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Shaping Professionalism:

Bioethics I
Prepared and presented by Marc Imhotep Cray, M.D.
Basic Medical Sciences and Clinical Knowledge (CK) Teacher

Marc Imhotep Cray, M.D.

What is Bioethics?
Study of ethical issues arising from biological and medical sciences

Marc Imhotep Cray, M.D.

Varieties of Bioethics

Medical ethics

Physician-centered

Health care ethics Clinical ethics

Includes nurses & other healthcare professionals

Hospital care decisions with aid of committees and consultants

Bioethics in general

Includes issues in genetics, reproductive technologies, experimentation, and distribution of life-saving resources

Marc Imhotep Cray, M.D.

Origins of Bioethics

Emerged in early 1960s in the U.S. Arose out of public concerns


E.g., issue of selecting patients for chronic haemodialysis in Seattle in 1962

Represented the view that ethical problems in medicine and biological sciences can be solved by applying moral principles

(Source: Albert R. Jonsen, Journal of Medicine and Philosophy (1991), pp. 113-30)

Marc Imhotep Cray, M.D.

Why is Bioethics Important?

Changing doctor-patient relationship


Recognition of patient autonomy in decision-making

New technologies
E.g., assisted reproduction, gene therapy, support and prolonging of life

Changing economics of medicine


Managed care, health insurance, commercialization of medicine (profit motive)
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Marc Imhotep Cray, M.D.

Who Should Do Bioethics?

Lawyers and Doctors


Historically, issue is for doctors to avoid or to deal with charges of negligence.

Philosophers

Ethical dilemmas go beyond issues of legality. Philosophers can help doctors to make sound ethical decisions and to justify them to their patients and the public. If you need an analysis, send the urine to the biochemist, and the ethics to the philosopher.

Marc Imhotep Cray, M.D.

Philosophy and Bioethics


PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY METAETHICS NORMATIVE ETHICS BIOETHICS APPLIED ETHICS

MEDICAL ETHICS

Marc Imhotep Cray, M.D.

What is Moral Philosophy?

Distinguish morality from law Distinguish moral philosophy from religious ethics and codes

Marc Imhotep Cray, M.D.

What Moral Philosophers Do

Use reason and arguments Apply general moral principles Provide conceptual and analytical tools Justify or question moral practices

Marc Imhotep Cray, M.D.

Normative Ethics
Developing principles that tell us which actions are right, and what we are morally required to do.

Marc Imhotep Cray, M.D.

Normative Theories

Deontological theories
Associated with German philosopher Immanuel Kant.

Consequentialist theories
Most well-known theory is utilitarianism. Utilitarians seek to maximize general human happiness or well-being. Famous utilitarian philosophers include John Stuart Mill and Jeremy Bentham.

Marc Imhotep Cray, M.D.

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Deontological Theories

A type of action is right or wrong no matter what its consequences are. Moral agents have duties which oblige them to do certain types of action. Duties can be specified in the form of rules that must be universally applicable. Persons and their autonomy should be respected at all times.

Marc Imhotep Cray, M.D.

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Consequentialist Theories

What makes an action right or wrong are its consequences. The consequences of an action can always be measured by a common standard: what it contributes to the good of all who are affected by the action The right action is one that has the maximum beneficial results. The same unit of benefit to any person should be given equal weight.
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Marc Imhotep Cray, M.D.

What is Applied Ethics?


Use of general moral principles to test the morality of particular actions.

Marc Imhotep Cray, M.D.

Problem for Applied Ethics


Presence of competing moral principles
Does this make applied ethics subjective?

Room for reasoning, argument and justification


Ethics is not a matter of taste.

Ethical dilemmas are real dilemmas


There are no easy answers.

Important to learn why people disagree


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Marc Imhotep Cray, M.D.

Ethical Theory and Bioethics

Straightforward application of principles


Four-principles approach (Childress & Beauchamp)

Case-study approach
Methodology of casuistry (Jonsen & Toulmin)

Interplay between theory and casestudy


Bioethics contributes to ethical theory as well as benefiting from it

Marc Imhotep Cray, M.D.

