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Shaping Professionalism: Bioethics I Prepared and presented by Marc Imhotep Cray, M.D. Basic Medical Sciences

Shaping Professionalism:

Bioethics I

Prepared and presented by

Marc Imhotep Cray, M.D.

Basic Medical Sciences and Clinical Knowledge (CK) Teacher

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

Marc Imhotep Cray, M.D.

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

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 Includes nurses & other

Varieties of Bioethics

Medical ethics

Physician-centered

Health care ethics

Includes nurses & other healthcare professionals

Clinical ethics

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

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Origins of Bioethics  Emerged in early 1960s in the U.S.  Arose out of

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)

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Why is Bioethics Important?  Changing doctor-patient relationship Recognition of patient autonomy in decision-making

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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Who Should Do Bioethics?  Lawyers and Doctors Historically, issue is for doctors to avoid

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.”

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Philosophy and Bioethics PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY APPLIED ETHICS BIOETHICS METAETHICS NORMATIVE ETHICS

Philosophy and Bioethics

PHILOSOPHY

PHILOSOPHY

PHILOSOPHY
PHILOSOPHY
MORAL PHILOSOPHY
MORAL PHILOSOPHY
Philosophy and Bioethics PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY APPLIED ETHICS BIOETHICS METAETHICS NORMATIVE ETHICS
Philosophy and Bioethics PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY APPLIED ETHICS BIOETHICS METAETHICS NORMATIVE ETHICS
ETHICAL THEORY
ETHICAL THEORY
ETHICAL THEORY

ETHICAL THEORY

and Bioethics PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY APPLIED ETHICS BIOETHICS METAETHICS NORMATIVE ETHICS MEDICAL
and Bioethics PHILOSOPHY MORAL PHILOSOPHY ETHICAL THEORY APPLIED ETHICS BIOETHICS METAETHICS NORMATIVE ETHICS MEDICAL
APPLIED ETHICS
APPLIED ETHICS
APPLIED ETHICS

APPLIED ETHICS

BIOETHICS
BIOETHICS
METAETHICS
METAETHICS
METAETHICS

METAETHICS

NORMATIVE ETHICS
NORMATIVE ETHICS
NORMATIVE ETHICS

NORMATIVE ETHICS

MEDICAL ETHICS
MEDICAL ETHICS

Marc Imhotep Cray, M.D.

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What is Moral Philosophy?  Distinguish morality from law  Distinguish moral philosophy from religious

What is Moral Philosophy?

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

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What Moral Philosophers Do  Use reason and arguments  Apply general moral principles 

What Moral Philosophers Do

Use reason and arguments Apply general moral principles

Provide conceptual and analytical tools

Justify or question moral practices

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Normative Ethics Developing principles that tell us which actions are right, and what we are

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

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.

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Deontological Theories  A type of action is right or wrong no matter what its

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.

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Consequentialist Theories  What makes an action right or wrong are its consequences.  The

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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What is Applied Ethics? Use of general moral principles to test the morality of particular

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?

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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Ethical Theory and Bioethics  Straightforward application of principles Four-principles approach (Childress &

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 case- study

Bioethics contributes to ethical theory as well as

benefiting from it

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Problems for application of principles  Choice of ethical theory cannot be justified  Real

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.

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Problems for case-study approach  Problem of bias Intuitions need to be critically examined. 

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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Bioethics and the Doctor  Philosophers can help doctors to identify goals in medicine and

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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Medical ethics  Medical ethics is grounded in philosophical ethics, it concerns itself with the

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

Doctor-patient relationship

Medical ethics has three centres:

doctor, patient and society.

Its centre is the doctor-patient relationship.

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The moral duties of the doctor  The duty to help, cure  The duty

The moral duties of the doctor

The duty to help, cure

The duty to promote and protect the patient’s

health

The duty to inform

The duty to confidentiality

The duty to protect the patient’s life

The duty to respect the patient’s autonomy

The duty to protect privacy

The duty to respect the patient’s dignity

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The moral rights of the patient  The right to high quality medical service 

The moral rights of the patient

The right to high quality medical service The right to autonomous choice

The right to decide

The right to be informed

The right to privacy

The right to health education

The right to dignity

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Principles of biomedical ethics  Nonmaleficence  Beneficence  Respect for autonomy  Justice Marc

Principles of biomedical ethics

Nonmaleficence Beneficence

Respect for autonomy Justice

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Hippocratic oath 5-4 centuries B.C.  An obligation of nonmaleficence and an obligation of beneficence

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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Nonmaleficence and beneficence  The principle of nonmaleficence asserts an obligation not to inflict harm

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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The differerence of two principles  Nonmaleficence One ought not to inflict evil or harm

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

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The concept of autonomy  The word “autonomy” is derived from the Greek “autos” (self)

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 self- governance 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

one’s behaviour, and being one’s own person.

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Autonomous person We analyze autonomous persons in tems of  liberty (independence from controlling influences)

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 

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 I s to acknowledge that person’s right to hold views,

To respect an autonomous

agent

Is to acknowledge that person’s 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.

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Informed consent is analyzable  Through the account of autonomous choice.  A person must

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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The standards used to determine the incompetence  Inability to express or communicate a preference

The standards used to

determine the incompetence

Inability to express or communicate a

preference or choice.

Inability to understand one’s 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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Paternalism is the intentional overriding of one person’s known preferences or actions by another person,

Paternalism

is the intentional overriding of one

person’s 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.

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Weak paternalism  In weak paternalism an agent intervenes on ground of beneficence or nonmaleficence

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

Strong paternalism

Strong paternalism involves

interventions intended to benefit a

person despite the fact that the person’s 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

A central problem in

biomedical ethics

Whether respect for autonomy of

patients should have priority over

professional beneficence.

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The concept of justice The terms fairness, desert (what is deserved), and entitlement (that to

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

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 free-

market exchanges

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Useful References  Tom Beauchamp & James Childress, Principles of Biomedical Ethics (Oxford University Press,

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)

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QUESTIONS AND ANSWERS  Q#: 1 Question: Under which circumstance is the mental health professional

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

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QUESTIONS AND ANSWERS  Q#: 2 Question: A medical resident will be entering private practice

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

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QUESTIONS AND ANSWERS  Q#: 3 Question: A 70-year-old female with a lifelong mental age

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

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QUESTIONS AND ANSWERS  Q#: 4 Question: A 5-year-old child is brought to your emergency

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

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 QUESTIONS AND ANSWERS Q #: 5 Question: A 15-year-old female presents to your office,

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

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QUESTIONS AND ANSWERS  Q#: 6 Question: A 35-year-old associate professor of chemical engineering returns

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

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QUESTIONS AND ANSWERS  Q#: 7 Question: A 42-year-old certified occupational therapy assistant (COTA) is

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

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QUESTIONS AND ANSWERS  Q#: 8 Question: During a first year medical school ethics class,

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

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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.

ANSWERS TO QUESTIONS

1=A

2=A

3=A

4=D

5=C

6=C

7=F

8=C

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