BIOETHICS LECTURE
2021
MODULE 2: Why Study Bioethics and Which Principles Should be Applied?
INTRODUCTION
ETHICS AND MORALITY
MORALITY
• concerned with relations between people and how they can
live in peace and harmony
• aims to protect cherished values or "goods"
o goods may refer to high quality of life for an individual
or for the community
o goods may be a property, a liberty or even an idea
• makes things go better and gives more meaning to life
• also pertains to the beliefs of the individual or groups as to
what is right or wrong
• may differ from society to society or culture to culture
• expressed in the form of general rules and statements
• usually consistent but sometimes can change if the
individual's belief change
• transcends cultural norms
ETHICS
• a systematic reflection on and analysis of morality
• a fundamental part of life of everyone in society
• can be applied to everyday problems among individuals, in
institutions and in society
• guiding principles which helps the individual or group to
decide what is right or wrong
• generally uniform and abstract
• governed by professional and legal guidelines within a
particular time and place
MAJOR AREAS OF ETHICAL ANALYSIS
METAETHICAL CONSIDERATIONS
• tries to discover reasons given for making a moral judgment
about the moral life
• geared to thinking about our reasons for defending a
particular position
• require that we become more aware of our beliefs
(religious, philosophical, what we have been taught or told)
and how we imagine them to influence what is right or
wrong
TWO METHAETICAL APPROACHES
1) ABSOLUTISM
• rest on the notion that what is right is based on
knowledge that can be known to be a truth
• moral sources are usually from religious beliefs, natural
laws and intuition
• asserts that there are certain universal moral principles
by which all people’s action may be judged
2) RELATIVISM
• rest on the assumption that ethical statements are not
known to be ultimately true or false
• moral sources are usually from cultural and societal
sources
DOC CHING / MEB24 – SPECIAL TERM
AY 2020
• believes that there is no universal or absolute set of
moral principles
NORMATIVE ETHICAL CONSIDERATIONS
• asks more concrete questions related to morality
• “what types of acts are morally right or wrong?”
• “what types of values are morally good or bad for the
harmonious functioning of society and the welfare of
individuals?”
MAIN THEORIES OF NORMATIVE ETHICS
1) DEONTOLOGICAL THEORY
• Greek deonto means “duty”
• relies on duties, rights or other means of acting
• MEANS theories
• holds that one is acting rightly when one acts
according to one’s duties and rights
• therefore, duties and rights are the correct means to
use in evaluating a course of action
• simple to apply; just requires that people follow the
rules and do their duty
• avoids subjectivity and uncertainty because you only
have to follow set rules
• identified with the writings of Immanuel Kant (1724-
1804)
o he held that every person has an inherent dignity
and on that basis alone is entitled to respect
o respect is shown by never using people to achieve
other goals or consequences
o he thought that the duties and rights of individuals
help to distinguish how their respect can be
honored
o it follows that the right thing is always to be guided
by moral duties,
o responsibilities and rights
o he concluded that some actions are intrinsically
immoral, no matter how positive and beneficial
one might judge the consequences to be; and
other actions are intrinsically moral, no matter how
negative the consequences might be
o in other words, one can’t judge the moral rightness
or wrongness of an act on the basis of its
consequences alone
2) TELEOLOGICAL THEORY
• Greek telos means “end”
• relies on ends or consequences to determine when
one is acting rightly or wrongly
• ENDS theories
• concerned with consequences
• based on the concept of utilitarianism
• an act is right if it is useful to bring about the best
consequences overall
1
 • holds that the most ethical choice is the one that will
produce the greatest good for the greatest number
• the only moral framework that can justify the use of
military forces or war
• also the most common approach to moral reasoning
used in business
• first developed by two English philosophers, Jeremy
Bentham (1748-1832) and John Stuart Mill (1806-
1873)
HISTORICAL DEVELOPMENT OF ETHICS
HISTORY: ETHICS
For as long as people have been living together in groups, the
moral regulation of behavior has been necessary to the group's
well-being.
Although the morals were formalized and made into arbitrary
standards of conduct, they developed, sometimes irrationally,
after religious taboos were violated, or out of chance behavior
that became habit and then custom, or from laws imposed by
chiefs to prevent disharmony in their tribes.
Even the great ancient Egyptian and Sumerian civilizations
developed no systematized ethics; maxims and precepts set
down by secular leaders, such as Ptahhotep, mingled with a strict
religion that affected the behavior of every Egyptian. In ancient
China the maxims of Confucius were accepted as a moral code.
The Greek philosophers, beginning about the 6th century BC,
theorized intensively about moral behavior, which led to the
further development of philosophical ethics.
EARLY GREEK ETHICS
PYTHAGORAS (6TH CENTURY BC)
• developed one of the earliest moral philosophies from the
Greek mystery religion Orphism
• believed that the intellectual nature is superior to the
sensual nature and that the best life is one devoted to
mental discipline
• founded a semi-religious order with rules emphasizing
simplicity in speech, dress, and food
THE SOPHISTS (5TH CENTURY BC)
• group of Greek philosophers who taught rhetoric, logic, and
civil affairs
• skeptical of moral absolutes
• divided into several schools of thought
o Sophist Protagoras taught that human judgment is
subjective, and that one's perception is valid only for
oneself
o Sophist Gorgias went to the extreme of arguing that
nothing exists; that if anything does exist, human
beings could not know it; and that if they did know it,
they could not communicate that knowledge
o Sophist Thrasymachus, believed that might makes right
DOC CHING / MEB24 -SPECIAL TERM
GREEK SCHOOLS OF ETHICS
SOCRATES
(LATE 5TH CENTURY BC AND EARLY 4TH CENTURY BC)
• opposed the Sophists
• “virtue is knowledge; people will be virtuous if they know
what virtue is; and vice, or evil, is the result of ignorance”
• “education can make people moral
• in his Dialogues, he maintains that human virtue lies in the
fitness of a person to perform that person's proper function
in the world
• explained that the human soul has three elements—
intellect, will, and emotion - each of which possesses a
specific virtue in the good person and performs a specific
role
• the virtue of intellect is wisdom, or knowledge of the ends
of life; that of the will is courage, the capacity to act; and
that of the emotions is temperance, or self-control
• the ultimate virtue, justice, is the harmonious relation of all
the others, each part of the soul doing its appropriate task
and keeping its proper place
• maintained that the intellect should be sovereign, the will
second, and the emotions subject to intellect and will
• the just person, whose life is ordered in this way, is
therefore the good person
• gave rise to four schools of thought build by his immediate
disciples: the Cynics, the Cyrenaics, the Megarians, and the
Platonists
o CYNICS, notably the philosopher Antisthenes,
maintained that the essence of virtue, the only good, is
self-control and that it is capable of being taught;
▪ described pleasure as an evil, if accepted as a
guide to conduct
▪ considered all pride a vice, including pride in
appearance or cleanliness
o CYRENAICS, notably Aristippus of Cyrene, were
hedonists, postulating pleasure as the chief good (as
long as it does not dominate one's life)
▪ that no one kind of pleasure is superior to another,
and that it is measurable only in degree and
duration
o MEGARIANS, Euclid's followers, posited that although
good may be called wisdom, God, or reason, it is “one,”
and that good is the final secret of the universe, which
can be revealed only through logical inquiry
o PLATONIST, believed that good is an essential element
of reality; evil does not exist in itself but is, rather, an
imperfect reflection of the real, which is good
2
 ARITSTOTLE (LATE 4TH CENTURY BC)
• Plato's pupil, regarded happiness as the aim of life