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Problems for application of principles

Choice of ethical theory cannot be justified Real life is too messy and detailed Priority of principles cannot be resolved
E.g., principles of autonomy and beneficence can be in conflict.

Marc Imhotep Cray, M.D.

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Problems for case-study approach

Problem of bias
Intuitions need to be critically examined.

Too many mid-level principles in evaluating cases Theoretical issues cannot be avoided
E.g., euthanasia raises questions about the value of human life; allocation of resources raises questions of distributive justice.
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Marc Imhotep Cray, M.D.

Bioethics and the Doctor

Philosophers can help doctors to identify goals in medicine and to develop practical principles. Moral philosophy will impact on clinical practice by improving understanding and affecting the way in which ethical problems in medicine are described.
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Marc Imhotep Cray, M.D.

Medical ethics

Medical ethics is grounded in philosophical ethics, it concerns itself with the ethical questions and dilemmas in medicine. Medical ethics is not any special ethics but an ethics which deals with special cases from medical practice.
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Marc Imhotep Cray, M.D.

Doctor-patient relationship

Medical ethics has three centres: doctor, patient and society. Its centre is the doctor-patient relationship.

Marc Imhotep Cray, M.D.

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The moral duties of the doctor

The duty The duty health The duty The duty The duty The duty The duty The duty

to help, cure to promote and protect the patients to to to to to to inform confidentiality protect the patients life respect the patients autonomy protect privacy respect the patients dignity
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Marc Imhotep Cray, M.D.

The moral rights of the patient

The The The The The The The

right right right right right right right

to to to to to to to

high quality medical service autonomous choice decide be informed privacy health education dignity
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Marc Imhotep Cray, M.D.

Principles of biomedical ethics

Nonmaleficence Beneficence Respect for autonomy Justice

Marc Imhotep Cray, M.D.

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Hippocratic oath 5-4 centuries B.C.

An obligation of nonmaleficence and an obligation of beneficence are both expressed in the Hippocratic oath: I will use treatment to help the sick according to my ability and judgement, but I will never use it to injure or wrong them.
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Marc Imhotep Cray, M.D.

Nonmaleficence and beneficence

The principle of nonmaleficence asserts an obligation not to inflict harm intentionally. Principles of beneficence potentially demand more than the principle of nonmaleficence, because agents must take positive steps to help others, not merely refrain from harmful acts.
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Marc Imhotep Cray, M.D.

The differerence of two principles

Nonmaleficence One ought not to inflict evil or harm

Beneficence One ought to prevent evil or harm One ought to remove evil or harm One ought to do or promote good

Marc Imhotep Cray, M.D.

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The concept of autonomy

The word autonomy is derived from the Greek autos (self) and nomos (rule, governance or law). It was first used to refer to the self-rule or selfgovernance of independent Hellenic city-states Autonomy has since been extended to individuals and has acquired meanings as diverse as self-governance, liberty rights, privacy, individual choice, freedom of the will, causing ones behaviour, and being ones own person.
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Marc Imhotep Cray, M.D.

Autonomous person
We analyze autonomous persons in tems of liberty (independence from controlling influences) agency (capacity for intentional action)

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Autonomous action
We analyze autonomous action in terms of persons who act Intentionally With understanding Without controlling influences that determine their action

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To respect an autonomous agent


Is to acknowledge that persons right to hold views, to make choices, and to take actions based on personal values and beliefs. Such respect involves respectful action, not merely a respectful attitude. Respect involves treating persons to enable them to act autonomously, whereas disrespect for autonomy involves attitudes and actions that ignore, insult, or demean others autonomy and thus deny a minimal equity to persons.
Marc Imhotep Cray, M.D.

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Informed consent is analyzable

Through the account of autonomous choice. A person must do more than express agreement or comply with a proposal. He/she must authorize through an act of informed and voluntary consent. in terms of the social rules of consent in institutions that must obtain legally valid consent from patients or subjects before proceeding with therapeutic procedures or research.
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Marc Imhotep Cray, M.D.

