarify the Logic of the Argument III


An Invalid argument

P1 If p then qP2 Not pC Not q

e.g.P1 If it is raining I

will wear a coatP2 It is not raining [C] [Therefore I will

not wear a coat]



& theories



3. Case comparison


the argument


Values

Tools


Thought Experiments I

Absolute Argument :

‘It is never right to kill someone’

The Case Of The Trapped

Lorry Driver

The Case Of The Trapped Lorry Driver1

A driver is trapped in a blazing lorry. There is no way in which he can be saved. He will soon burn to death. A friend of the driver is standing by the lorry. This friend has a gun and is a good shot. The driver asks his friend to shoot him dead. It

will be less painful for him to be shot than to burn to death.

Should the friend shoot the driver dead?

1 As quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008)

Thought Experiments II

Absolute Argument:

‘There is an absolute right to life’

The Case Of The Connected

Violinist

The Case Of The Connected Violinist (JJ Thompson, A Defense of Abortion , 1971)

You wake up one morning with your circulatory system connected to another person. It turns out that you are connected to a famous violinist, with a fatal kidney ailment. If he remains connected to your circulatory system, he will eventually be cured. The Society of Music Lovers have kidnapped you and connected you up, as you are the only person with a suitable blood type. ‘But, never mind’, his doctors say, ‘It is only for 9 months and then he will be fully recovered and then you can be disconnected.’

Thought Experiments III

Acts and Omissions:

‘Is there a moral difference between killing and letting die’

The Cases of Smith and Jones (Rachels J, ‘Active and Passive Euthanasia’, NEJM (1975)

The Cases of Smith and JonesRachels J, ‘Active and Passive Euthanasia’, NEJM (1975)

Smith stands to gain a huge inheritance should anything happen to his 6 yr old cousin.

One evening, he sneaks in while the child is having a bath and drowns the boy.

Jones also stands to inherit if anything happens to his 6 yr old cousin. He sneaks into the bathroom, to drown his cousin, but finds that the child has slipped and is drowning in the bath. Jones does nothing and allows him to drown.

Is there any moral difference between what Smith and Jones did?



& theories



3. Case comparison


the argument


Values

Tools


Rational Decision Theory

Consequentialist approach

To determine / maximise the best outcome, e.g. in the allocation of scarce health resources, etc.

Assign probabilities and values to outcomes to calculate the best ‘expected utility’ and thus

make decision on this basis.

Rational Decision Theory Clinical Scenario

A decision must be made on whether or not to resuscitate Mr. O’Connor, in the event of cardiac arrest.

Possibilities

Resuscitation Outcome Future QoL (value)

10% (p=0.1) success Reasonable (+5)

40% (p=0.4) success Poor (-10)

50% (p=0.5) death 0

No resuscitation (DNR) = Death = value of 0Adapted from Hope, Savulescu, Hendrik, Hope, Savulescu, Hendrik, Medical Ethics and LawMedical Ethics and Law (2008) (2008)

Rational Decision Theory Clinical Scenario II

Whether or not to resuscitate Mr. O’Connor?

DNR :

‘Expected Utility’ 1 x 0 = 0

Resuscitation:

‘Expected Utility’ (0.1 x 5) + (0.4 x -10) +(0.5 x 0) = -3.5

Hence on basis of ‘expected utilities’, it is better not to attempt resuscitation.




& theories



3. Case comparison


the argument


Values

Tools


‘The Four Principles’ in Medical Ethics

Beauchamp & Childress (2001)

The Four Principles in Medical Ethics

Respect for (Patient) Autonomy

Beneficence

Justice

Non-Maleficence

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


‘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.


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).





Beneficence

Justice

Non-Maleficence

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.





Beneficence

Justice

Non-Maleficence

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).





Beneficence

Justice

Non-Maleficence

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.

ethical reasoning & contemporary medical ethics lecture 3 21 st october 2009 dr. ruth pilkington

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