• in his principal work on ethics, the Nicomachean Ethics, he
defined happiness as activity that accords with the specific
nature of humanity
• pleasure accompanies such activity but is not its chief aim
• happiness results from the unique human attribute of
reason, functioning harmoniously with human faculties
• held that virtues are essentially good habits, and that to
attain happiness a person must develop two kinds of habits:
those of mental activity, such as knowledge, which lead to
the highest human activity, contemplation; and those of
practical action and emotion, such as courage
• moral virtues are habits of action that conform to the golden
mean, the principle of moderation, and they must be
flexible because of differences among people and
conditioning factors
• for example, the amount one should eat depends on one's
size, age, and occupation defines the mean as being
between the two extremes of excess and insufficiency; thus,
generosity is the mean between prodigality and stinginess
• the intellectual and the moral virtues are merely means
toward the attainment of happiness, which results from the
full realization of human potential.
HISTORICAL DEVELOPMENT OF ETHICS
HISTORY: BIOETHICS
HIPPOCRATES (4TH CENTURY BC)
• Greek physician, associated with more than 70 works
pertaining to medicine; however, modern scholars are not
certain how many of these works can be attributed to
Hippocrates himself, as some may have been written by his
followers
• one work that is generally credited to Hippocrates contains
one of the first statements on medical ethics
o in Epidemics I, in the midst of instructions on how to
diagnose various illnesses, he offers the following, As to
diseases, make a habit of two things—to help and not
to harm
• the most famous ethical work—although the exact origin of
the text is unknown—is the Hippocratic Oath
o in eight paragraphs, those swearing the oath pledge to
“keep [patients] from harm and injustice.”
o the oath also requires physicians to give their loyalty
and support to their fellow physicians, promise to apply
dietetic measures for the benefit of the sick, refuse to
provide abortion or euthanasia, and swear not to make
improper sexual advances against any members of the
household
o the oath still symbolizes a physician’s duties and
obligations.
DOC CHING / MEB24 -SPECIAL TERM
HISTORY: BIOETHICS
IN ASIA
• the idea of ethical conduct is common in many early texts,
including those from Ancient India and China
• believed that medical knowledge was divine or magical in
origin
• counterpart of the Hippocratic Oath, the Caraka Samhita, a
Sanskrit text written in India roughly 2,000 years ago, urges
the following commandment to physicians
o Day and night, however you may be engaged, you shall
strive for the relief of the patient with all your heart and
soul. You shall not desert the patient even for the sake
of your life or living
• similar sentiments can be found in the Chinese text Nei Jing
(The Yellow Emperor's Classic of Inner Medicine), dating
from the 2nd century BC
• three centuries later, the work of the Chinese physician Sun
Simiao emphasized compassion and humility, “a great
physician should not pay attention to status, wealth, or
age.... he
should meet everyone on equal ground....”
IN EUROPE DURING THE MIDDLE AGES
• the ethical standards of physicians were put to the test by
the bubonic plague, the highly contagious Black Death that
arrived around the mid-1300s and remained a threat for
centuries
• when plague broke out, physicians had a choice: They could
stay and treat the sick—risking death in the process—or flee
• the bubonic plague and other epidemics provide an early
example of the challenges that still exist today when doctors
must decide whether they are willing to face personal risks
when caring for their patients
BY THE 18TH CENTURY, PARTICULARLY IN BRITAIN
• the emphasis in medical ethics centered on proper,
honorable behavior
• one of the best-known works from the period is Medical
Ethics; or, a Code of Institutes and Precepts, Adapted to the
Professional Conduct of Physicians and Surgeons, published
in 1803 by the British physician Thomas Percival
o in his 72 precepts, Percival urged a level of care and
attention such that doctors would “inspire the minds of
their patients with gratitude, respect, and confidence”
o his ethics, however, also permitted withholding the
truth from a patient if the truth might be “deeply
injurious to himself, to his family, and to the public”
• at roughly the same time American physician Benjamin
Rush, a signer of the Declaration of Independence, was
promoting American medical ethics
• he spoke of the virtues of generosity, honesty, piety, and
service to the poor.
3
 BY THE EARLY 19TH CENTURY DUTIES
• it seemed that such virtues were in short supply, and the • Duties or obligations is more than merely a feeling in our
public generally held physicians in North America in low everyday lives
esteem • we experience it as a commitment to acting in certain ways
• complicating the problem was the existence of a variety of within our numerous relationships
faith healers and other unconventional practitioners who • e.g. when you have wronged someone, you may feel
flourished in an almost entirely unregulated medical compelled to make some kind of reparation, at least in the
marketplace form of at apology; when you have made a promise, you feel
• in part to remedy this situation, physicians convened in compelled to try to keep it
1847 to form a national association devoted to the • in our daily conversation, we rely on a number of
improvement of standards in medical education and expressions to convey our experience of having
practice commitments that lead to certain types of action: I really
o the American Medical Association (AMA), as the group must, I should, I have to, I ought to…
called itself, issued its own code of ethics, stating, “A • these commitments proved the existence of moral bonds; it
physician shall be dedicated to providing competent is adopted to describe the whole range of such bonds is
medical service with compassion and respect for obligations and the specific forms of it are called duties
human dignity. A physician shall recognize a • when duties arise…
responsibility to participate in activities contributing to
an improved community.” I HAVE A DUTY OF WHEN…
o the Canadian Medical Association (CMA), established in I am in a position to
1867, also developed a Code of Ethics as a guide for NON-MALEFICENCE
potentially destroy or
physicians. Today the CMA code provides over 40 (refraining from harming
otherwise harm someone
guidelines about physician responsibilities to patients, myself or another)
else
society, and the medical profession. BENEFICENCE I am in a position to benefit
(bringing about good) someone else
IN RECENT YEARS I have made a promise,
FIDELITY
• the field of medical ethics has struggled to keep pace with explicit or implicit to
(promise-keeping)
the many complex issues raised by new technologies for someone else
creating and sustaining life VERACITY I am in a position to tell the
• artificial-respiration devices, kidney dialysis, and other (telling the truth) truth or deceive someone.
machines can keep patients alive who previously would I am in a position to
have succumbed to their illnesses or injuries distribute benefits and
• advances in organ transplantation have brought new hope burdens among individuals
JUSTICE
to those afflicted with diseased organs or groups in society who
• new techniques have enabled prospective parents to have legitimate claims on
conquer infertility the benefits
• progress in molecular biology and genetics has placed I have wronged someone
REPARATION
scientists in control of the most basic biochemical processes else.
of life I have been the beneficiary
GRATITUDE
• with the advent of these new technologies, codes of medical of someone else’s goodness.
ethics have become inadequate
or obsolete as new questions and issues continue to • NON-MALEFICENCE AND BENEFICENCE
confront medical ethicists o not harming and acting to benefit another
o considered as two duties in a
ELEMENTS OF ETHICS continuum
INTRODUCTION ▪ do no harm
• Normative ethical theory is a theory devoted to discovering ▪ prevent harm
what makes a right act or a good person praiseworthy. ▪ remove harm
• A norm (element or principle) is the basic unit of morality ▪ bring about positive good
used in normative ethical theory. beneficence
• Norms can be grouped into three general categories: (1)
duties, (2) right, and (3) character traits

