medical ethics year 1 1 ethical reasoning & contemporary medical ethics lecture 3 21 st october...

Medical Ethics Year 1 1

Ethical Reasoning Ethical Reasoning & &

Contemporary Medical Contemporary Medical EthicsEthicsLecture 3Lecture 3

2121stst October 2009 October 2009Dr. Ruth PilkingtonDr. Ruth Pilkington

2Medical Ethics Year 1

Ethics Lectures to dateEthics Lectures to date

1.1. Historical Overview of Medical Historical Overview of Medical EthicsEthics

2.2. Traditional Moral TheoryTraditional Moral Theory

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

index.phpindex.php


Traditional Moral TheoryTraditional Moral TheoryKantian

(Deontological)Ethics

Virtue EthicsUtilitarianism


Contemporary Medical Contemporary Medical EthicsEthics

‘‘...the student begins with the patient, ...the student begins with the patient, continues with the patient, and ends continues with the patient, and ends

his studies with the patient, using his studies with the patient, using books and lectures as tools...’books and lectures as tools...’

Sir William Osler, Canadian Physician(1906)Sir William Osler, Canadian Physician(1906)As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics

(2008)(2008)


Ethical ReasoningEthical Reasoning

Clinical EthicsClinical Ethics is learnt in the same way as is learnt in the same way as clinical medicine is learnt, ‘clinical medicine is learnt, ‘at the coalfaceat the coalface’, ’, through meeting patients and their families, through meeting patients and their families, being involved in their cases. being involved in their cases. It is a practical It is a practical discipline.discipline.

The doctor must learn to recognise the ethical The doctor must learn to recognise the ethical aspects of his/her clinical (and scientific aspects of his/her clinical (and scientific research work), and to make reasoned research work), and to make reasoned decisions about this work within the framework decisions about this work within the framework of the law and Medical Council guidelines.of the law and Medical Council guidelines.


Ethical ReasoningEthical Reasoning

Learning to ReasonLearning to Reason

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

factual concerns and ethical issues.factual concerns and ethical issues.


Ethical ReasoningEthical Reasoning Learning to ReasonLearning 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 ReasoningScientific ReasoningThe skill of evaluating The skill of evaluating the scientific evidence the scientific evidence available and applying available and applying it, using clinical it, using clinical judgement to the clinical judgement to the clinical scenario at hand. This is scenario at hand. This is a fundamental part of a fundamental part of your medical education your medical education and later practice.and later practice.

Ethical ReasoningEthical ReasoningIn the same way, ethical In the same way, ethical reasoning is a skill reasoning is a skill required to allow you to required to allow you to identify and negotiate identify and negotiate ethical problems, using an ethical problems, using an organized framework of organized framework of ethical methods or tools ethical methods or tools in the clinical setting.in the clinical setting.


Ethical ReasoningEthical Reasoning Learning to ReasonLearning to Reason

JudgementJudgementJudgement is needed in making final Judgement is needed in making final

decisions – there is no ethical decisions – there is no ethical algorithm that can be applied algorithm that can be applied

without judgement.without judgement.


Tools of Ethical ReasoningTools of Ethical Reasoning

Methods or Tools in BioethicsMethods or Tools in Bioethics – – to help determine how best to guide human to help determine how best to guide human

actionaction

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


Bioethical MethodologiesBioethical 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 Clarify the Logic of the Argumentthe 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.P1P1 If p then qIf p then q

P2 P2 ppCC qq

e.g.e.g.P1 P1 If a foetus is a If a foetus is a

person it is person it is wrong to kill wrong to kill itit

P2 P2 A foetus is a personA foetus is a personC C It is wrong to kill a It is wrong to kill a

foetusfoetus

P1P1 If p then qIf p then qP2 P2 Not qNot qCC Not pNot p


person it is person it is wrong to wrong to kill itkill it

P2 P2 It is not wrong to It is not wrong to kill a kill a foetusfoetus

C C A foetus is not a personA foetus is not a person


Clarify the Logic of Clarify the Logic of the Argument IIthe Argument II


An Invalid argument

P1P1 If p then qIf p then qP2 P2 Not pNot pCC Not qNot q


person it is person it is wrong to kill wrong to kill itit

P2 P2 A foetus is not a A foetus is not a person person

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


Clarify the Logic of Clarify the Logic of the Argument IIIthe Argument III


An Invalid argument

P1P1 If p then qIf p then qP2 P2 Not pNot pCC Not qNot q

e.g.e.g.P1 P1 If it is raining I If it is raining I

will will wear a coatwear a coatP2 P2 It is not raining It is not raining [C][C] [Therefore I will [Therefore I will

not wear not wear a coat]a coat]




