STATE UNIVERSITY OF MEDICINE AND PHARMACY “NICOLAE TESTEMITANU”

OF THE REPUBLIC OF MOLDOVA

Chair of Philosophy and Bioethics

BIOETHICS

Didactic material for medical students

Chisinau, 2011

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 Table of content:

1. Morality and ethics: history and general

concepts……………………………………………………….

1.1. Ethics and Morality: general concepts

1.2. Theories of morality

1.3. Study case

2. Bioethics, the origin, the subject-matter and its paths of development. Bioethics’
principles……………………………………………

2.1. The origins and development of Bioethics. Bioethical aspects.

2.2. Bioethics’ principles

2.3. Cases

3. Bioethics as socio-cultural phenomenon. Paternalism and anti - paternalism in

medicine and bioethics…………………………………………

3.1. Paternalism and anti-paternalism

3.2. Inform consent

3.3. Study cases

4. Bioethics in practical medicine. ……………………………………..

4.1. Euthanasia

4.2. Bioethics and reproduction

4.3. Bioethics and genetic

4.4. Study cases

5. Social problems of bioethics: socio-philosophical analysis………………..

5.1. Ethics and sex: transexualism

5.2. Ethical issues in mental disorder patients.

5.3. Suicide.

5.4. Study cases

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 6. Medical ethics - compartment of bioethics……………………………

6.1. Medical ethics: patient-doctor relation

6.2. The problem of confidentiality

6.3. Study cases

7. Scientific research and clinical trials in the biomedical world from the perspective
of bioethics………………………………………….

7.1. Ethical issues in human subjects research

7.2. Ethical issues in nonhuman subjects research

7.3. Study cases

Chapter I
1. Ethics and Morality : general concepts.
After Bernard Gert. The Definition of Morality. Stanford encyclopedia of philosophy.
Principal Editor: Edward N. Zalta. First published Wed Apr 17, 2002; substantive
revision Mon Mar 14, 2011.

http://plato.stanford.edu/entries/morality-definition/

Ethics is the branch of philosophy that involves systematizing, defending, and recommending
values and principles for good human behavior. Or it is the systematical study of morality. Term Morality
comes from the Latin moralitas which means manner, character, and proper behavior. In the widest
formula morality refers to well-founded standards of right and wrong that prescribe what humans ought to
do, usually in terms of rights, obligations, benefits to society, fairness etc. Morality for instance refers to:
standards that impose the reasonable obligations to refrain from rape, stealing, murder, assault, slander,
and fraud; standards that enjoin virtues of honesty, compassion, and loyalty; standards relating to rights,
such as the right to life, the right to freedom from injury, and the right to privacy. Generalizing, morality
is a code of conduct accepted by humans (the members of that society) as a guide to behavior, and the
basic feature of which is avoiding and preventing harm to some others. However, in human society there
are other guides for behavior: etiquette, law, and religion. What is the distinction among morality and that
mentioned above?

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 Etiquette is usually included as a part of morality, but it applies to norms that are considered less
serious than the kinds of norms for behavior that are part of morality in the basic sense. Hobbes
expresses the distinction between morality and etiquette in this way: “By manners I mean not here
decency of behavior, as how one man should salute another, or how a man should wash his mouth or pick
his teeth before company, and such other points of small morals, but those qualities of mankind that
concern their living together in peace and unity.” (Leviathan, Chapter XI, paragraph 1)

Law or a legal system is distinguished from morality or a moral system by having explicit written
rules, penalties, and officials who interpret the laws and apply the penalties. Although there is often
considerable overlap in the conduct governed by morality and that governed by law, laws are often
evaluated on moral grounds. Moral criticism is often used to support a change in the law. (Dworkin).

Religion differs from morality or a moral system in that it includes stories about events in the past,
usually about supernatural beings, that are used to explain or justify the behavior that it prohibits or
requires. Sometimes there is no distinction made between a moral code and a code of conduct put forward
by a religion, and there is often a considerable overlap in the conduct prohibited or required by religion
and that prohibited or required by morality. But religions may prohibit or require more than is prohibited
or required by guides to behavior that are explicitly labeled as moral guides, and may allow some
behavior that is prohibited by morality. In the same time some religious practices and precepts are
criticized on moral grounds, e.g., discrimination on the basis of race, gender, or sexual orientation. So
morality cannot be confined to religion, nor is it the same as religion, as well as vice versa. While
religious guide is applied only to religious people, morality applies as much to the behavior of the atheist
as to that of the saint. Nevertheless morality is only a guide to conduct, while religion is always more than
this. (1)

2. Ethical theories

After James Fieser. Ethics. Internet enchiclopedia of philosophy. http://www.iep.utm.edu/ethics/

As was mention in previous paragraph ethics is a branch of philosophy studing values relating to human
conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness
of the motives and ends of such actions. As moral philosophy ethics consist in a sistem of theories
usually divide into three general subject areas: metaethics, normative ethics, and applied ethics.

A. Metaethics

Metaethics is the study of the origin and meaning of ethical concepts. Dealing with such question as:
Where our ethical principles come from, and what they mean, methaethics arises and covers two basic
issues: (1) metaphysical issues concerning whether morality exists independently of humans, and (2)
psychological issues concerning the underlying mental basis of our moral judgments and conduct.

(1) Metaphysical Issues involves discovering specifically whether moral values are eternal truths that
exist in a spirit-like realm (are objective), or simply human conventions (are relative). There are two

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general directions that discussions of this topic take, one other-worldly(objectivism) and one this-worldly
(relativism).

Proponents of the other-worldly view typically hold that moral values are objective in the sense that
they exist in a spirit-like realm beyond subjective human conventions. They also hold that they are
absolute, or eternal, in that they never change, and also that they are universal insofar as they apply to all
rational creatures around the world and throughout time. The most dramatic example of this view is Plato,
who was inspired by the field of mathematics. When we look at numbers and mathematical relations,
such as 1+1=2, they seem to be timeless concepts that never change, and apply everywhere in the
universe. Humans do not invent numbers, and humans cannot alter them. Plato explained the eternal
character of mathematics by stating that they are abstract entities that exist in a spirit-like realm. He noted
that moral values also are absolute truths and thus are also abstract, spirit-like entities. In this sense, for
Plato, moral values are spiritual objects. A different other-worldly approach to the metaphysical status of
morality is divine commands issuing from God’s will. Sometimes called voluntarism (or divine command
theory), this view was inspired by the notion of an all-powerful God who is in control of everything. God
simply wills things, and they become reality. He wills the physical world into existence, he wills human
life into existence and, similarly, he wills all moral values into existence. Proponents of this view, such as
medieval philosopher William of Ockham, believe that God wills moral principles, such as “murder is
wrong,” and these exist in God’s mind as commands. God informs humans of these commands by
implanting us with moral intuitions or revealing these commands in scripture.

The second and more this-worldly approach to the metaphysical status of morality follows in the
skeptical philosophical tradition, such as that articulated by Greek philosopher Sextus Empiricus, and
denies the objective status of moral values. Technically, skeptics did not reject moral values themselves,
but only denied that values exist as spirit-like objects, or as divine commands in the mind of God. Moral
values, they argued, are strictly human inventions, a position that has since been called moral relativism.
There are two distinct forms of moral relativism. The first is individual relativism, which holds that
individual people create their own moral standards. Friedrich Nietzsche, for example, argued that the
superhuman creates his or her morality distinct from and in reaction to the slave-like value system of the
masses. The second is cultural relativism which maintains that morality is grounded in the approval of
one’s society – and not simply in the preferences of individual people. This view was advocated by
Sextus, and in more recent centuries by Michel Montaigne and William Graham Sumner. In addition to
espousing skepticism and relativism, this-worldly approaches to the metaphysical status of morality deny
the absolute and universal nature of morality and hold instead that moral values in fact change from
society to society throughout time and throughout the world. They frequently attempt to defend their
position by citing examples of values that differ dramatically from one culture to another, such as
attitudes about polygamy, homosexuality and human sacrifice.

(2) Psychological Issues in Metaethics involves the psychological basis of our moral judgments and
conduct, particularly understanding what motivates us to be moral. We might explore this subject by
asking the simple question, “Why be moral?” Even if I am aware of basic moral standards, such as don’t
kill and don’t steal, this does not necessarily mean that I will be psychologically compelled to act on
them. Some answers to the question “Why be moral?” are to avoid punishment, to gain praise, to attain
happiness, to be dignified, or to fit in with society.

i. Egoism and Altruism

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One important area of moral psychology concerns the inherent selfishness of humans. 17th century
British philosopher Thomas Hobbes held that many, if not all, of our actions are prompted by selfish
desires. Even if an action seems selfless, such as donating to charity, there are still selfish causes for this,
such as experiencing power over other people. According to Hobbes, for purely selfish reasons, the agent
is better off living in a world with moral rules than one without moral rules. For without moral rules, we
are subject to the whims of other people’s selfish interests. Our property, our families, and even our lives
are at continual risk. Selfishness alone will therefore motivate each agent to adopt a basic set of rules
which will allow for a civilized community. Not surprisingly, these rules would include prohibitions
against lying, stealing and killing. However, these rules will ensure safety for each agent only if the rules
are enforced. As selfish creatures, each of us would plunder our neighbors’ property once their guards
were down. Each agent would then be at risk from his neighbor. Therefore, for selfish reasons alone, we
devise a means of enforcing these rules: we create a policing agency which punishes us if we violate these
rules.