DOC CHING / MEB24 -SPECIAL TERM 4

• FIDELITY (L. FIDES, FAITHFULNESS) • the patient’s right to autonomy has come to be accepted as
o being faithful = meeting the patients’ reasonable a moral claim
expectations • autonomy is one’s own choices according to principles that
▪ basic respect could be valid for everyone; the reasons for actions
▪ competence • each person should be permitted to act according to his own
▪ following the code of ethics of profession convictions
▪ following the rules and regulation of the institution • may be exemplified by the right to die through the living will
▪ honor internal agreement (testament) or through the special power of attorney
• JUSTICE
o most complex duty THE RIGHT TO HEALTH CARE
o consider as an “arbiter” because only called on when • considered as one of the positive or entitlement rights like
there are already problems regarding what is rightfully
food and shelter
due to a person, group or institution
• the right to claim for money, health care personnel, facilities
o divided into three types
and medicines from the society in order to assure that
▪ distributive justice – concerns with the
individuals will receive the necessary health care services
comparative treatment of individual in the
allotment of benefits and burdens
CHARACTER TRAITS (VALUES)
▪ compensatory justice – concerns with
compensations for wrongs that have done • the disposition to act in certain ways or the habit that allows
▪ procedural justice – concerns with the ordering of people to act in certain ways
procedure in a fair manner e.g. “first come, first • also called virtues if moral-bound (vices, if not), e.g. honesty,
served” policy courage and compassion
o honesty will manifest itself if you refrain from deceiving
• REPARATION AND GRATITUDE others for your own comfort or protection
o most common forms of duties o courage is required in order to speak out against
o regardless of age and position in life injustice or wrongdoings
o duty to say "sorry" and "thank you" ▪ honesty and courage can lead you in admitting
your mistake
RIGHTS o compassion can help motivate you to refrain from
thoughtlessly harming vulnerable people
• Rights are stringent claims a person or group makes on
society or to other person
• moral rights means you are in a position to lay claim to
something on the basis of the moral correctness of you
• rights relevant to health care may be divided into three
categories:
THE RIGHT TO LIFE
• also known as “pro-life” position
• always been associated with abortion debate
• include both “leave me alone” and to provide necessary
supports for me to live claims
• understood as one of the freedom rights in which your claim
on someone is to not interfere with the continuance of your
life
• comes from religion, philosophy, laws and common sense

THE RIGHT TO AUTONOMY

• sometimes called as the right to self-determination
• also best viewed as freedom right
• the patient’s basic health care needs have not changed but
the responses have changed
o different types of interventions are possible leading to
suffering and prolonged agony of the patient who is
going to die
o response becomes regret rather than an expression of
respect

DOC CHING / MEB24 -SPECIAL TERM 5

 ETHICAL ISSUES AND PROBLEMS • there is more than one right thing to do but to act on one
ETHICAL ISSUE necessarily prohibits you from acting on the others
• situation in which one or more moral norms or principles o as a result, you (the agent) necessarily are doing
are present but do not create a problem. something right and also wrong (by not doing the other
ETHICAL PROBLEM right thing)
• a situation in which two or more moral norms or principles • sometimes an ethical dilemma may be presented in special
create a challenge about what to do case of paternalism or parentalism
• there are 4 basic types of ethical problems: (1) ethical o the patient’s autonomy conflicts with the health
distress, (2) ethical dilemma, (3) ethical dilemma of justice, professional’s judgment of what is best for the patient
and (4) locus of authority issue o the health professional is acting as a parent to the
• the first 3 focused on what to do?, while the last one patient
focused on who should do it? DILEMMAS OF JUSTICE
• a dilemma that arises in
Each of the types can be diagrammed using 3 basic concepts: regard to distributing
societal benefits and
THE MORAL AGENT (A) burdens
• anyone who is in a situation in which he must (and can) • the competition is among
assure responsibility for the outcome of his actions different individuals or
• capable of thinking, deciding and acting in accordance with groups, each of which
moral standards and rules want a share of the
• may not always fulfill the requirements of a moral standard available resources
or rule i.e. he need not be morally perfect but must have the • the scarce supply of these resources requires difficult
capacity to judge himself decisions by the agent
• because to choose to provide the good to one group may
THE COURSE OF ACTION (C) necessarily mean there are no resources available for others
• the agent’s judgments process and final decision about LOCUS OF AUTHORITY ISSUES
what will happen if one or more paths are chosen
• also called the process of applying ethics