The standards used to determine the incompetence


Inability to express or communicate a preference or choice. Inability to understand ones situation and its consequences. Inability to understand relevant information. Inability to give a (rational) reason. Inability to give risk/benefit related reasons. Inability to reach a reasonable decision.
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Marc Imhotep Cray, M.D.

Paternalism
is the intentional overriding of one persons known preferences or actions by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose will is overriden.

Marc Imhotep Cray, M.D.

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Weak paternalism

In weak paternalism an agent intervenes on ground of beneficence or nonmaleficence only to prevent substantially nonvoluntary conduct, i.e. to protect persons against their own substantially nonautonomous actions.

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Strong paternalism
Strong paternalism involves interventions intended to benefit a person despite the fact that the persons risky choices and actions are informed, voluntary and autonomous.

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A central problem in biomedical ethics


Whether respect for autonomy of patients should have priority over professional beneficence.

Marc Imhotep Cray, M.D.

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The concept of justice


The terms fairness, desert (what is deserved), and entitlement (that to which one is entitled) have been used by various philosophers in attempts to explicate justice. These accounts all interpret justice as fair, equitable, and appropriate treatment in light of what is due or owed to person.
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Principles of distributive justice


To each person an equal share (formal equity) To each person according to need To each person according to effort To each person according to contribution To each person according to merit To each person according to freemarket exchanges
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Marc Imhotep Cray, M.D.

Useful References

Tom Beauchamp & James Childress, Principles of Biomedical Ethics (Oxford University Press, 1994) Nancy Jecker, Albert Jonsen & Robert Pearlman (editors), Bioethics: An Introduction to the History, Methods, and Practice (Jones & Bartlett, 1997) Robert Veatch (editor), Medical Ethics (Jones & Bartlett, 1997)

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 1 Question: Under which circumstance is the mental health professional required to disregard doctor-patient confidentiality in most jurisdictions by reporting to the proper peace-keeping authorities? A. The patient who states that he's going to kill his girlfriend the coming weekend by shooting her at home B. The patient who says that at least once a week he feels like killing his boss, but that on other days he interacts adequately with his boss and coworkers C. The patient who states that he secretly put arsenic in his brother's food over a three month period five years earlier, but that now he loves his brother dearly D. The patient who says that he would like to see France bombed out of existence E. The patient who threatens to kill himself

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 2 Question: A medical resident will be entering private practice next year and is concerned about the ethics of patient confidentiality and when it can be breached. There are certain circumstances under which physicians in most jurisdictions are obligated to violate patient confidentiality. Which of the following is a common one? A. Gunshot wounds B. Intravenous drug abuse C. Venereal diseases, including acquired immunodeficiency syndrome (AIDS) D. Psychosis E. Spousal abuse

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 3 Question: A 70-year-old female with a lifelong mental age of 18 to 24 months lives in a special care area where her special needs are met is referred to your hospital when she is observed to be somewhat pale. An examination of her peripheral blood reveals a pattern consistent with an acute leukemia. Her only living relatives are her two younger brothers, a 68-year-old retired automotive mechanic, and a 62-year-old retired police officer, who, on being informed of their sister's condition state, "Doctor you do what you think is best. We trust you to do the right thing for our sister!" How will you proceed? A. Obtain a guardian ad litem B. Obtain an ethics committee consultation for the patient C. Obtain a written consultation from a colleague D. Obtain a pastoral counseling consultation for the patient E. Obtain an informed consent from the patient

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 4 Question: A 5-year-old child is brought to your emergency department with full thickness, third degree burns over seventy percent of her body. It is the strong opinion of the director of your burn unit that she must have blood transfusions or she will die. Her parents inform you that blood transfusions violate their faith. How do you resolve this issue? A. Contact your hospital chaplain B. Allow the parents to take their child home to die C. Ask a colleague what you should do D. Contact your hospital attorney E. Ask a friend in law school what you should do F. Order blood over the objections of the parents and their spiritual beliefs