This view is called psychological egoism and maintains that self-oriented interests ultimately motivate all
human actions. Closely related to psychological egoism is a view called psychological hedonism which is
the view that pleasure is the specific driving force behind all of our actions. 18th century British
philosopher Joseph Butler agreed that instinctive selfishness and pleasure prompt much of our conduct.
However, Butler argued that we also have an inherent psychological capacity to show benevolence to
others. This view is called psychological altruism and maintains that at least some of our actions are
motivated by instinctive benevolence.

ii. Emotion and Reason

A second area of moral psychology involves a dispute concerning the role of reason in motivating moral
actions. If, for example, I make the statement “abortion is morally wrong,” am I making a rational
assessment or only expressing my feelings? On the one side of the dispute, 18th century British
philosopher David Hume argued that moral assessments involve our emotions, and not our reason. We
can amass all the reasons we want, but that alone will not constitute a moral assessment. We need a
distinctly emotional reaction in order to make a moral pronouncement. Reason might be of service in
giving us the relevant data, but, in Hume’s words, “reason is, and ought to be, the slave of the passions.”
Inspired by Hume’s anti-rationalist views, some 20th century philosophers, most notably A.J. Ayer,
similarly denied that moral assessments are factual descriptions. For example, although the statement “it
is good to donate to charity” may on the surface look as though it is a factual description about charity, it
is not. Instead, a moral utterance like this involves two things. First, I (the speaker) I am expressing my
personal feelings of approval about charitable donations and I am in essence saying “Hooray for charity!”
This is called the emotive element insofar as I am expressing my emotions about some specific behavior.
Second, I (the speaker) am trying to get you to donate to charity and am essentially giving the command,
“Donate to charity!” This is called the prescriptive element in the sense that I am prescribing some
specific behavior.

From Hume’s day forward, more rationally-minded philosophers have opposed these emotive
theories of ethics (see non-cognitivism in ethics) and instead argued that moral assessments are indeed
acts of reason. 18th century German philosopher Immanuel Kant is a case in point. Although emotional
factors often do influence our conduct, he argued, we should nevertheless resist that kind of sway.
Instead, true moral action is motivated only by reason when it is free from emotions and desires. A recent
rationalist approach, offered by Kurt Baier (1958), was proposed in direct opposition to the emotivist and
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prescriptivist theories of Ayer and others. Baier focuses more broadly on the reasoning and argumentation
process that takes place when making moral choices. All of our moral choices are, or at least can be,
backed by some reason or justification. If I claim that it is wrong to steal someone’s car, then I should be
able to justify my claim with some kind of argument. For example, I could argue that stealing Smith’s car
is wrong since this would upset her, violate her ownership rights, or put the thief at risk of getting caught.
According to Baier, then, proper moral decision making involves giving the best reasons in support of one
course of action versus another.

B. Normative Ethics

Normative ethics takes on a more practical task, which is to arrive at moral standards that regulate right
and wrong conduct. This may involve articulating the good habits that we should acquire, the duties that
we should follow, or the consequences of our behavior on others. In a sense, it is a search for an ideal
litmus test of proper behavior. The Golden Rule is a classic example of a normative principle: We should
do to others what we would want others to do to us. Since I do not want my neighbor to steal my car, then
it is wrong for me to steal her car. Since I would want people to feed me if I was starving, then I should
help feed starving people. Using this same reasoning, I can theoretically determine whether any possible
action is right or wrong. So, based on the Golden Rule, it would also be wrong for me to lie to, harass,
victimize, assault, or kill others. The Golden Rule is an example of a normative theory that establishes a
single principle against which we judge all actions. Other normative theories focus on a set of
foundational principles, or a set of good character traits. The key assumption in normative ethics is that
there is only one ultimate criterion of moral conduct, whether it is a single rule or a set of principles.
Three strategies will be noted here: (1) virtue theories, (2) duty theories, and (3) consequentialist theories.

a. Virtue Theories

Many philosophers believe that morality consists of following precisely defined rules of conduct,
such as “don’t kill,” or “don’t steal.” Presumably, I must learn these rules, and then make sure each of my
actions live up to the rules. Virtue ethics, however, places less emphasis on learning rules, and instead
stresses the importance of developing good habits of character, such as benevolence. Once I’ve acquired
benevolence, for example, I will then habitually act in a benevolent manner. Historically, virtue theory is
one of the oldest normative traditions in Western philosophy, having its roots in ancient Greek
civilization. Plato emphasized four virtues in particular, which were later called cardinal virtues: wisdom,
courage, temperance and justice. Other important virtues are fortitude, generosity, self-respect, good
temper, and sincerity. In addition to advocating good habits of character, virtue theorists hold that we
should avoid acquiring bad character traits, or vices, such as cowardice, insensibility, injustice, and
vanity. Virtue theory emphasizes moral education since virtuous character traits are developed in one’s
youth. Adults, therefore, are responsible for instilling virtues in the young.

Aristotle argued that virtues are good habits that we acquire, which regulate our emotions. For
example, in response to my natural feelings of fear, I should develop the virtue of courage which allows
me to be firm when facing danger. Analyzing 11 specific virtues, Aristotle argued that most virtues fall at
a mean between more extreme character traits. With courage, for example, if I do not have enough
courage, I develop the disposition of cowardice, which is a vice. If I have too much courage I develop the
disposition of rashness which is also a vice. According to Aristotle, it is not an easy task to find the

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perfect mean between extreme character traits. In fact, we need assistance from our reason to do this.
After Aristotle, medieval theologians supplemented Greek lists of virtues with three Christian ones, or
theological virtues: faith, hope, and charity. Interest in virtue theory continued through the middle ages
and declined in the 19th century with the rise of alternative moral theories below. In the mid 20th century
virtue theory received special attention from philosophers who believed that more recent approaches
ethical theories were misguided for focusing too heavily on rules and actions, rather than on virtuous
character traits. Alasdaire MacIntyre (1984) defended the central role of virtues in moral theory and
argued that virtues are grounded in and emerge from within social traditions.

b. Duty Theories

Many of us feel that there are clear obligations we have as human beings, such as to care for our children,
and to not commit murder. Duty theories base morality on specific, foundational principles of obligation.
These theories are sometimes called deontological, from the Greek word deon, or duty, in view of the
foundational nature of our duty or obligation. They are also sometimes called nonconsequentialist since
these principles are obligatory, irrespective of the consequences that might follow from our actions. For
example, it is wrong to not care for our children even if it results in some great benefit, such as financial
savings. There are four central duty theories.

The first is that championed by 17th century German philosopher Samuel Pufendorf, who classified
dozens of duties under three headings: duties to God, duties to oneself, and duties to others. Concerning
our duties towards God, he argued that there are two kinds:

- a theoretical duty to know the existence and nature of God, and

- a practical duty to both inwardly and outwardly worship God.

Concerning our duties towards oneself, these are also of two sorts:

- duties of the soul, which involve developing one’s skills and talents, and

- duties of the body, which involve not harming our bodies, as we might through gluttony or
drunkenness, and not killing oneself.

Concerning our duties towards others, Pufendorf divides these between absolute duties, which are
universally binding on people, and conditional duties, which are the result of contracts between people.
Absolute duties are of three sorts:

- avoid wronging others,

- treat people as equals, and

- promote the good of others.

Conditional duties involve various types of agreements, the principal one of which is the duty is to keep
one’s promises.

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 A second duty-based approach to ethics is rights theory. Most generally, a “right” is a justified claim
against another person’s behavior – such as my right to not be harmed by you. Rights and duties are
related in such a way that the rights of one person implies the duties of another person. For example, if I
have a right to payment of $10 by Smith, then Smith has a duty to pay me $10. This is called the
correlativity of rights and duties. The most influential early account of rights theory is that of 17th century
British philosopher John Locke, who argued that the laws of nature mandate that we should not harm
anyone’s life, health, liberty or possessions. For Locke, these are our natural rights, given to us by God.
Following Locke, the United States Declaration of Independence authored by Thomas Jefferson
recognizes three foundational rights: life, liberty, and the pursuit of happiness. Jefferson and others rights
theorists maintained that we deduce other more specific rights from these, including the rights of
property, movement, speech, and religious expression. There are four features traditionally associated
with moral rights. First, rights are natural insofar as they are not invented or created by governments.
Second, they are universal insofar as they do not change from country to country. Third , they are equal in
the sense that rights are the same for all people, irrespective of gender, race, or handicap. Fourth, they are
inalienable which means that I cannot hand over my rights to another person, such as by selling myself
into slavery.