THE DESIRED OUTCOME (O)

the projected positive result/s of having taken the course of
action

ETHICAL DISTRESS
• a kind of ethical problem a • these situations arise as problems when roles or other
health professional faces institutional policy or societal arrangements create a
when ho knows exactly confusion about who is in charge
what course of action is • in the diagram, the 2 agents, each of whom assumes himself
right but there is a barrier to be the legitimate authority for making a particular
keeping the person from decision, they may come to different conclusions about how
doing it to achieve the best outcome for a patient
• arises when one knows the right thing to do but institutional o they may disagree on the course of action and benefit,
constraints make it nearly impossible to pursue the right or they agree on the course of action and desired
course of action outcome, disagreeing solely on who is the proper
ETHICAL DILEMMA authority to effect that outcome
• the most common type of • there are several aspects that may consider in deciding who
ethical problem is in charge
o difference in professional expertise
• involves 2 (or more) morally
o traditional arrangements
correct courses of action but
o institutional arrangements and mechanisms
you cannot do both (or all)
o the weight of experience
• sometimes considered as a
problem in which there is no
right or wrong solution
•

DOC CHING / MEB24 -SPECIAL TERM 6

 ETHICAL DECISION MAKING 4) EXPLORE THE PRACTICAL ALTERNATIVES
FIVE STEP-PROCESS OF ETHICAL DECISION MAKING • the health professional has to explore the actual strategies
and options open to him
1) GATHER RELEVANT INFORMATION • these alternatives should be duty-bound and would
RELEVANT FACTS INCLUDE produce the desired outcome
• CLINICAL INDICATIONS
o Is the illness or condition reversible? 5) COMPLETE THE ACTION
o Is the lifesaving treatment medically useless? • the final and necessary step in moral judgment and action
o What is the usual treatment for this type of condition in • without the necessary attention to a strategy for carrying
the community? out the plan, the entire process, steps 1 to 4, is just an
o What is needed to relieve suffering and provide intellectual exercise
comfort? • the health professional must assume that he is prepared to
o Is the patient brain dead or in persistent vegetative accept the consequences of his actions, and that he has the
state? motivation to go beyond mere identification of the problem
• PATIENT PREFERENCES • in order to see the benefits of his own struggle he must now
o Is the patient informed? proceed to action
o Is the patient competent? • to do this, he needs the character traits of compassion, a
o If the patient is not competent, how can I discern what sense of responsibility, and the courage to go ahead
this patient would want? (Substituted or surrogate
judgment)
o If the patient is not competent, how can I discern what
this type of person would want? (Best interest)
• QUALITY OF LIFE
o What is the patient’s judgment?
o What is the health professional’s judgment?
o Is there any hope for improvement from present quality
of life?
• EXTERNAL FACTORS
o Costs? Reimbursement issues?
o What policies are there? Hospital, judicial opinions,
professional societies, etc.
o What are the legal implications? (court cases, statutes)
o Is allocation of beds, other resources an issue?

2) IDENTIFY THE TYPE OF ETHICAL PROBLEM

• simultaneous with the initial fact-finding and sorting of
information, the health professional can begin to determine
the type of ethical problem he is facing
• as he observes, asks questions, and reflects, he can begin to
decipher where his initial observations were correct and
where they were not until he arrives at a point where he has
as clear a picture of the situation as he is able to put
together
3) DETERMINE THE ETHICS APPROACH TO BE USED
• if the moral agent is a deontologist his thinking will be
guided by the duties and/or rights that are in conflict
o he will spend a lot of time weighing the two duties in
dilemma and will probably decide that the weightier or
more compelling duty is to the patient
• if the moral agent is a utilitarian, he will spend less time
thinking about the duties and will be guided by his desire to
bring about the over-all best consequences in the situation
o the over-all best consequences might well be to leave
well enough alone, not to make waves with the patient

DOC CHING / MEB24 -SPECIAL TERM 7

 BIOETHICS LECTURE
MODULE 3: Should Doctors be Patient with Patients?
DOCTOR-PATIENT RELATIONSHIPS
BEGINNING AND ENDING THE RELATIONSHIP
• a voluntary relationship entered freely by both sides
• a patient cannot be compelled to accept a particular doctor
as his/her physician; a physician cannot be compelled to
accept a patient without his/her agreement
• there is no legal obligation on the part of the physician to
accept a patient; this is true no matter what need the
patient has and whatever expertise the doctor may possess
• this is different from a hospital’s mandate to provide
emergency treatment to anyone who comes to the
emergency department; hospital cannot turn anyone away
at the door of the emergency room
• once a patient and a physician have entered into a care
relationship, there is far greater complexity in ending the
relationship
• the doctor cannot suddenly end the relationship; he/she
must maintain the care of the patient until the patient can
find an appropriate alternate source of care and the doctor
must give reasonable notice
GIFTS FROM PATIENTS (OR FROM PHARMACEUTICAL
INDUSTRY)
• small gifts from patients of nominal or modest value are
acceptable
• provided that there is no expectation of a different form of
therapy, or a higher level of care based on the value of the
gift
• rules on gifts from patients are less rigorous, precise or clear
than the rules on gifts from pharmaceutical industry
• there is an automatic presumption that gifts from
pharmaceutical industry always carry an influence toward a
product, service or prescribing practice
• gifts from industry are viewed differently because there can
only be no other intention behind them except to buy
influences
DOCTOR/PATIENT SEXUAL CONTACT
• sexual contact between a physician and a patient is always
inappropriate
• at the very least, the physician and the patient must
mutually agree to end the formal professional relationship
of a doctor and a patient
• not clear how much time must elapse between the ending
of the formal relationship and the start of the personal
relationship
• the American Psychiatric Association guidelines specifically
state that there can never be a sexual or personally intimate
private relationship between doctor and patient even after
the professional relationship
• these guidelines apply no matter who initiates the
relationship; it is not more acceptable for a doctor and
patient to have sexual relations if the patient initiates the
relationship
DOC CHING / MEB24 – SPECIAL TERM
AY 2020
2021
• no account is given on gender or sexual orientation
• it is always unacceptable for a physician of any kind to have
sexual relationship with a current patients
HIPPOCRATIC OATH
CLASSIC VERSION
I swear by Apollo Physician and Asclepius and Hygieia and
Panaceia and all the gods and goddesses, making them my
witnesses, that I will fulfill according to my ability and judgment
this oath and this covenant:
To hold him who has taught me this art as equal to my parents
and to live my life in partnership with him, and if he is in need of
money to give him a share of mine, and to regard his offspring as
equal to my brothers in male lineage and to teach them this art -
if they desire to learn it - without fee and covenant; to give a
share of precepts and oral instruction and all the other learning
to my sons and to the sons of him who has instructed me and to
pupils who have signed the covenant and have taken an oath
according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according
to my ability and judgment; I will keep them from harm and
injustice.
I will neither give a deadly drug to anybody who asked for it, nor
will I make a suggestion to this effect. Similarly, I will not give to
a woman an abortive remedy. In purity and holiness, I will guard
my life and my art.
I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick,
remaining free of all intentional injustice, of all mischief and in
particular of sexual relations with both female and male persons,
be they free or slaves.
What I may see or hear in the course of the treatment or even
outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself, holding
such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me
to enjoy life and art, being honored with fame among all men for
all time to come; if I transgress it and swear falsely, may the
opposite of all this be my lot.
The classical version of the Hippocratic Oath is from the
translation from the Greek by Ludwig Edelstein. From The
Hippocratic Oath: Text, Translation, and Interpretation, by
Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.
8
 HIPPOCRATIC OATH PMA CODE OF ETHICS
MODERN VERSION
I swear to fulfill, to the best of my ability and judgment, this
covenant:

I will respect the hard-won scientific gains of those physicians in

whose steps I walk, and gladly share such knowledge as is mine
with those who are to follow.

I will apply, for the benefit of the sick, all measures which are
required, avoiding those twin traps of overtreatment and
therapeutic nihilism.

I will remember that there is art to medicine as well as science,

and that warmth, sympathy, and understanding may outweigh
the surgeon's knife or the chemist's drug.
RIGHTS OF THE PATIENTS
I will not be ashamed to say "I know not," nor will I fail to call in
my colleagues when the skills of another are needed for a
patient's recovery.

I will respect the privacy of my patients, for their problems are

not disclosed to me that the world may know. Most especially
must I tread with care in matters of life and death. If it is given
me to save a life, all thanks. But it may also be within my power
to take a life; this awesome responsibility must be faced with
great humbleness and awareness of my own frailty. Above all, I
must not play at God.

I will remember that I do not treat a fever chart, a cancerous

growth, but a sick human being, whose illness may affect the
person's family and economic stability. My responsibility includes
these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable

to cure.

I will remember that I remain a member of society, with special

obligations to all my fellow human beings, those sound of mind
and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected
while I live and remembered with affection thereafter. May I
always act so as to preserve the finest traditions of my calling and
may I long experience the joy of healing those who seek my help.

Written in 1964 by Louis Lasagna, Academic Dean of the

School of Medicine at Tufts University, and used in many
medical schools today.

DOC CHING / MEB24 -SPECIAL TERM 9

 BIOETHICS LECTURE
MODULE 4: How should Life and its Extension be Ethically Viewed?
ETHICAL CASES ABOUT BEGINNING OF LIFE
Among the bioethical issues arise at the beginning of life which
will be covered in this module under human choice and decision
includes abortion, contraception, Assisted conception (In Vitro
Fertilization or IVF), Surrogacy, Savior Sibling, Prenatal Genetic
Screening Test.
ABORTION
termination of pregnancy by expulsion of embryo or fetus from
the mother’s womb prior to its viability. Deliberate destruction
of human life at any stage between fertilization to birth.
METHODS
• VACUUM ASPIRATION
use of powerful pump inserted into womb (29x home
vacuum cleaner) to tear fetus into pieces.
• ORAL ADMINISTRATION OF DRUGS
combination of abortive pills used to detached implanted
egg and cause uterine contraction.
• DILATION AND CURETTAGE
dilation of the womb to insert curette (sharp knife) to cut
the fetus into pieces.
• HYSTEROTOMY
cutting the umbilical cord to cut the oxygen supply of baby
via caesarean section
• DILATION AND EVACUATION
combination of dilation of the cervix and suction of the
contents of uterus
• SALINE INJECTION
salts kills the baby after injection using long needle through
abdomen of the mother directed to the baby sac.
• HORMONE INJECTION
causes to labor at any stage of pregnancy
TYPES
SPONTANEOUS ABORTION/MISCARRIAGES
It is a natural occuring termination of pregnancy without
intervention. It usually occurs due to diseases, genetic defects,
trauma or biochemical incompatibility of mother and fetus.
It may be basically of two types
• NATURAL - miscarriages that occur due to natural reasons
like ill-health, disease, shock, fear, excessive joy of the
mother.
• ACCIDENTAL - not intended to occur due to trauma of sexual
intercourse, poisoning, or accidental fall resulting to
dislodging of implanted ovum.
• ISOLATED - occurs at single phase for both natural and
accidental
• RECURRENT - sequence of three or more consecutive
spontaneous abortion.
DOC CHING / MEB24 – SPECIAL TERM
AY 2020
2021
DIVISIONS OF SPONTANEOUS TYPES
(Natural, accidental, isolated, or recurrent)
• THREATENED ABORTION - abortion has started but not
progressed
• INEVITABLE ABORTION - clinical type of abortion where
changes has progressed to state of impossible pregnancy 
• COMPLETE ABORTION - product of conception expelled
from the uterus
• INCOMPLETE ABORTION - part of the entire conception has
expelled 
• MISSED ABORTION - dead fetus is retained inside the uterus
• SEPTIC ABORTION - occurs due to clinical evidences of
infection in the uterus (example: spontaneous vaginal
bleeding, foul smell, fever, chill etc.)
INDUCED
Purposeful termination of pregnancy. it is intentional expulsion
of fetus or embryo from the uterus due to the following reasons:
• Saving the life or preservation of physical and mental health
of the mother
• Prevention of pregnancy due to incest or rape 
• Prevention of pregnancy due to social or economic reasons