& theories



3. Case comparison


the argument


Values

Tools



Thought Experiments IThought Experiments I

Absolute Argument : Absolute Argument : ‘‘It is never right to kill someone’It is never right to kill someone’

The Case Of The Trapped The Case Of The Trapped Lorry DriverLorry Driver


The Case Of The Trapped The Case Of The Trapped Lorry DriverLorry Driver11

A driver is trapped in a blazing lorry. There is A driver is trapped in a blazing lorry. There is no way in which he can be saved. He will no way in which he can be saved. He will

soon burn to death. A friend of the driver is soon burn to death. A friend of the driver is standing by the lorry. This friend has a gun standing by the lorry. This friend has a gun

and is a good shot. The driver asks his friend and is a good shot. The driver asks his friend to shoot him dead. It will be less painful for to shoot him dead. It will be less painful for

him to be shot than to burn to death.him to be shot than to burn to death.

Should the friend shoot the driver dead?Should the friend shoot the driver dead?

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


Thought Experiments IIThought Experiments II

Absolute Argument: Absolute Argument: ‘‘There is an absolute right to life’There is an absolute right to life’

The Case Of The Connected The Case Of The Connected ViolinistViolinist


The Case Of The Connected The Case Of The Connected ViolinistViolinist

(JJ Thompson, (JJ Thompson, A Defense of AbortionA Defense of Abortion , 1971) , 1971)

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


Thought Experiments IIIThought Experiments III

Acts and Omissions:Acts and Omissions:‘‘Is there a moral difference between Is there a moral difference between

killing and letting die’killing and letting die’

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


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

SmithSmith stands to gain a stands to gain a huge inheritance should huge inheritance should anything happen to his 6 anything happen to his 6 yr old cousin. yr old cousin. One evening, he sneaks in One evening, he sneaks in while the child is having a while the child is having a bath and drowns the boy.bath and drowns the boy.

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

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




& theories



3. Case comparison


the argument


Values

Tools



Rational Decision TheoryRational Decision Theory

Consequentialist Consequentialist approachapproach

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

resources, etc.resources, etc.

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

thus make decision on this basis.thus make decision on this basis.


Rational Decision Theory Rational Decision Theory Clinical ScenarioClinical Scenario

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

PossibilitiesPossibilitiesResuscitation OutcomeResuscitation Outcome Future QoLFuture QoL (value) (value)10% (p=0.1) success 10% (p=0.1) success Reasonable (+5)Reasonable (+5)

40% (p=0.4) success40% (p=0.4) success Poor (-10)Poor (-10)50% (p=0.5) death50% (p=0.5) death 00

No resuscitation (DNR) = Death = value of 0No resuscitation (DNR) = Death = value of 0



Rational Decision TheoryRational Decision Theory Clinical Scenario IIClinical Scenario II

Whether or not to resuscitate Mr. Whether or not to resuscitate Mr. O’Connor?O’Connor?

DNR :DNR :‘‘Expected Utility’ Expected Utility’ 1 1 xx 0 = 0 = 00

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

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





& theories



3. Case comparison


the argument


Values

Tools



‘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 AutonomyAutonomyAutonomy 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 such think, decide and act, freely, on the basis of such thought and decision.thought and decision.

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


Respect for Patient AutonomyRespect for Patient Autonomy

‘‘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 acting on the basis of his or her desires and plansand plans’, ’, (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.


Respect for Patient AutonomyRespect for Patient Autonomy

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



Beauchamp & Childress (2001)Beauchamp & Childress (2001)The Four Principles in Medical Ethics


Beneficence

Justice

Non-Maleficence


Non-MaleficenceNon-MaleficenceWe 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


BeneficenceBeneficenceThe obligation to do good / promote what is The obligation to do good / promote what is

best for the patient.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


JusticeJusticeDistributive Justice: Decisions re the allocation of scarce Distributive Justice: 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 diagnostic technologies/pharmaceutical same diagnostic technologies/pharmaceutical interventions).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 Forensic Medicine (psychiatrists Justice also applies to Forensic Medicine (psychiatrists assessment of sanity for court), Employment Justice assessment of sanity for court), Employment Justice

(fair promotion in the workplace), Prohibition of (fair promotion in the workplace), Prohibition of involvement in Torture (Declaration of Tokyo), etc.involvement in Torture (Declaration of Tokyo), etc.

medical ethics year 1 1 ethical reasoning & contemporary medical ethics lecture 3 21 st october...

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