A third duty-based theory is that by Kant, which emphasizes a single principle of duty. Influenced by
Pufendorf, Kant agreed that we have moral duties to oneself and others, such as developing one’s talents,
and keeping our promises to others. However, Kant argued that there is a more foundational principle of
duty that encompasses our particular duties. It is a single, self-evident principle of reason that he calls the
“categorical imperative.” A categorical imperative, he argued, is fundamentally different from
hypothetical imperatives that hinge on some personal desire that we have, for example, “If you want to
get a good job, then you ought to go to college.” By contrast, a categorical imperative simply mandates an
action, irrespective of one’s personal desires, such as “You ought to do X.” Kant gives at least four
versions of the categorical imperative, but one is especially direct: Treat people as an end, and never as a
means to an end. That is, we should always treat people with dignity, and never use them as mere
instruments. For Kant, we treat people as an end whenever our actions toward someone reflect the
inherent value of that person. Donating to charity, for example, is morally correct since this acknowledges
the inherent value of the recipient. By contrast, we treat someone as a means to an end whenever we treat
that person as a tool to achieve something else. It is wrong, for example, to steal my neighbor’s car since I
would be treating her as a means to my own happiness. The categorical imperative also regulates the
morality of actions that affect us individually. Suicide, for example, would be wrong since I would be
treating my life as a means to the alleviation of my misery. Kant believes that the morality of all actions
can be determined by appealing to this single principle of duty.

A fourth and more recent duty-based theory is that by British philosopher W.D. Ross, which
emphasizes prima facie duties. Like his 17th and 18th century counterparts, Ross argues that our duties
are “part of the fundamental nature of the universe.” However, Ross’s list of duties is much shorter,
which he believes reflects our actual moral convictions:

- Fidelity: the duty to keep promises

- Reparation: the duty to compensate others when we harm them

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 - Gratitude: the duty to thank those who help us

- Justice: the duty to recognize merit

- Beneficence: the duty to improve the conditions of others

- Self-improvement: the duty to improve our virtue and intelligence

- Nonmaleficence: the duty to not injure others

Ross recognizes that situations will arise when we must choose between two conflicting duties. In a
classic example, suppose I borrow my neighbor’s gun and promise to return it when he asks for it. One
day, in a fit of rage, my neighbor pounds on my door and asks for the gun so that he can take vengeance
on someone. On the one hand, the duty of fidelity obligates me to return the gun; on the other hand, the
duty of nonmaleficence obligates me to avoid injuring others and thus not return the gun. According to
Ross, I will intuitively know which of these duties my actual duty is, and which my apparent or prima
facie duty is. In this case, my duty of nonmaleficence emerges as my actual duty and I should not return
the gun.

c. Consequentialist Theories

It is common for us to determine our moral responsibility by weighing the consequences of our actions.
According to consequentialism, correct moral conduct is determined solely by a cost-benefit analysis of
an action’s consequences: An action is morally right if the consequences of that action are more favorable
than unfavorable. Consequentialist normative principles require that we first tally both the good and bad
consequences of an action. Second, we then determine whether the total good consequences outweigh the
total bad consequences. If the good consequences are greater, then the action is morally proper. If the bad
consequences are greater, then the action is morally improper. Consequentialist theories are sometimes
called teleological theories, from the Greek word telos, or end, since the end result of the action is the sole
determining factor of its morality.

Consequentialist theories became popular in the 18th century by philosophers who wanted a quick
way to morally assess an action by appealing to experience, rather than by appealing to gut intuitions or
long lists of questionable duties. In fact, the most attractive feature of consequentialism is that it appeals
to publicly observable consequences of actions. Most versions of consequentialism are more precisely
formulated than the general principle above. In particular, competing consequentialist theories specify
which consequences for affected groups of people are relevant. Three subdivisions of consequentialism
emerge:

- Ethical Egoism: an action is morally right if the consequences of that action are more favorable
than unfavorable only to the agent performing the action.

- Ethical Altruism: an action is morally right if the consequences of that action are more favorable
than unfavorable to everyone except the agent.

- Utilitarianism: an action is morally right if the consequences of that action are more favorable than
unfavorable to everyone.

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 All three of these theories focus on the consequences of actions for different groups of people. But, like
all normative theories, the above three theories are rivals of each other. They also yield different
conclusions. Consider the following example. A woman was traveling through a developing country
when she witnessed a car in front of her run off the road and roll over several times. She asked the
hired driver to pull over to assist, but, to her surprise, the driver accelerated nervously past
the scene. A few miles down the road the driver explained that in his country if someone
assists an accident victim, then the police often hold the assisting person responsible for
the accident itself. If the victim dies, then the assisting person could be held responsible
for the death. The driver continued explaining that road accident victims are therefore
usually left unattended and often die from exposure to the country’s harsh desert
conditions. On the principle of ethical egoism, the woman in this illustration would only
be concerned with the consequences of her attempted assistance as she would be affected.
Clearly, the decision to drive on would be the morally proper choice. On the principle of
ethical altruism, she would be concerned only with the consequences of her action as
others are affected, particularly the accident victim. Tallying only those consequences
reveals that assisting the victim would be the morally correct choice, irrespective of the
negative consequences that result for her. On the principle of utilitarianism, she must
consider the consequences for both herself and the victim. The outcome here is less clear,
and the woman would need to precisely calculate the overall benefit versus disbenefit of
her action.

i. Utilitarianism

Utilitarianism is more famous conception among other conseqventialist conception.

Jeremy Bentham presented one of the earliest fully developed systems of utilitarianism.
Two features of his theory are noteworty. First, Bentham proposed that we tally the
consequences of each action we perform and thereby determine on a case by case basis
whether an action is morally right or wrong. This aspect of Bentham’s theory is known as
act-utilitiarianism. Second, Bentham also proposed that we tally the pleasure and pain
which results from our actions. For Bentham, pleasure and pain are the only consequences
that matter in determining whether our conduct is moral. This aspect of Bentham’s theory
is known as hedonistic utilitarianism. Critics point out limitations in both of these aspects.
First, according to act-utilitarianism, it would be morally wrong to waste time on
leisure activities such as watching television, since our time could be spent in ways that
produced a greater social benefit, such as charity work. But prohibiting leisure activities
doesn’t seem reasonable. More significantly, according to act-utilitarianism, specific acts
of torture or slavery would be morally permissible if the social benefit of these actions
outweighed the disbenefit. A revised version of utilitarianism called rule-utilitarianism

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addresses these problems. According to rule-utilitarianism, a behavioral code or rule is
morally right if the consequences of adopting that rule are more favorable than
unfavorable to everyone. Unlike act utilitarianism, which weighs the consequences of each
particular action, rule-utilitarianism offers a litmus test only for the morality of moral
rules, such as “stealing is wrong.” Adopting a rule against theft clearly has more favorable
consequences than unfavorable consequences for everyone. The same is true for moral
rules against lying or murdering. Rule-utilitarianism, then, offers a three-tiered method for
judging conduct. A particular action, such as stealing my neighbor’s car, is judged wrong
since it violates a moral rule against theft. In turn, the rule against theft is morally binding
because adopting this rule produces favorable consequences for everyone. John Stuart
Mill’s version of utilitarianism is rule-oriented.
Second, according to hedonistic utilitarianism, pleasurable consequences are the only
factors that matter, morally speaking. This, though, seems too restrictive since it ignores
other morally significant consequences that are not necessarily pleasing or painful. For
example, acts which foster loyalty and friendship are valued, yet they are not always
pleasing. In response to this problem, G.E. Moore proposed ideal utilitarianism, which
involves tallying any consequence that we intuitively recognize as good or bad (and not
simply as pleasurable or painful). Also, R.M. Hare proposed preference utilitarianism,
which involves tallying any consequence that fulfills our preferences.

3. Applied Ethics

Applied ethics is the branch of ethics which consists of the analysis of specific,
controversial moral issues such as abortion, animal rights, or euthanasia. In recent years
applied ethical issues have been subdivided into convenient groups such as medical ethics,
business ethics, environmental ethics, and sexual ethics. (More recently some of this
gropes are coverd by bioethics.) Generally speaking, two features are necessary for an
issue to be considered an “applied ethical issue.” First, the issue needs to be controversial
in the sense that there are significant groups of people both for and against the issue at
hand. The issue of drive-by shooting, for example, is not an applied ethical issue, since
everyone agrees that this practice is grossly immoral. By contrast, the issue of gun control
would be an applied ethical issue since there are significant groups of people both for and
against gun control.