• Prevention of birth of child with serious genetic defects.
TYPES OF INDUCED ABORTION
• LEGAL - performed in accordance with the law of the
country
• CRIMINAL -performed in violation of the law of the country
CONTRACEPTION
deliberate prevention of pregnancy as the consequence of
sexual intercourse by interfering the normal process of
ovulation, fertilization, and implantation using different kinds of
birth control method.
TYPES
REVERSIBLE
• NATURAL METHOD - avoiding the chances of meeting the
sperm and egg during high period of fertility (10th to 17th
day of menstrual cycle).
o Ovulation test kits
o Cervical mucus examination
o Rhythm method
• BARRIER METHOD - prevention of meeting of sperms and
egg during sexual intercourse using barriers
o Diaphragms
o Condoms
o Cervical caps
o Spermicide (gels, foam, cream)
10
• ORAL CONTRACEPTIVES - it involves oral administration of
drugs containing hormones that prevent the release of egg
and fertilization.
o Birth control pills
o Hormonal pills
• IMPLANTS - the use of contraceptive devices placed in the
uterus.
o IUD - intrauterin device such as small plastic T-shaped
that contains copper or progesterone to prevent
pregnancy.
PERMANENT CONTRACEPTION
• SURGICAL METHODS - Surgical blocking of eggs in female
fallopian tube (tubectomy)/tubal ligation or surgical
blocking of sperms in male vas deferens (vasectomy).
o Essure, transcervical sterilization using flexible inserts
in each fallopian tubes through vagina and cervix
creating scar tissue over months to block the sperms
from reaching egg.
ADVANTAGES FOR CONTRACEPTION
• HUMAN RIGHTS BENEFITS - freedom of choice to control
their lives.
• HEALTH BENEFITS - prevent health risk of woman and
possible transmission of diseases.
• FAMILY BENEFITS - enjoy quality time for children and
couple
• BENEFITS FOR WOMAN - promotes gender equality and
autonomy
• DEMOGRAPHIC BENEFITS - control population,
environment protection, and reduction of poverty
ASSISTED CONCEPTION
the use of medical intervention to help couples with fertility
problem to conceive a baby.
TYPES
IN VITRO FERTILIZATION
IVF eggs are gathered through laparoscopy and combined with
sperms in the laboratory dish. After fertilization, the zygote is
implanted into the womb.
• Purpose To treat infertility associated with:
o Endometriosis
o Low sperm count
o Problem with uterus or fallopian tubes
o Antibody problems that harm sperms or egg
o Inability of sperm to penetrate or survive in cervical
mucus
o Poor egg quality
o Genetic disease of father or mother
o Unexplained fertility problem
DOC CHING / MEB24 -SPECIAL TERM
INTRAUTERINE INSEMINATION
IUI sperms inserted directly into the womb during ovulation
INTRACYTOPLASMIC SPERM INJECTION
ICSI single sperm is directed injected into single egg in the
laboratory and transplanted into womb.
SPERM DONATION
for low sperm count or nothing to produce to be used for IVF
EGG OR EMBRYO DONATION
for unable to conceive with own egg, donated egg will be
combined with partner’s sperm, and embryo will be
transplanted to your own womb. Likewise in the case of donated
embryo.
SURROGACY
another woman will carry the embryo of couple and entrust after
birth.
DISADVANTAGES OF ASSISTED CONCEPTION
• Invasive and expensive treatments
• Side effects and potential risks of fertility drugs used.
• Possible high risk for baby being born through conception
techniques
• Greater risk of complication of pregnancy, labour and birth.
• Occurrence of multiple pregnancies
• Fertility treatment for old age may have corresponding
complication of miscarriage, pre-eclampsia, gestational
diabetes and may require caesarean.
SURROGACY
legal arrangement between the person who will bear a child and
the person who will become the child’s parent after birth. During
pregnancy, surrogates do not share blood with the baby since
only nutrient and oxygen are passed from pregnant woman to
the womb. The genetic materials of the baby would be inherited
from the egg and sperm donors. The appearance of the baby
would look like from whom contributed the egg and the sperm,
not the uterus that carries the baby. Regardless of whether the
child is biologically related to her or not, or if born via surrogate,
the real people who raise and love the child are the real parents.
INDICATIONS FOR SURROGACY
• Unable to carry children on their own.
• Abnormal uterus or complete absence of uterus due to
post-hysterectomy
• Complication of hysterectomy due to child birth such as
heavy bleeding or rupture or uterus
• Surgical removal of uterus due to cervical or uterine cancer.
• Past implantation failure, miscarriages
• Severe heart or renal condition that can be harmful to
pursue pregnancy
• Biological impossibility of single men or same sex couples.
11
 TYPES
TRADITIONAL SURROGACY
biological mother of the baby for intended parents. The mother
is genetically related because of the egg combined with donated
sperms of intended father. Similar to adoption.
• The surrogates are blood relatives to the babies
GESTATIONAL SURROGACY
modern method “extreme babysitting” whereby the baby is
created through IVF from donated egg and sperms of intended
parents, then transplanted to the gestational surrogate’s uterus
to be carried.
o the surrogates are not blood relatives to the babies
METHODS
• Decide if surrogacy is the right choice.
• Prepare for surrogacy
• Find a match
• Satisfy legal requirements
• Begin the fertilization and embryo transfer
• Welcome the new baby.
REQUIREMENTS
• AGE - preferably between the ages of 21 and 45)
• Reproductive Background - had one full- term,
uncomplicated pregnancy where she successfully had at
least one child, and has had no more than five deliveries or
three Caesarean sections.
• TEST - must have mental health screening, complete
physical and medical screening is also required to prevent
transmission of communicable diseases.
• LIFESTYLE - must live in a supportive home environment.
ETHICAL INVOLVES THE FOLLOWING:
• Social justice
• Women ‘s rights
• Child welfare
• Bioethics
DOC CHING / MEB24 -SPECIAL TERM
SAVIOR SIBLING
is conceived through IVF to provide umbilical cord blood
(hematopoietic stem cell transplantation ) for bone marrow
transplantation in order to save the life of the older sibling from
fatal disease ( cancer or Fanconi anemia).
• they are born to donate HLA (human leukocyte antigen)
compatible body parts
• originally named “medicine babies”
PROCEDURE
• Creation of multiple embryos
• Preimplantation Genetic Diagnosis (PGD) to detect and
select ones without genetic disorder
• Matching human leukocyte antigen (HLA) of siblings
• Taking umbilical cord blood upon birth, or bone marrow or
peripheral blood
• Transplantation of hemapoietic stem cell or hematopoietic
stem cell therapy.
ETHICAL GUIDING PRINCIPLES
• RESPECT FOR AUTONOMY - There is prioritization of
autonomy - one child over the other. Autonomy of parents
