Chapter Sifteen ghe Moral Issues of Behavioral control and Claim to Health Care Abnormal and violent behavior duc to insanity, epilepsy, izophrenia, and other forms of mental disorders, has been a problem schol eal science since the beginning of human civilization. In ancient Bet mental illness was thought to be caused by the malign influence sn spirits. Various forms of exorcism were applied to expel demons ‘il spi e rs to restore the normal self-control of the patient (Varga:110). i fact, the Christian bible narrates several occasions on which Jesus of Nazareth cast away (exorcised) demons from possessed individuals (Matt. 8:16,28,31,33). And many Filipinos, in this age of high-tech computers and biotechnology, still believe in “pinasukan ng maligno,” “pinaglalaruan ng sirena,” “nabati ng nuno sa puso,” “kinulam,” etc., to account for weird and bizarre human behavior. Filipino experience along this line also includes “karma,” “kondena ng Diyos,” or “parusa ng langit’ as the alleged cause or reason for an individual’s genetic psychosis, inborn lunacy, and other mental illnesses or neuroses. Modern man and modern medical science, however, do not subscribe to demons and spirits and their harmful influence upon human beings. Psychological scientists claim that the cause of abnormal behavior is to be found in mental or psychological factors hidden in the subconscious stratum of man’s psyche. Certain scientists andave turned to the exploration of another possiby t mely, an illness of the brain (Varga: | 1 » the center of the human person: physicians hi i © cay of abnormal behavior, nap 0-1 Use 1), introduced psychosurgery in the 1930s and developed the technique known as leukotomy or lobotomy, as a therapeutic measure in the treatment of mental illnesses, e.g., severe depression and schizophrenia. In this procedure, the white nerve fibers connecting BIOETHICS AND Morat DECISIONSne frontal and prefrontal lobes of the brain are severed (Pahl:41 é). Lobotomy operations slowly gained favor with ne 415- the United States and in Britain, where as many as seve! Haar ouomies Were performed from 1935 to 1955 ae jousand fruction of new antischizophrenic and antidepressa ac isi caused the decline in popularity of this surgical aan rugs has 52 Types of Psychosurgical (Neurosurgical) Operations 15.3 in which chemical drugs are kinds of mood and thought s have focused their research on specific ones that alter behavior, moods, or of chemotechnology various ‘This is a type used for behavior control, €-8s disorders. 245 Bioeriics AND MORAL DECISIONS escauses of mental disorders (abnorma: , AV ] i OF Sura ang ulo,” lie hidden in a person's subconscious. Certain psychotherapeutic techniques are supposed to unfold and disclose these unconscious forces or factors so as to “exorcise” or cast them away. It is believed that expelling the unconscious cause of a deviant behavior in this way will cure the patient. Psychotherapy requires the voluntary participation of the individual in the process. Its method consists primarily in talking to people, and so there is a relatively long-term face-to-face relationship with a therapist. For these reasons, psychotherapeutic techniques cannot easily be made the instrument of widespread social control. However, the therapist as an agent of the state or of the society i 246 Biorrnics anD Mora. Decisions See a0 able © shape the behavior of dui ind ot proved patterns or social convention, 0 ividual citize zen to conf s (Pahl:4 15) ie fation which was hence it was first .” Later it was less and Stephen Delgado and his make an animal sexually aroused, ther behaviors” humans to evoke a finger move. Ing electrodes in timoceiver. This to a computer. When characterisuc brain-wave patterns maicate tie onsct of a violent episode, the computer transmits a message that activates the stimoceiver to stimulate the brain with electricity and the violent episodes are aborted (Varga: 115; Pahl: 41 1-412). Dr. Delgado used the ESB technique to experiment on a large bull. First, he implanted electrodes at precise locations in the bull’s brain and then attached a miniature radio receiver (stimoceiver, his own invention) to its skull. Then Dr. Delgado climbed into the bullring and waved a red cape at the bull. The brutal beast charged towards him. Dr, Delgado then pressed a button on a tiny transmitter concealed in his right hand, and the bull suddenly stopped in its place. Dr. Delagado pushed another button, and the bull walked quietly away. The experiment was a success, and the doctor was cheered by ey dience of hundreds that witnessed the phenomenon “The reactions of human beings to the electrical stimulation of 6 those of animals, according to Dr. Delgado. the brain are similar