The second requirement for an issue to be an applied ethical issue is that it must be a
distinctly moral issue. On any given day, the media presents us with an array of sensitive
issues such as affirmative action policies, gays in the military, involuntary commitment of
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the mentally impaired, capitalistic versus socialistic business practices, public versus
private health care systems, or energy conservation. Although all of these issues are
controversial and have an important impact on society, they are not all moral issues. Some
are only issues of social policy. The aim of social policy is to help make a given society
run efficiently by devising conventions, such as traffic laws, tax laws, and zoning codes.
Moral issues, by contrast, concern more universally obligatory practices, such as our duty
to avoid lying, and are not confined to individual societies. Frequently, issues of social
policy and morality overlap, as with murder which is both socially prohibited and
immoral. However, the two groups of issues are often distinct. For example, many people
would argue that sexual promiscuity is immoral, but may not feel that there should be
social policies regulating sexual conduct, or laws punishing us for promiscuity. Similarly,
some social policies forbid residents in certain neighborhoods from having yard sales. But,
so long as the neighbors are not offended, there is nothing immoral in itself about a
resident having a yard sale in one of these neighborhoods. Thus, to qualify as an applied
ethical issue, the issue must be more than one of mere social policy: it must be morally
relevant as well.

In theory, resolving particular applied ethical issues should be easy. With the issue of
abortion, for example, we would simply determine its morality by consulting our
normative principle of choice, such as act-utilitarianism. If a given abortion produces
greater benefit than disbenefit, then, according to act-utilitarianism, it would be morally
acceptable to have the abortion. Unfortunately, there are perhaps hundreds of rival
normative principles from which to choose, many of which yield opposite conclusions.
Thus, the stalemate in normative ethics between conflicting theories prevents us from
using a single decisive procedure for determining the morality of a specific issue. The
usual solution today to this stalemate is to consult several representative normative
principles on a given issue and see where the weight of the evidence lies.

3.1. Sudy Cases

Case 1
After Caroline Whitbeck. Gender Issues: Should You Find a New Supervisor?

http://www.onlineethics.org/Resources/Cases/gender_issues.aspx

You are nearing the end of your first year of graduate study at Tough Tech and have
been working with Professor Grimm's group within the large Laboratory for Better
Technology. You are very interested in the subject area of your research. However,
whenever you make a significant contribution and start feeling good about yourself and
13
your work, Professor Grimm gives you a lecture about what hard places Tough Tech and
the Laboratory for Better Technology are, and how you really have to keep your nose to
the grindstone if you expect to make it here. You try to make a joke of Grimm's "anti-pep"
talks, but they do demoralize you. It has gotten to the point that whenever you make a
contribution to the project, you send him something in writing and avoid talking to him for
several days to avoid hearing his pessimistic assessment of your abilities.

On several occasions, Grimm has walked into the men's room while having an
interesting conversation with the group. He seems not to notice that this leaves you asking
male students to fill you in on what he said in there.

You are thinking about finding a different supervisor. The trouble is, there is only one
other faculty member who works in this area, which you enjoy very much. From the two
women in his group you learn that this second faculty member opens his group meetings
by addressing everyone as "Gentlemen."

What should you do and how should you go about it?

Are there established standards of behavior that are being violated here?

If so, what could be done to get others to help uphold those standards?

Case 2

Female circumcision/genital cutting

http://www.bbc.co.uk/ethics/femalecircumcision/femalecirc_1.shtml

Female circumcision usually involves the cutting or removal of the clitoris. This area
of the genitals is very sensitive because it contains the most nerve endings.

Genital cutting is a painful practice that is often poorly carried out, and endangers the
health and lives of millions of girls, particularly in Africa. In some communities the
controversial practice is a female rite of passage and remains an important religious and
cultural tradition. In regions where a new religion has become dominant, the tradition of
genital cutting does not necessarily die out. It is seen as the climax of initiation, something
that both boys and girls have to take part in before they are accepted as adults in the
community.

14
In the Middle East, female circumcision is practised in the Yemen, Saudi Arabia, Iraq,
Jordan and Syria. Even in the United States, 10,000 girls are believed to be at risk from
illegal operations within their own communities. It has also been reported that young
women in Australia, Canada, Denmark, France, Italy, the Netherlands, Sweden and the
UK have also undergone similar operations.Genital cutting is widespread within some
African cultures and ethnic groups.

It is certainly a painful process. It is sometimes carried out by a midwife with

anaesthetics, but more often than not there is nothing to ease the pain.The operation
involved varies widely from culture to culture. In its most extreme form (infibulation) it
can involve the removal of all external genitalia and the stitching up of the labia leaving
only a very small opening for sex, urination, menstruation and giving birth. This often
makes a later operation necessary to create a larger opening. Many objections to the
practice of genital cutting are concerned with the particular circumstances in which it is
done. Amnesty International, a human rights organisation, reports that the operation is
often carried out using blunt tools (penknives, fragments of glass or tin cans). A
particularly brutal operation can leave a woman with haemorrhaging, infections, abscesses
and sometimes a lifelong loss of sensation during sex. The Pan-African Committee on
Traditional Practices estimates that two million girls in Africa each year undergo some
kind of genital cutting which endangers both their health and their lives. Another objection
concerns the inability of some young women to make a choice. Cutting takes place when a
girl is young (aged between three and ten), vulnerable and unable to make an informed
decision. In a small village community pressure to take part is enormous.

Chapter 2
Bioethics, the origin, the subject-matter and its paths of development.
Bioethics’ principles.
2.1. The origins and evolution of bioethics. Bioethical aspects.

Bioethicists is a form of applied ethics concerned with the ethical questions that arise in
the relationships among life sciences, biotechnology, medicine, politics, law, and
philosophy. The term Bioethics (Greek bios, life; ethos, behavior) was coined in 1927 by
Fritz Jahr, who "anticipated many of the arguments and discussions now current in
biological research involving animals" in an article about the "bioethical imperative," as he
called it, regarding the scientific use of animals and plants. Aldo Leopold (January 11,
1887 – April 21, 1948) American author, scientist, ecologist, forester, and
environmentalist, was influential in the development of modern bioethics in its
15
environmental aspect and in the movement for wilderness conservation. His ethics of
nature and wildlife preservation had a profound impact on the environmental movement,
with his biocentric or holistic ethics regarding land. Leopold offered frank criticism of the
harm he believed was frequently done to natural systems (such as land) out of a sense of a
culture or society's sovereign ownership over the land base – eclipsing any sense of a
community of life to which humans belong. He felt the security and prosperity resulting
from "mechanization" now gives people the time to reflect on the preciousness of nature
and to learn more about what happens there. These ideas were unfolded in his book
published in 1949, shortly after his death. One of the well-known quotes from the book
which clarifies his land ethic is: A thing is right when it tends to preserve the integrity,
stability, and beauty of the biotic community. It is wrong when it tends otherwise.
In 1970, the American biochemist Van Rensselaer Potter used the term Bioethics with a
broader meaning including solidarity towards the biosphere, a discipline representing a
link between biology, ecology, medicine and human values in order to attain the survival
of both human beings and other animal species. Nevertheless later (in 1988) he preferred
to call this domain "global ethics".
The field of bioethics first emerged as an academic discipline in Anglophone societies in
the 1960s. By the 1970s, bioethical think tanks and academic bioethics programs had
emerged. Among the earliest such institutions were the Hastings Center, USA (originally
known as The Institute of Society, Ethics and the Life Sciences), founded in 1969 by
philosopher Daniel Callahan and psychiatrist Willard Gaylin, and the Kennedy Institute of
Ethics, established at Georgetown University in 1971. The publication of Principles of
Biomedical Ethics by James F. Childress and Tom Beauchamp—the first American
textbook of bioethics—marked a transformative moment in the discipline.

A great contribution of evolution of bioethics in its medical aspect had scandals

concerning involvement of human subject in scientific research, among which Nazi
experiments conducted during World War II, Tuskegee syphilis experiment conducted
between 1932 and 1972 in Tuskegee, Alabama by the U.S. Public Health Service to study
the natural progression of untreated syphilis in poor, rural black men who thought they
were receiving free health care from the U.S. government, Willowbrook State School case,
where mentally handicapped were infected with hepatitis for research objectives etc.
These and other case contributed to formulation of a set of moral norms for researchers in
biomedical aria while involving human subjects in experiments. These norms are written
in international documents like: Nuremberg code, declaration of Helsinki, CIOMS Guides
etc.
Bioethical issues gained widespread attention also through the court cased caused by
technological advances in such diverse areas as organ transplantation and end-of-life care,
including the development of kidney dialysis and respirators, which posed novel ethical
16
questions, for instants question regarding when and how care might be withdrawn. The
very famous case in this respect is the case surrounding the deaths of Karen Ann Quinlan.
Karen Ann Quinlan (March 29, 1954 – June 11, 1985) was an important figure in the
history of the right to die controversy in the United States. When she was 21, Quinlan
became unconscious after arriving home from a party. She had consumed diazepam,
dextropropoxyphene, and alcohol. After she collapsed and stopped breathing twice for 15
minutes or more, the paramedics arrived and took her to hospital, where she lapsed into a
persistent vegetative state. After she was kept alive on a ventilator for several months
without improvement, her parents requested the hospital to discontinue active care and
allow her to die. The hospital refused, and the subsequent legal battles made newspaper
headlines and set significant precedents. The tribunal eventually ruled in her parents'
favor. Although Quinlan was removed from mechanical ventilation during 1976, she lived
on in a persistent vegetative state for almost a decade until her death from pneumonia in
1985.
Quinlan's case continues to raise important questions in moral theology, bioethics,
euthanasia, legal guardianship and civil rights. Her case has affected the practice of
medicine and law around the world. Two significant outcomes of her case were the
development of formal ethics committees in hospitals, nursing homes and hospices, and
the development of advance health directives.