supersede that savior child while the self-rule of savior
siblings is threatened even before they born. In this case
that children cannot make decision for themselves, when
their autonomy is not seen legally?
• BENEFICENCE - The good the savior sibling will do for the
sick child must be weighed to the suffering it will cause the
savior sibling. How sick is the child and if he or she gets
treatment from a savior sibling, will it benefit in the end?
• NON-MALEFICENCE - If a doctor promises to do no harm,
who is he promising- the child or the parents and to what
extent? How can these risks and benefits to two different
people be compared?
• JUSTICE - If the treatment does not work, was it all for
nothing?
12
 ETHICAL CASE ABOUT EXTENSION OF LIFE
Case about Extension of Life (Organ Transplantation)
ORGAN TRANSPLANTATION
• is a medical procedure in which an organ is removed from
one body and placed in the body of a recipient, to replace a
damaged or missing organ
• It involves surgically replacing a failing organ with a healthy
donor organ
• The donor and recipient may be at the same location, or
organs may be transported from a donor site to another
location
AUTOGRAFTS
organs and /or tissues that are transplanted within the same
person's body.
ALLOGRAFTS
Transplants that are recently performed between two subjects
of the same species. It can either be from a living or cadaveric
source.
Organs that have been successfully transplanted
• Heart, kidneys, liver, lungs, pancreas, intestines,
thymus and uterus.
• Tissues include bones, tendons (both referred to as
musculoskeletal grafts), cornea, skin, heart valves, nerves
and veins.
• Kidneys are the most commonly transplanted
organs worldwide, followed by the liver and then the heart.
• Cornea and musculoskeletal grafts are the most commonly
transplanted tissues; these outnumber organ transplants by
more than tenfold.
Organ donors may be living,brain dead, or dead via circulatory
death.
• Tissue may be recovered from donors who die of circulatory
death, as well as of brain death – up to 24 hours past the
cessation of heartbeat.
• Unlike organs, most tissues (with the exception of corneas)
can be preserved and stored for up to five years, meaning
they can be "banked".
TRANSPLANTS
• Transplants offer a great solution for many patients with
organ failure and can improve their lifespan and quality of
life.
• Undergoing an organ transplant can lengthen a person’s life
and allow those with a chronic illness to live a normal
lifespan.
TRANSPLANTED ORGANS REJECTION
• donor organs are often rejected by the host's (recipient's)
immune system.
• The immune system recognizes that the new tissue is
foreign, causing an inflammatory attack on the new tissue
DOC CHING / MEB24 -SPECIAL TERM
which if not stopped results in failure of the transplanted
organ.
• Multiple inflammatory cytokines stimulate cytotoxic T cells
to attack the transplanted organ while simultaneously
inhibiting the action of protective T regulatory cells.
CONVENTIONAL TREATMENTS
• help suppress the immune system and protect the
transplanted organ
• however, they often have severe side effects.
• Importantly, certain immunosuppressive drugs also reduce
the amount of T regulatory cells in circulation, preventing
the immune system from developing tolerance to the new
organ.
• Natural interventions such as curcumin and omega-3 fatty
acids may help lessen the inflammatory immune response
and promote more successful transplant tolerance.
Conventional Medical Treatment
• Help Prevent Organ Transplant Rejection
o Immunosuppressive drugs (eg, calcineurin inhibitors
[eg, cyclosporine])
NATURAL INTERVENTIONS
CURCUMIN
a component of the spice turmeric, is a potent anti-inflammatory
agent. Numerous studies demonstrate curcumin's ability to
inhibit inflammatory cytokines involved in transplant rejection.
An animal study showed mice that had heart transplants
survived significantly longer when treated with an
immunosuppressive drug in combination with curcumin than the
drug alone.
OMEGA-3 FATTY ACIDS
found in fish oil, known for their anti-inflammatory properties,
also suppress cytokines involved in transplant rejection. Many
studies demonstrate their beneficial effects, including a study
where kidney transplant patients supplemented with fish oil
experienced better recovery of renal function after a rejection
episode than control patients.
RESVERATROL
has been shown to inhibit the activity of multiple inflammatory
cytokines. Animals who received a genetically incompatible liver
transplant had reduced levels of cytotoxic T cells and survived
significantly longer when supplemented with resveratrol.
QUERCETIN
is known to modulate the action of several inflammatory
cytokines. In combination with vitamin E, quercetin has been
shown in vitroto combat the hepatotoxic effects of cyclosporine,
a common immunosuppressive drug. Quercetin also inhibited T-
cell proliferation, suggesting it may be effective in reducing
transplant rejection.
13
 VITAMIN D
Researchers investigating the importance of vitamin D on
transplant success found heart transplant patients with the
lowest blood levels of the active form of vitamin D (1,25-
dihydroxy vitamin D) were over 8 times as likely to die one year
post transplant than those with the highest levels.
GRAPE SEED EXTRACT
The ratio of protective T regulatory cells to Th17 cells, T cells that
are particularly aggressive, is associated with the likelihood of
transplant tolerance. Grape seed extract has been shown to alter
the ratio favorably and modulate immune response.
HIGHER HOMOCYSTEINE LEVELS
have been shown to be associated with increased mortality after
transplantation. Several natural interventions can lower
homocysteine levels, including B complex vitamins (vitamins
B6, B12, and folate) and N-acetylcysteine.
POLYPHENOLS
such as those found in green andblack tea, cocoa,
and pomegranate, have cardioprotective effects that may be
beneficial after organ transplantation.
Other natural interventions that may benefit transplant patients
include coenzyme Q10, vitamins C andE, L-arginine, probiotics,
and magnesium.
STEPS IN ORGAN TRANSPLANTATION
1. Identification of the Potential Donor by the Hospital
Medical professionals at a hospital identify a potential candidate
for donation. The nature of the injury leads a physician to
determine the patient is brain dead or a potential donation after
circulatory death (DCD) candidate.
2. Evaluation of Donor Eligibility
Information is provided on the patient's medical status and the
recovery coordinator evaluates the patient. The evaluation
includes a medical and social history and physical examination of
the patient. This determines whether or not the patient is a
suitable candidate for donation.
3. Authorization for Organ Recovery
If the patient is a candidate for organ and/or tissue donation, at
an appropriate time the legal next-of-kin is approached with the