c the depth of the brain can produce pleasant Electrical stimulation © 247 Broeruics AND Monat. DECISIONS__ Jings. Patients suffering from schizophrenia or Parkinson’ a eclings. Pa n i os ae became “relaxed and at case after stimulation ts ei egiaD One individual's narcolepsia (a condition marke : septal . sudden, uncontro! Ase, lable attacks of sleep of brief duration) was ” ; mK relieved by pressing his “septal button” (Varga; 114), ents pileptic pai also relieved when they were subjected to ESB Procedures were a What is good about ESB is that, unlike psychosurgery, don not destroy any part of the brain; furthermore, it is painless, and the electrodes can ‘remain implanted or they can be removed atany time TI is is a great advantage over brain surgery, which is irreversible a may have detrimental side effects. bias This is a form of behavior modification that is based on the concept of operant conditioning. T he latter consists in the application of negative or positive reinforcements (ec. 8 punishments or Tewards) in such a way that the probability of particular behavior Tesponses jg increased or decreased, if not gradually eliminated. Let us illustrate: A homosexual male in his early twenties is seated in a chair before a screen. A picture of a nude man is flashed on the screen, and the man in chair receives a brief but painful electric shock through the electrodes taped in his arm. Then a slide of a nude female appears, and the seated man receives no shock. The process is repeated several times during a number of sessions. The electric shock administered to the homosexual male when he sees pictures of nude males is intended to totally eliminate his sexual responses to men (Pahl: 413), 15.7 Application of Ethical Theories It seems that the moral principles of Kant, Ross, Rawls, and Roman Catholicism would rule out psychosurgery that threatens to destroy an individual’s ability to function as an effective agent. It would undermine his autonomy and destroy his dignity. The counter argument, however, is that it is precisely because of the desire to restore a particular Patient’s autonomy that he/she should undergo psychosurgery. But who would make the decision for him or her, if he/she is not capable of informed consent? Those who are concerned for his/her well-being can 248 Bioerics AND Moral. Decisions>» ope he principle of paternalism, The aim 1 w c ; 0 in?” | functioning should inspire Patern Visti ° alisti ft vt tore patients to olla Jhatever pr 0 yentions- Whatever procedure is best chosen { St chosen ic decisions or ore for hi ae solely for his/her own good or well-being for the patient is ; : he same arguments the The nify cl that support psychosur ery ca ced 10 justily chemotherapy, ps; ‘ Bery can also be uw . petavior® control. Of course, one See and other forms of be esq ill object that the techni in cach of these cases are so unreliable as therapies, and enue a no matter jae their aim may: be, a patient is more likely to | than to gaint In this regard, Ross’s moral aot 1 : Which decision is more stringent for the benefit of ey De apptied: st let him/her suffer from his/her mental condition f he raint—t0 Hertain behavior Control procedure for hivher sake? tory autonomy For the utilitarians, the most important thing to consider is th effectiveness of a particular procedure of behavior pen : technology. How effective and useful and workable would a cera procedure be to a patient suffering from a particular psychosis? If the procedire raises @ genuine hope of increasing the happiness of those receiving it, then such technique is desirable and acceptable—more so if it is likely to increase the overall happiness and well-being of society (Pahl:422). 15.8 Claim to Health Care Does one have a claim-right to health care? A claim-right is one’s right to demand or claim—i.e., one’s right to health care. “Right here should be understood in its moral sense—i.e., moral right. The latter is one that is derived from the principles of a moral theory. Hence, the source of justification for a moral right and for the corresponding duty lies in moral principles and not in the laws or practices of society (Pahl:450-451). Health is necessary for any individual to lead a normal life—no one can adequately care for his health alone. In earlier days, the family looked after its old and sick members, but with the advance of the seience of medicine, the simple medical care 2 family can provide is no longer sufficient (Varga: 172). This is why the moral issue of the claim-right to health care 1s of great significance. Three perceptions Biosrites AND Moral, DECISIONS 249 a ay —URC ReO UE Rec ) the concept of the individuay’ is sectit . ed in thissecaon: ee nd 3) social commitme, presente