Bioethical aspects
Bioethics appeared as a result of problems brought about by advances in science and
technologies, especially that in biology and medicine. It is an interdisciplinary area dealing
with a collection on ethical issues related to health care, biomedical research,
biotechnology, and the environment. As complex area bioethics has several aspects:
philosophical, legal, environmental and medical aspects.
Philosophical aspect of bioethics is related to elaboration and arguing in favor of a
system of values and principles applicable in different aria of human activity so that to
assure good results in condition of morally correct action or agency. The normative
theories mentioned in the first Chapter are relevant in this context. Legal aspect refers to
the mandatory documents formulated on the base of ethical principles mentioned above
and which consist in set of compulsory rules. In this context is relevant UNESCO
Universal Declaration on Bioethics and Human Rights.
Environmental aspect refers to the problem of necessity biosphere, for the protection
of the integrity of a certain ecosystem. In this aspect bioethics entry covers: (1) the
challenge to the anthropocentrism (i.e., human-centeredness) embedded in traditional
western ethical thinking; (2) the connection of deep ecology and social ecology to politics;
(3) the attempt to apply traditional ethical theories, including consequentialism,
deontology, and virtue ethics, to support contemporary environmental concerns.
17
 Medical aspect of bioethics has addressed a broad swath of human inquiry, ranging
from debates over the boundaries of life (e.g. abortion, euthanasia), surrogacy to the
allocation of scarce health care resources (e.g. organ donation, health care rationing) to the
right to refuse medical care for religious or cultural reasons. It includes the study of the
more commonplace questions of values which arise in primary care and other branches of
medicine. Issues arise about the morality of surrogate mothering, genetic manipulation of
fetuses, the status of unused frozen embryos, and abortion. Other issues arise about patient
rights and physician’s responsibilities, such as the confidentiality of the patient’s records
and the physician’s responsibility to tell the truth to dying patients. The AIDS crisis has
raised the specific issues of the mandatory screening of all patients for AIDS, and whether
physicians can refuse to treat AIDS patients. Additional issues concern medical
experimentation on humans, the morality of involuntary commitment, and the rights of the
mentally disabled.

2.2. Bioethics’ principles

Bioethicists often disagree among themselves over the precise limits of their
discipline, debating whether the field should concern itself with the ethical evaluation of
all questions involving biology and medicine, or only a subset of these questions. Some
bioethicists would narrow ethical evaluation only to the morality of medical treatments or
technological innovations, and the timing of medical treatment of humans. Others would
broaden the scope of ethical evaluation to include the morality of all actions that might
help or harm organisms capable of feeling fear. Accordingly nowadays is spoken about
two paths of bioethics evolution or of two types of bioethics: a) bioethics in widest sense
covering issues of environmental ethics as well as that biomedical; b) bioethics in narrow
sense dealing with issues arise in medical context. Thus, the moral principles, used in
these two directions, differ one from other, even though the overlapping of them is not
excluded as well. Also it is important to say that the principles in both cases represent a
spectrum of traditional normative principles and are derived from consequentialist and
duty-based approaches.

a. Normative Principles of bioethics in widest sense

 Principle of biospherocentrism: acknowledge the extent to which an action produces

beneficial consequences for both nature and society. It emphasizes the necessity of
co evolution between nature and society.

18
  Principle of social benefit: acknowledge the extent to which an action produces
beneficial consequences for society.

 Principle of benevolence: acknowledge the importance to help those in need (not

only human but also inhuman beings).

 Principle of harm: do not harm others beings.

 Principle of honesty: do not deceive others.

 Principle of responsibility and lawfulness: do your duties and do not violate the law.

 Principle of autonomy: acknowledge a person’s freedom over his/her actions or

physical body.

 Principle of justice: acknowledge a person’s right to due process, fair compensation

for harm done, and fair distribution of benefits.

 Rights: acknowledge a person’s rights to life, information, privacy, free expression,

and safety.

b) Principles of Bioethics in narrow sense

After Thomas R. McCormick, D Min Faculty, Medical History and Ethics. Principles of Bioethics.
University of Washington School of Medicine. http://depts.washington.edu/bioethx/tools/princpl.html

In the realm of health care it is difficult to hold rules or principles that are absolute.
This is due to the many variables that exist in the context of clinical cases as well as the
fact that in health care there are several principles that seem to be applicable in many
situations. Even though they are not considered absolute, these rules and principles serve
as powerful action guides in clinical medicine. Over the years, these moral principles have
won a general acceptance as applicable in the moral analysis of ethical issues in medicine.
The commonly accepted principles of health care ethics include:
 the principle of respect for autonomy,
 the principle of nonmaleficency,

 the principle of beneficence, and

 the principle of justice.

1. Respect for Autonomy

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 Any notion of moral decision making assumes that rational agents are involved in making
informed and voluntary decisions. In health care decisions, our respect for the autonomy
of the patient would, in common parlance, mean that the patient has the capacity to act
intentionally, with understanding, and without controlling influences that would mitigate
against a free and voluntary act. This principle is the basis for the practice of "informed
consent" in the physician/patient transaction regarding health care.

2. The Principle of Nonmaleficence

The principle of nonmaleficence requires of us that we not intentionally create a needless

harm or injury to the patient, either through acts of commission or omission. In common
language, we consider it negligence if one imposes a careless or unreasonable risk of harm
upon another. Providing a proper standard of care that avoids or minimizes the risk of
harm is supported not only by our commonly held moral convictions, but by the laws of
society as well. In a professional model of care one may be morally and legally
blameworthy if one fails to meet the standards of due care. The legal criteria for
determining negligence are as follows:

 the professional must have a duty to the affected party

 the professional must breach that duty
 the affected party must experience a harm; and
 the harm must be caused by the breach of duty.

This principle affirms the need for medical competence. It is clear that medical mistakes
occur; however, this principle articulates a fundamental commitment on the part of health
care professionals to protect their patients from harm.

3. The Principle of Beneficence

The ordinary meaning of this principle is the duty of health care providers to be of a
benefit to the patient, as well as to take positive steps to prevent and to remove harm from
the patient. These duties are viewed as self-evident and are widely accepted as the proper
goals of medicine. These goals are applied both to individual patients, and to the good of
society as a whole. For example, the good health of a particular patient is an appropriate
goal of medicine, and the prevention of disease through research and the employment of
vaccines is the same goal expanded to the population at large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to
harm another individual. Whereas, beneficence is a limited duty. A physician has a duty to
seek the benefit of any or all of her patients, however, the physician may also choose
whom to admit into his or her practice, and does not have a strict duty to benefit patients
not acknowledged in the panel. This duty becomes complex if two patients appeal for
20
treatment at the same moment. Some criteria of urgency of need might be used, or some
principle of first come first served, to decide who should be helped at the moment.

4. The Principle of Justice

Justice in health care is usually defined as a form of fairness, or as Aristotle once said,
"giving to each that which is his due." This implies the fair distribution of goods in society
and requires that we look at the role of entitlement. The question of distributive justice
also seems to hinge on the fact that some goods and services are in short supply, there is
not enough to go around, thus some fair means of allocating scarce resources must be
determined. It is generally held that persons who are equals should qualify for equal
treatment. This is borne out in the application of Medicare, which is available to all
persons over the age of 65 years. This category of persons is equal with respect to this one
factor, their age, but the criteria chosen says nothing about need or other noteworthy
factors about the persons in this category. In fact, our society uses a variety of factors as
criteria for distributive justice, including the following:

 to each person an equal share

 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
John Rawls and others claim that many of the inequalities we experience are a result of a
"natural lottery" or a "social lottery" for which the affected individual is not to blame,
therefore, society ought to help even the playing field by providing resources to help
overcome the disadvantaged situation. One of the most controversial issues in modern
health care is the question pertaining to "who has the right to health care?" Or, stated
another way, perhaps as a society we want to be beneficent and fair and provide some
decent minimum level of health care for all citizens, regardless of ability to pay.

How do principles "apply" to a certain case?