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 5 Question: A 15-year-old female presents to your office, requesting a prescription for isotretinoin (Accutane). She has previously tried topical benzoyl peroxide, topical and oral antibiotics, and topical tretinoin (Retin-A) products, with only minimal improvement in her acne. Family history is positive for cystic acne in her father and brother. Examination reveals nodulocystic acne localized to her face and chest, with diffuse comedones and pustules across the face, chest and back, and some scarring. You ask her mother to leave the exam room, and ask the patient if she is sexually active. She reports that she has had intercourse "a couple of times," but becomes tearful when you tell her that she will need to use two forms of contraception if you prescribe isotretinoin for her acne. She refuses to take oral contraceptives, saying that she promises not to have intercourse while on isotretinoin. What should you do next? A. Tell her mother that she is sexually active and thus isotretinoin is contraindicated B. Prescribe isotretinoin at only 10 mg, since the teratogenicity of isotretinoin is dose-dependent C. Counsel the patient regarding the teratogenicity-pregnancy prevention program and do not prescribeisotretinoin D. Tell the patient to avoid intercourse during the fertile period of her cycle E. Prescribe isotretinoin, since the risk for pregnancy is low in a 15-year-old female and her acne is so severe

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 6 Question: A 35-year-old associate professor of chemical engineering returns to your office following surgery for terminal, metastatic ovarian cancer. She states that she has persistent dull pain so you obtain an x-ray. The x-ray reveals a ten-centimeter metal clamp. What do you do now? A. Say nothing to the patient about the clamp since she is terminal and may never find out about it B. Inform her about the clamp and tell her you hope it will dissolve in time on its own C. Inform her about the clamp and refer her back to her surgeon D. Telephone your attorney and ask for advice E. Telephone the surgeon and ask for advice

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 7 Question: A 42-year-old certified occupational therapy assistant (COTA) is diagnosed with ovarian carcinoma. After a long battle, including surgery and chemotherapy, she succumbs. As you are leaving her graveside funeral, having expressed your sense of grief and loss to her family and friends, the funeral director takes you aside and informs you, "I found a metal clamp inside of her when I was embalming her." The funeral director states further, "Doctor I have a whole box of clamps that I found while preparing bodies for burial". What do you do with this information? A. Thank the funeral director and inform the operating surgeon immediately B. Thank the funeral director and say nothing further since she is dead and buried C. Thank the funeral director and inform your attorney immediately D. Thank the funeral director and inform the bereaved family immediately E. Thank the funeral director and inform any plaintiffs attorney in your community F. Thank the funeral director and inform your hospital quality control office immediately

Marc Imhotep Cray, M.D.

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QUESTIONS AND ANSWERS


Q#: 8 Question: During a first year medical school ethics class, a 25-year-old medical student interrupts stating, "Gosh I just don't understand why so much of our time is spent on ethics. I thought that ethics was if a patient wants to use your office telephone, do you or do you not charge him or her a quarter?" You are understandably aghast at his gauche interruption and you inform him that A. He must leave the classroom as he has just failed the ethics course B. He must leave the classroom and write one hundred times I will not interrupt our ethics class with silly questions C. He must leave the classroom to prepare a special paper on the value of ethics in medical school D. He must leave the classroom, as he is clearly a ninny E. He must leave the classroom and report directly to the office of the dean for dismissal from medical school

Marc Imhotep Cray, M.D.

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ANSWERS TO QUESTIONS
1=A 2=A 3=A 4=D 5=C 6=C 7=F 8=C
Marc Imhotep Cray, M.D.

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Reference Resources and Further Study


Bioethics Online Study Recourses NIH - Bioethics Resources University of Toronto - Joint Center for Bioethics World Medical Association - Medical Ethics Manual Virtual Mentor Video Education (drimhoteptv)

IVMS-MEDICAL ETHICS & PROFESSIONALISM 12 videos, 3 hrs. and 16 min. http://www.youtube.com/playlist?list=PL08E700EA3F8313EB

E-Textbook Medical Ethics Today: The BMAs handbook of ethics and law Books; 3 edition (January 30, 2012) Updates http://bma.org.uk/practical-support-at-work/ethics/medical-ethics-today Best Price $148.33 or Buy New $181.49

Marc Imhotep Cray, M.D.

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