idualism; ar ig ty, 2) medical ind ign) s inhere, nt. in a manner ys! S be subservient to social Pressure and would be de of their autonomy. In other words, they would be m: 250 Biorrics anD Monat. Decisio’Robert M. Sade, a propo jaim to any right to heal Ree of medical individual mec’, oe health care. One’s pri ividualism, rejects Hie right 1 one's own life which she primary right, he assert ; Accordingly, everye 18 the basi: a sserts, nt phy rictaa ce ae has right to pursue thei pat the P by can also choose the condi © their own values, so der services. This is a consequence of th itions under which to le n life. In the event that the government u: Tight to support one’s s ow i det es {c to guarantee the right of every individual to health force or compulsion care, the physician’ ‘lan § Upc to hisfher own life will be greatly undermined, i Thus, in the phy ician’s view, to regard every zined if Not subverted. care as @ right is not only immoral but alae inh ecieo medical jnsofar as it involves the use of threat or violen nea at onesie, in order to ensure its implementation, ce against physicians Another medical individuali : fe rented iba acces hel eek pat ah every : ess to health care, it would absorb intolerable portion of the physician’s income. He is, how Pati toarant a right to a “decent minimum” of health cai Aeneas 453), Faced with the problem of determining the minimum, ed so mend that physicians be classified so that they will be paid according to their training, experience, and expertise. He also iceiti that patients be granted a wider or greater choice in the “medical marketplace” by giving each person a certain amount of money to secure the medical services that he/she chooses. This matter, however, requires a variety of medical delivery systems suited to consumers’ needs. Those who want more individualized medical care could get it by paying the cost out of their own pocket. 1 aT Opposing medical individualism, John D. Arras and Andrew Jameton disagree with Robert Sade. The right to life justifies an absolute control over property and services (Pahl:455). Claim-rights, in their view, including the physicians’ right to life, are not absolute; they may be restricted if and when serious ‘social reasons and purposes Rights may be limited when they grant some people ° are at stake. 1 over the lives of others. It is maintained that the excessive contro) physicians’ right to employ their medical knowledge and skills is restricted by society’s medical demands, even as the physicians 251 pioerics AND Moras, DECISIONSa ) Iso members of a society that needs their me, es for its own survival. Moreover, the knowledge and ski services has acquired represent more than an individual ame i 153 ). They also involve a social investment through public funn 55). The) , (i peoples’ taxe ) that were spent on education and Uaining : s ily of the physicians but of other professionals as well, ot only S n be remarked, therefore, that the phys ian’s medica, training is a social commitment because it : fociety-oriemted, 4 physician studies and trains not’ for persona ul iment but mos, especially for “service to humanity (Beauchamp and Childres 989) 1 As is beautifully enshrined in the AMA's preamble of the Principle i Medical Ethics, Section 1, “The principal objective of the medical render service to humanity with full respect for the themselves are a Cal It can rofession is to aa : s dignity of man...” (Beauchamp and Childress:282). It is clear then that the service aspect of medical training makes medicine the most humane and Christian profession; humane, for its compassion and concern for the weak and the ill; Christian, for its selflessness and self-denial for the sake of the people’s health and survival. 15.12 Allocation of Scarce Resources In medicine as well as in many other areas of human endeavors man is usually confronted with the problem of how to allocate scarce resources in the midst of great demands. For example, the need for organs (kidneys in particular) is always greater than the supply (Pahl:433; Beauchamp and Walters:347-351). In such a situation, where scarcity and demand conflict, it is often necessary to decide who among the candidates for a transplant should receive an available organ. It is not only organ transplants that call public attention to the issue of resource allocation. This also occurs in the treatment of renal diseases where there are many more candidates for hemodialysis than there are “kidney machines” (dialysis units or equipment). Almost always, there are many more patients needing hemodialysis than there is equipment available to treat them. ee *TL Beauchamp and J. Childres: .F.C 8, Op. cit.,p. 281. Physician's Oath: “I solemnly pledge mysetf