Principles in current usage in health care ethics seem to be of self-evident value. For
example, the notion that the physician "ought not to harm" any patient appears to be
convincing to rational persons. Or, the idea that the physician should develop a care plan
designed to provide the most "benefit" to the patient in terms of other competing
alternatives, seems self-evident. Further, before implementing the medical care plan, it is
now commonly accepted that the patient must indicate a willingness to accept the
proposed treatment, if the patient is cognitively capable of doing so. Finally, medical
21
benefits should be dispensed fairly, so that people with similar needs and in similar
circumstances will be treated with fairness.
One might argue that we are required to take all of the above principles into account
when they are applicable to the clinical case under consideration. Yet, when two or more
principles apply, we may find that they are in conflict. For example, consider a patient
diagnosed with an acutely infected appendix. Our medical goal should be to provide the
greatest benefit to the patient, an indication for immediate surgery. On the other hand,
surgery and general anesthesia carry some small degree of risk to an otherwise healthy
patient, and we are under an obligation "not to harm" the patient. Our rational calculus
holds that the patient is in far greater danger from harm from a ruptured appendix if we do
not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery.
In other words, we have a "prima facie" duty to both benefit the patient and to "avoid
harming" the patient. However, in the actual situation, we must balance the demands of
these principles by determining which carries more weight in the particular case. Moral
philosopher W.D. Ross claims that prima facie duties are always binding unless they are in
conflict with stronger or more stringent duties. A moral person's actual duty is determined
by weighing and balancing all competing prima facie duties in any particular case.

2. 3. Study cases

Case 1

Baby Doe

The case illustrates the function of principles in an applied ethical discussion.

In 1982, a couple from Bloomington, Indiana gave birth to a baby with severe mental and
physical disabilities. Among other complications, the infant, known as Baby Doe, had its
stomach disconnected from its throat and was thus unable to receive nourishment.
Although this stomach deformity was correctable through surgery, the couple did not want
to raise a severely disabled child and therefore chose to deny surgery, food, and water for
the infant. Local courts supported the parents’ decision, and six days later Baby Doe died.
Should corrective surgery have been performed for Baby Doe? Arguments in favor of
corrective surgery derive from the infant’s right to life and the principle of paternalism
which stipulates that we should pursue the best interests of others when they are incapable
of doing so themselves. Arguments against corrective surgery derive from the personal
and social disbenefit which would result from such surgery. If Baby Doe survived, its
quality of life would have been poor and in any case it probably would have died at an

22
early age. Also, from the parent’s perspective, Baby Doe’s survival would have been a
significant emotional and financial burden. When examining both sides of the issue, the
parents and the courts concluded that the arguments against surgery were stronger than the
arguments for surgery. First, foregoing surgery appeared to be in the best interests of the
infant, given the poor quality of life it would endure. Second, the status of Baby Doe’s
right to life was not clear given the severity of the infant’s mental impairment. For, to
possess moral rights, it takes more than merely having a human body: certain cognitive
functions must also be present. The issue here involves what is often referred to as moral
personhood, and is central to many applied ethical discussions.

Moral issue:

Do you consider that the decision of parents (court) is right or not? Justified your opinion!

Case 2

Don't Goose me!

A role-play case study on animal protection

Authors: Kinchel Doerner (Dep. Biology, Western Kentucky Univ., USA), Bonnie Furman (Dep.
Biology, Western Kentucky Univ., USA), Deborah Power (Centro de Ciências Marinhas, Univ.
Algarve, Portugal), Adelino Canário (Centro de Ciências Marinhas, Univ. Algarve, Portugal),
Terri Klinger (School Marine Affairs, Univ. Washington, USA) Copyright © 2003, Iowa State
University. http://www.bioethics.iastate.edu/classroom/dontgooseme.html

Factual background
Canada Geese historically have bred in the Arctic in summer and migrated south only in
winter. With increasing urbanization in northern cities, food and nest sites have become
widely available, and predation rates are low. Consequently, the geese have become year
round residents in cities, and their population numbers have greatly expanded. In many
northern cities (Seattle, Chicago, London, Vancouver) the Canada geese are a nuisance
and create potential public health problems by defecating in parks, on golf courses, and in
public waterways (ponds, lakes), where they can foul local water supplies. However, no
incidences of goose-borne illness have been reported. Their abundance now exceeds that
at any time in the recent past. As a consequence of the perceived threat to public health
and well-being, management strategies have been proposed that would lethally remove the
geese by collecting and gassing them with carbon dioxide. The resulting goose meat would
be provided to the starving homeless.

23
A public meeting in which all stakeholders are present has been called for the Mayor to
take a final decision on the proposed course of action.

Stakeholders and concerns

Decision-making
The Mayor will take the final decision after the hearing.

Municipal Services
Municipal Services are responsible for animal population control. Alternative methods of
removing the birds have been considered (e.g hormone control, egg removal) but the
urgency in resolving the problem and anticipated costs led to the proposal that gassing by
carbon dioxide is the most efficient method. Because the meat will be of excellent quality,
there is a proposal to sell it for public consumption and the proceeds would cover some of
the costs of the operation. Alternatively, there is a proposal from the Social Services to
distribute the meat to the homeless through charitable service organizations.

Public Health Bureau

The Department of Public Health favors’ lethal removal of Canada geese for the following
reasons:
Goose excrement fouls both land and water resources within the city. These droppings can
contain high levels of bacteria and avian parasites. The bacteria and parasites both
potentially threaten public health, especially that of children and the elderly.
Other animal pests associated with Canada geese are increasing within the city. For
example, rats that prey on goose eggs and chicks are more numerous now than before.

Parents Against Geese

This is a popular movement that aims to wrest the control of local parks from geese. The
group professes to be animal lovers (most members have dogs, cats and other pets). When
geese were present in low numbers they were a popular attraction for parents and children.
However, there are now so many geese that they are perceived as a serious problem. They
defecate everywhere, they destroy lawns and gardens, and the park is out of bounds for
children. There is fear of a health risk. Presence of geese on roadways makes driving more
dangerous. In addition, some people have claimed an increase in allergies perhaps
attributable to the geese, and their honking disturbs the peace.

CRAP - Citizens Responsible for Animal Protection

CRAP is an activist group for animal rights that is currently involved in many issues
where animal welfare is under consideration such as farm animal production, animal
research and traditional hunting. This group will not allow the geese to be molested in any
24
way. They believe that in this case humans unfairly modified the environment, which as it
turns out, now is favourable for the geese. The geese should be left alone and instead,
humans should modify their behaviour to accommodate the geese. In the past CRAP has
allegedly committed acts of violence against those who don´t agree with them.

Social Services
The Department of Social Services is responsible for providing care and assistance to the
large population of homeless individuals within the city. In general, the department is
understaffed and underfunded and has difficulty providing sufficient support for the
homeless. Social Services strongly support the proposed method of culling and gassing the
geese. This will provide an affordable source of protein for distribution to the homeless.

Chamber of Commerce
The Chamber of Commerce favors removal of the geese. The geese foul local parks and
shopping areas driving away both tourists and shoppers. However, the Chamber of
Commerce is STRONGLY OPPOSED to the free distribution of goose meat to the
homeless because of potential negative effects on retailers´ profits.

Moral issues
Should we proceed with lethal removal?
If yes, should the carcasses be sold, given to the homeless, or otherwise disposed of?
If not, propose and defend alternative management strategies.

Classroom Procedure

1. Students will divide into groups of five.

a. A chairperson will be identified by determination of who is born first in the year.

(Instructor will explain)

b. The chairperson will chair the discussions and appoint a:

i. Recorder- will write down in a coherent manner all pertinent arguments

ii. Proactive Student- will develop the arguments to convince the city council to adopt
their group´s position

iii. Reactive Student #1 and #2 these two students will anticipate the positions of other
groups and develop counter arguments.

2. The groups will have 5 minutes to formulate their arguments.

25
3. At the end of these 5 minutes the students will sign up (as individuals) in the order they
wish to speak at the public meeting.

4. The public meeting will convene with the instructor acting as the mayor.

a. The format will be that of a typical public meeting.

b. The floor will be opened and each individual will be allowed 1 minute to present their
comment(s).

c. Individuals will be allowed to speak only once.

d. After all that are signed up have spoken, the mayor will retire to consider public
comment and will return with a final decision.

Chapter 3
Bioethics as socio-cultural phenomenon. Paternalism and anti-paternalism
in medicine and bioethics.
3.1. Paternalism and anti-paternalism

Cultural pluralism is one of the characters of contemporary world. People from

disparate cultural backgrounds can make disparate moral judges on an act, taking place
under the same circumstances. Culture and tradition have a great impact on how bioethical
issues are approach. Nowadays is even spoken about different cultural models of
bioethics: pragmatic model – approach to ethical problem in the key of utilitarian ethics,
liberal model - approach ethical problems in the scope of deontological theories,
personality model – approach the ethical problems in religious manner. Studies on
cultural anthropology suggest that there are cultural variations in attitudes toward truth
telling, pain relief, and planning for end-of-life, care and person autonomy. In what will
follow in focus will be two different culturally approaches to person autonomy:
paternalistic - anti paternalistic approaches.