opportunity of donation. If a donor designation or individual
authorization by the decedent cannot be identified, the family
must give their consent in order for the donation process to
proceed. If the family consents, the legal next-of-kin signs a
donor consent form.
4. Medical Maintenance of the Patient
Once family consent or donor designation has been provided,
the clinical coordinator, in concert with the hospital staff,
maintains the patient medically. In some cases, physician
support is requested on a consultation basis.
DOC CHING / MEB24 -SPECIAL TERM
5. Matching Organs to Potential Recipients
Information on the organs available for donation, the donor's
blood type and body size is provided to clinical coordinator. The
computer then matches the donated organs to potential
recipients. Recipient selection is based on blood type, body size,
medical urgency and length of time on the waiting list. The heart,
liver and lungs are matched by blood type and body size. In
matching the pancreas and kidneys, genetic tissue type is also
considered.
6. Offering Organs Regionally, Then Nationally
A computerized list of waiting patients in the matching blood
group is provided to the coordinator who seeks to match organs
with recipients in the donation service area. If a match cannot be
made for a specific organ within this area, the organ is offered
on a regional basis, then nationally, if necessary.
7. Placing Organs and Coordinating Recovery
When a recipient match has been found, the coordinator calls
the transplant center for the patient who matches the donated
organ(s). The patient's transplant surgeon is responsible for
making the decision whether to accept the organ. If the surgeon
declines the organ for that patient, the coordinator contacts
the transplant surgeon of the next patient on the list. This
process continues for each organ until all of the organs have
been appropriately matched with recipients. The coordinator
then arranges for the operating room (for the recovery of
the organs) and the arrival and departure times of the transplant
surgery teams.
8. Surgical Recovery of Organs
When the surgical team arrives, the donor is taken to the
operating room where the organs and tissues are recovered
through a dignified surgical procedure. In accordance with law,
physicians recovering the organs do not participate in
the donor's care prior to the determination of brain death.
9. Preparing Recipients for Surgery
Once the recipients have been identified, they are called by their
transplant surgeons for the final pre-operative preparations
while the organ recovery process is occurring at the donor
hospital. Upon the organs' arrival at the transplant hospital, the
recipients are taken to surgery and the transplants
are performed.
10. Distribution of Organs
The coordinator takes a sample of the lymph node tissue to a
laboratory for tissue typing and subsequent matching with
recipients. Other organs are taken directly to the recipients by
the surgical recovery teams.
14
 BIOETHICAL ISSUES IN TRANSPLANTATION
• Transplantation raises a number of bioethical Issues
o including the definition of death,
o when and how consent should be given for an organ to
be transplanted,
o payment for organs for transplantation.
o Other ethical issues include transplantation tourism
(medical tourism)
o more broadly the socio-economic context in which
organ procurement or transplantation may occur. A
particular problem is organ trafficking.
• There is also the ethical issue of not holding out false
hope to patients
GUIDING PRINCIPLE
AUTONOMY
Cells, tissues and organs may be removed from the bodies of
deceased person for the for the purpose of transplantation if:
a. any consent required by law is obtained, and
b. there is no reason to beleive that the deceased person
objected to such removal.
BENEFICENCE
Physician determining that a potential donor has died should not
directly involved in cell, tissue or organ removal from the donor
or subsequent transplantation procedure; nor should they be
responsible for the care of any intended recipient of such cells,
tissues and organs.
Cells, tissues and organs should only be donated freely without
monetary payment or reward of monetary value. The prohibition
on sale or purchase of cells, tissues and organs does not preclude
reimbursing reasonable and verifiable expenses incurred by the
donor, including loss of income, or paying the cost of recovering,
processing, preserving and supplying human cells, tissues and
organs for transplantation.
NON-MALEFICENCE
Minors and legally incompetent people no cells, tissues or
organs should be removed from the body of a living minor for
the purpose of transplantation other than narrow exceptions
allowed under national law. Specific measures should be in place
to protect the minor and, wherever possible the minor assent
should be obtained before donation.
Physicians and other health professionals should not engage in
transplantation procedures, and health insurers and other
payers should not cover such procedures, if the cells, tissues and
organs concerned have been obtained through exploitation or
coercion of, or payment to, the donor or the next of kin of a
deceased donor.
DOC CHING / MEB24 -SPECIAL TERM
JUSTICE
The allocation of organs, cells and tissues should be guided by
clinical criteria and ethical norms, and financial or other
considerations. Allocation rules, defined by appropriately
constituted committees, should be equitable, externally justified
and transparent.
ETHICAL ISSUES FOR DEBATE
• Is human body a commodity? How should decisions be
made about who receive scarce organs?
• Who should pay for transplants?
• Should one person receive several organs or several persons
receive one?
• Should one person have second transplant when the first
one fails or should a different person be given a first chance
at a new organ?
• Should organs be donated to those persons who have
abused their bodies by drinking and smoking or only those
whose organs are damaged by disease? Should state law
maker be involved in transplantation?
•
ADDT’L
ISOGRAFT
A subset of allografts in which organs or tissues are transplanted
from a donor to a genetically identical recipient (such as an
identical twin). Isografts are differentiated from other types of
transplants because while they are anatomically identical to
allografts, they are closer to autografts in terms of the recipient's
immune response.
XENOGRAFT AND XENOTRANSPLANTION
A transplant of organs or tissue from one species to another.
Xenotransplantion is often an extremely dangerous type of
transplant. Examples include porcine heart valves, which are
quite common and successful, a baboon-to-human heart
(failed), and piscine-primate (fish to non-human primate) islet
(i.e. pancreatic or insular tissue), the latter's research study
directed for potential human use if successful.
See: xenotransplantation.
15