to consecrate my life to the service of humanly a (252 Biorrics np Moral Dicistonswhen f nal, failure occurs, « plood of waste products by c C immersed in a chemical bath ube yh the membrane and into yprous” 7 ihe purified blood is then returne ‘The issue of resource alloca neir patients with limit f incubation units for pre} hospital beds, operati *s time or insufficient p to treat th number 0 of drugs> physician Our main concern here they that involves the welfare of cert These people are in situations in needed for their medical treatme! and who shall go wi shall get it succinctly puts it, “Who shall li obvious that any commodity or s' relative to the demangd for it raisq This gives rise to certain criteria} Nicholas Rescher cites two (for the selection of candidates) selection of recipients). The criteria of 1clus e.g. _Is the person a member of the community that the institution 1s designed to serve? (2) progress of science—€-§-» Can new knowledge be gained from the case? (3) success—e.gs 1s the treatment of the person likely to be effective? constituen' -2 of comparison are as follows: () + hand, the criteri t compared with others in the On the othe! the likelihood of successful treatmen! group; (2) the life-expectancy of the person; (3) the person’s family role; (4) the potential of the person in making future contributions; and (5) the person’s record of services OF contributions (Pahl:437). s F. Childress favors some sort 0! ed” basis for the selection loyed to determine who is to have an increased h person is being treated as least exercised Jame: f random selection, i-€., 4 “first come, first serv! of candidates. Likewise, a lottery may be emp! chance of survival. In such cases, eac having equal value, and the person who loses has at 253 BioeTHics AND Moral. DECISIONSN for there has been an equality of opportuni frown upon using a lottery to resolve the int Some h situation, gambling ventures must beaut: For avoid, ed his autonomy, critics, howeve® them, ina life and deat! (Pahl:436, 438). 15.13 Application of Natural law ethicians Ethical Theories and Ross would seem to support a ra; cedure. We all have a duty (0 preserve O07 lives, but wo sometimes have to risk them in such situations as in agreeing to ap do by the outcome of a random procedure to decide who will get me ra aid and who should not “who will be sacrificed and who will a saved” (Pahl:436). For the rule vnclitarian, the “first come, first serveq™ although the principle of utility suggests would be legitimate, ake into consideration the consequences of sacrificing r than others. In this light, a set of criteria (“calculus of utilities”) must be formulated which will be based on the social worth of people who would be saved; for instance, candidates who could make a significant contribution to society at large (e.g., for the benefit of the greatest number of individuals) should be given greater priority in the allocation of scarce resources. pro procedure that we ought to t some people rathe! es of justice, however, would rule out the based on social worth. Whatever benefits of value to all and open to all. For distributed under conditions of random selection) Rawls’s principl distribution of resources ilable, in his view, must be must be fair procedure (such as are avs medical resources that scarcity then, some genuinely must be used (Pahl:436). Who shall make the allocation decision? se who are in a good position to judge the he welfare of the society as a whole. A variety of people representative of d. This committee is cies as those A utilitarian would suggest tho: likelihood of an individual’s contributing to committee to be composed of a the society at large may be formed or create’ tasked to make allocation decisions and such poli necessary for carrying out its decisions. Broeriics AND Moral. Dectst0?with regard to behavior control, would y i undergoing psychosurgery fora possible Bo te ee a remaining a helpless victim of epileptic se ae, a your life? If you could not make the deciitor ye ' qe mental incompetence, would it be legitimate for ae See guardians, or benefactors under th er the con i ES doco? cept of paternalism a is the ee of medical individualism concerning the moral issue 0} everyone s claim-right to health care? Explain the meaning of ‘medical profession’ as a social commitment. How would you resolve the issue on the allocation of scarce medical resources? What is the utilitarian solution to the problem? Due to the shortage of medical resources (e.g., drugs, artificial respirators and other life-support machines, kidney transplants), “who shall live when not all can live”? Discuss “random selection,” “lottery” and “first come, first served” procedures in resource allocation.