Paternalism

After Dworkin, Gerald, "Paternalism", The Stanford Encyclopedia of Philosophy (Summer

2010 Edition), Edward N. Zalta (ed.), http://plato.stanford.edu/entries/paternalism/

Paternalism refers to attitudes or states of affairs that exemplify a traditional relationship

between father (pater) and child. Two conditions of paternalism are usually identified:

26
interference with liberty and a beneficent intention towards those whose liberty is
interfered with. Paternalism is the interference of a state or an individual with another
person, against their will, and defended or motivated by a claim that the person interfered
with will be better off or protected from harm.
The issue of paternalism is in concern when:
- The government requires people to contribute to a pension system (Social Security).
It requires motorcyclists to wear helmets. It forbids people from swimming at a
public beach when lifeguards are not present. It forbids the sale of various drugs
deemed to be ineffective. It forbids the sale of various drugs believed to be harmful.
It does not allow consent to certain forms of assault to be a defense against
prosecution for that assault.
- Doctors do not tell their patients the truth about their medical condition. A
physician may tell the wife of a man whose car went off a bridge into the water and
drowned that he died instantly when in fact he died a rather ghastly death.

- A husband may hide the sleeping pills from a depressed wife. A psychiatrist
confiscating sharp objects from someone who is suicidally depressed. A parent
forbidding their children to engage in dangerous activities,

- A teacher may be less than honest about telling a student that he has little
philosophical (Mathematical etc. ) ability.

As the examples indicate the question of paternalism is one that arises in many different
areas of our personal and public life. All of these rules, policies, and actions may be done
for various reasons; may be justified by various considerations. When they are justified
solely on the grounds that the person affected would be better off, or would be less
harmed, as a result of the rule, policy, etc., and the person in question would prefer not to
be treated this way, we have an instance of paternalism.

The analysis of paternalism involves at least the following elements. It involves some kind
of limitation on the freedom or autonomy of some agent and it does so for a particular
class of reasons. Condition one is the trickiest to capture. Clear cases include threatening
bodily compulsion, lying, withholding information that the person has a right to have, or
imposing requirements or conditions. So being it is raised certain theoretical issues.
Perhaps the most important is: what powers it is legitimate for a state, operating both
coercively and in terms of incentives, to possess. It also raises questions about the proper
ways in which individuals, either in an institutional or purely personal setting, should
relate to one another. How should we think about individual autonomy and its limits?
What is it to respect the personhood of others? What is the trade-off, if any, between
regard for the welfare of another and respect for their right to make their own decisions?
Or when paternalism is justified?
27
There are various views about when paternalism is justified. The following terminology is
useful.
Hard vs. soft paternalism
Soft paternalism is the view that the only conditions under which state paternalism is
justified is when it is necessary to determine whether the person being interfered with is
acting voluntarily and knowledgeably. To use Mill's famous example of the person about
to walk across a damaged bridge, if we could not communicate the danger (he speaks only
Japanese) a soft paternalist would justify forcibly preventing him from crossing the bridge
in order to determine whether he knows about its condition. If he knows, and wants to,
say, commit suicide he must be allowed to proceed. A hard paternalist says that, at least
sometimes, it may be permissible to prevent him from crossing the bridge even if he
knows of its condition. We are entitled to prevent voluntary suicide.
Broad vs. narrow paternalism
A narrow paternalist is only concerned with the question of state coercion, i.e. the use of
legal coercion. A broad paternalist is concerned with any paternalistic action: state,
institutional (hospital policy), or individual.
Weak vs. strong paternalism
A weak paternalist believes that it is legitimate to interfere with the means that agents
choose to achieve their ends, if those means are likely to defeat those ends. So if a person
really prefers safety to convenience then it is legitimate to force them to wear seatbelts. A
strong paternalist believes that people may be mistaken or confused about their ends and it
is legitimate to interfere to prevent them from achieving those ends. If a person really
prefers the wind rustling through their hair to increased safety it is legitimate to make them
wear helmets while motorcycling because their ends are irrational or mistaken. Another
way of putting this: we may interfere with mistakes about the facts but not mistakes about
values. So if a person tries to jump out of a window believing he will float gently to the
ground we may restrain him. If he jumps because he believes that it is important to be
spontaneous we may not.
Moral vs. welfare paternalism
The usual justification for paternalism refers to the interests of the person being interfered
with. These interests are defined in terms of the things that make a person's life go better;
in particular their physical and psychological condition. It is things like death or misery or
painful emotional states which are in question. Sometimes, however, advocates of state
intervention seek to protect the moral welfare of the person. So, for example, it may be
argued that prostitutes are better off being prevented from plying their trade even if they
make a decent living and their health is protected against disease. They are better off
because it is morally corrupting to sell one's sexual services. The interference is justified,
therefore, to promote the moral well-being of the person. This then can be called moral
paternalism. Still another distinction within moral paternalism is between interferences to
28
improve a person's moral character, and hence her well-being, and interferences to make
someone a better person—even if her life does not go better for her as a result.
Normative Issues
Normatively spiking the question is: is paternalism justified at all or not?
The normative options seem to be just two. Either we are never permitted to do good for
others against their wishes, and in ways which limit their liberty, or we are permitted to do
so.
Why might one think that at least the state may never do so? One might think so because
of various beliefs about the impossibility of in fact doing good for people against their will
or because one thinks that although possible to do good it is in fact inconsistent with some
normative standard which ought to prevail. With respect to the impossibility question one
might believe either that it is not possible to do any good by acting paternalistically or that
although it is possible to do some good the process will (almost) always produce bads
which outweigh the good.
If one thought that almost)always more harm than good is done by the state when it acts
paternalistically this raises the question of whether we can distinguish the conditions in
which (rarely) more good than harm is done and build that into our guidelines. If this is
possible, and so distinguishing does not create further harms which outweigh the good
produced, and we think, the only issue is good promotion we should sometimes be
paternalists. If it is impossible to distinguish the “good” from the “bad” cases then, at least
if we are rule consequentialists, we ought not to have such a rule; and we ought not to try
and make the distinctions on a case by case basis.
But one might believe that the question of whether more good than harm is produced is
not simply an empirical one. It depends on our understanding of the good of persons. If the
good simply included items such as longer life, greater health, more income, or less
depression, then it makes it look like an empirical issue. But if we conceive of the good of
individuals as including items such as being respected as an independent agent, having a
right to make decisions for oneself, or having one's autonomy not infringed, then the issue
of whether the agent is better off after being paternalised is partly a normative matter. One
might believe that one cannot make people better off by infringing their autonomy in the
same way that some people believe one cannot make a person better off by putting them in
a Nozickian experience machine (one in which they are floating in a tank but seem to be
having all kinds of wonderful experiences). Compare Mill's statement that “…a man's
mode of laying out his own existence is best not because it is the best in itself, but because
it is his own mode…” (1859, Chapter III).
Kantian views are frequently absolutistic in their objections to paternalism. On these
views we must always respect the rational agency of other persons. To deny an adult the
right to make their own decisions, however mistaken from some standpoint they are, is to
treat them as simply means to their own good, rather than as ends in themselves. In a way
29
anti-paternalism is already incorporated into Kantian theories by their prohibition against
lying and force—the main instruments of paternalistic interference. Since these
instrumentalities are already denied even to prevent individuals from harming others, they
will certainly be forbidden to prevent them from harming themselves. Of course, one may
object to the former absolutism while accepting the latter.

If one believes that sometimes paternalism is justifiable one may do so for various kinds
of theoretical reasons. The broadest is simply consequentialist, i.e. more good than harm is
produced. A narrower justification is that sometimes the individuals (long-run) autonomy
is advanced by restricting his autonomy (short-run). So one might prevent people from
taking mind-destroying drugs on the grounds that allowing them to do so destroys their
autonomy and preventing them from doing so preserves it. This is essentially Mill's
argument against allowing people to contract into slavery. Note that if the theory of the
good associated with a particular consequentialism is broad enough, i.e., includes
autonomy as one of the goods, it can be equivalent to the autonomy theory (assuming that
the structure of the autonomy view is a maximizing one).
A different theoretical basis is (moral) contractualism. On this view if there are cases of
justified paternalism they are justified on the basis that we (all of us) would agree to such
interference, given suitable knowledge and suitable motivation. So, for instance, it might
be argued that since we know we are subject to depression we all would agree, at least, to
short-term anti-suicide interventions, to determine whether we are suffering from such a
condition, and to attempt to cure it. More generally, we might accept what Feinberg called
“soft paternalism.” This is the view that when we are not acting fully voluntarily it is
permissible to intervene to provide information, or to point out defects in our rationality,
but that if we then do make a voluntary choice it must be respected. Or we might agree to
being forced to wear seat-belts knowing our disposition to discount future benefits for
present ones. The justification here is neither consequentialist nor based simply on the
preservation of autonomy. Rather either kind of consideration may be taken into account,
as well as others, in determining what we would reasonably agree to.

Anti - paternalism
After Buss, Sarah, "Personal Autonomy", The Stanford Encyclopedia of Philosophy (Fall 2008 Edition), Edward
N. Zalta (ed.), http://plato.stanford.edu/cgi-bin/encyclopedia/archinfo.cgi?entry=personal-autonomy

Christman, John, "Autonomy in Moral and Political Philosophy", The Stanford Encyclopedia of Philosophy
(Spring 2011 Edition), Edward N. Zalta (ed.), http://plato.stanford.edu/entries/autonomy-moral/

Ant - paternalism is opposite to paternalism. It is the liberal view interfere with the idea of
human autonomy.

