Introduction to Bioethics

Anita Ho, PhDEthicist, Ethics Services, PHCAssistant Professor, Center for Applied Ethics, UBC

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 analysis• do no harm• best interest standard

– Autonomy• respect for one’s rights and dignity• informed and voluntary consent

– Justice• fairness• caring 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