30
Individual autonomy is an idea that is generally understood to refer to the capacity to be
one's own person, to live one's life according to reasons and motives that are taken as one's
own and not the product of manipulative or distorting external forces. To be autonomous
is to be a law to oneself; autonomous agents are self-governing agents.
What conditions must be satisfied in order to ensure that we govern ourselves when we
act? To govern oneself one must be in a position to act competently and from desires
(values, conditions, etc.) that are in some sense one's own. This picks out the two families
of conditions often proffered in conceptions of autonomy: competency conditions and
authenticity conditions. Competency includes various capacities for rational thought, self-
control, and freedom from debilitating pathologies, systematic self-deception, and so on.
Authenticity conditions often include the capacity to reflect upon and endorse (or identify
with) one's desires, values, and so on. The most influential models of authenticity in this
vein claim that autonomy requires second-order identification with first order desires.
Thus, when an individual makes declaration that has the right to live autonomously, she is
denying that anyone else has the authority to control her activity within this sphere; she is
saying that any exercise of power over this activity is illegitimate unless she authorizes it
herself.
Most of us want to be autonomous because we want to be accountable for what we do, and
because it seems that if we are not the ones calling the shots, then we cannot be
accountable. More importantly, perhaps, the value of autonomy is tied to the value of self-
integration. We don't want to be alien to, or at war with, ourselves; and it seems that when
our intentions are not under our own control, we suffer from self-alienation. Of course, no
one can govern herself without being subject to influences whose power does not derive
from her own authority: everything we do is a response to past and present circumstances
over which we have no control. But some of the forces that move us to act do not merely
affect which actions we choose to perform, nor how we govern ourselves in making these
choices. They influence us in a way that makes a mockery of our authority to determine
our own actions. They undermine our autonomy. What distinguishes autonomy-
undermining influences on a person's decision, intention, or will from those motivating
forces that merely play a role in the self-governing process? This is the question that all
accounts of autonomy try to answer. As the number and variety of these accounts indicate,
the distinction is extremely elusive. There is certainly widespread agreement about the
paradigm threats to personal autonomy: brainwashing and addiction are the favorite
examples in the philosophical literature. If an agent fails to govern herself when she acts,
this must be because what she does is independent of her power to determine how she will
act.

3.2. Inform consent

31
 After Kelly A. Edwards, M.A. Informed Consent. 1998, University of Washington.
http://depts.washington.edu/bioethx/topics/consent.html

Gail Van Norman, MD. Informed Consent in the Operating Room. university of Washington School of Medicine.
http://depts.washington.edu/bioethx/topics/infc.html

The paternalistic - non paternalistic quarrel is especially hot in medical context. In same
eastern cultural traditions the paternalism is the dominant approach to patient. In western
world the physician can justifiably apply the principle of paternalism in a particular case
only after he has determined both that there are no alternate non-paternalistic courses of
action which will have the same results. Concluding it is to say that in western culture
medical paternalism is justified only when utilitarian considerations apply and when they
do not violate personal rights. This occurs only when the subject of paternalism is not fully
competent, when he has explicitly or by implication given consent, or when it can be
reasonably concluded, from the knowledge of his emotional and cognitive make up, that
he would approve of such treatment.
The practical form of anti paternalism is informed consent.
Informed consent is the process by which a fully informed patient can participate in
choices about her health care. It originates from the legal and ethical right the patient has
to direct what happens to her body and from the ethical duty of the physician to involve
the patient in her health care. It is originate in idea of autonomy, analyzed above. The
most important goal of informed consent is that the patient has an opportunity to be an
informed participant in his health care decisions. It is generally accepted that complete
informed consent includes a discussion of the following elements:
- the nature of the decision/procedure
- reasonable alternatives to the proposed intervention
- the relevant risks, benefits, and uncertainties related to each alternative
- assessment of patient understanding
- the acceptance of the intervention by the patient

In order for the patient's consent to be valid, he must be considered competent to make the
decision at hand and his consent must be voluntary. It is easy for coercive situations to
arise in medicine. Patients often feel powerless and vulnerable. To encourage
voluntariness, the physician can make clear to the patient that he is participating in a
decision, not merely signing a form. With this understanding, the informed consent
process should be seen as an invitation to him to participate in his health care decisions.
The physician is also generally obligated to provide a recommendation and share her
reasoning process with the patient. Comprehension on the part of the patient is equally as
important as the information provided. Consequently, the discussion should be carried on
in layperson's terms and the patient's understanding should be assessed along the way.

32
 How do you know when you have said enough about a certain decision? Most of the
literature and law in this area suggest one of three approaches:
- reasonable physician standard: what would a typical physician say about this
intervention? This standard allows the physician to determine what information is
appropriate to disclose. However, it is probably not enough, since most research in
this area shows that the typical physician tells the patient very little. This standard is
also generally considered inconsistent with the goals of informed consent as the
focus is on the physician rather than on what the patient needs to know.

- reasonable patient standard: what would the average patient need to know in order
to be an informed participant in the decision? This standard focuses on considering
what a patient would need to know in order to understand the decision at hand.

- subjective standard: what would this patient need to know and understand in order
to make an informed decision? This standard is the most challenging to incorporate
into practice, since it requires tailoring information to each patient.

Most states have legislation or legal cases that determine the required standard for
informed consent. In the state of Washington, we use the "reasonable patient standard."
The best approach to the question of how much information is enough is one that meets
both your professional obligation to provide the best care and respects the patient as a
person with the right to a voice in health care decisions.
Most health care institutions must have policies that state which health interventions
require a signed consent form. For example, surgery, anesthesia, and other invasive
procedures are usually in this category. These signed forms are really the culmination of a
dialogue required to foster the patient's informed participation in the clinical decision. For
a wide range of decisions, written consent is neither required nor needed, but some
meaningful discussion is needed. For instance, a man contemplating having a prostate-
specific antigen screen for prostate cancer should know the relevant arguments for and
against this screening test, discussed in layman's terms.
In most cases, it is clear whether or not patients are competent to make their own
decisions. Occasionally, it is not so clear. Patients are under an unusual amount of stress
during illness and can experience anxiety, fear, and depression. The stress associated with
illness should not necessarily preclude one from participating in one's own care. However,
precautions should be taken to ensure the patient does have the capacity to make good
decisions. There are several different standards of decision making capacity. Generally
you should assess the patient's ability to:

- understand his or her situation,

- understand the risks associated with the decision at hand, and

33
 - communicate a decision based on that understanding.

When this is unclear, a psychiatric consultation can be helpful. Of course, just because a
patient refuses a treatment does not in itself mean the patient is incompetent. Competent
patients have the right to refuse treatment, even those treatments that may be life-saving.
Treatment refusal may, however, be a flag to pursue further the patient's beliefs and
understanding about the decision, as well as your own.
Patients can move in and out of a coherent state as their medications or underlying
disease processes ebb and flow. You should do what you can to catch a patient in a lucid
state - even lightening up on the medications if necessary - in order to include him in the
decision making process.
If the patient is determined to be incapacitated/incompetent to make health care
decisions, a surrogate decision maker must speak for her. There is a specific hierarchy of
appropriate decision makers defined by state law (also see the DNR topic page). If no
appropriate surrogate decision maker is available, the physicians are expected to act in the
best interest of the patient until a surrogate is found or appointed.
The patient's consent should only be "presumed", rather than obtained, in emergency
situations when the patient is unconscious or incompetent and no surrogate decision maker
is available. In general, the patient's presence in the hospital ward, ICU or clinic does not
represent implied consent to all treatment and procedures. The patient's wishes and values
may be quite different than the values of the physician's. While the principle of respect for
person obligates you to do your best to include the patient in the health care decisions that
affect his life and body, the principle of beneficence may require you to act on the patient's
behalf when his life is at stake.

Influence can be applied to the information given to patients, and generally falls into three
categories:
- coercion
- manipulation
- persuasion
Coercion is the application of a credible threat to the patient, and is always unethical.
Manipulation involves incomplete or nontruthful presentation of information, such as
lying, omitting vital information, or deliberately deceiving. Manipulation is always
ethically suspected. Persuasion involves the presentation of a rational argument for a
choice, and is permissible, even desirable during the consent process. Patients recognize
that physicians have expertise and advice to offer about their care, and expect physicians
to be forthright with recommendations. The idea that information may harm patients is
often cited as a reason to curtail the discussion of risks with patients about to undergo
treatment/care (anesthesia and surgery). Multiple studies have failed to demonstrate
differences in the way patients and observers rate the stress levels of patients who receive
34
detailed information when compared with patients who received little or no information
about risks.
Patients have the right to refuse information, but the request must originate from the
patient and not the physician.

3.3. Study cases

Case 1
Mrs. R, a 29-year old mother, is admitted into hospital with abdominal pain. The medical
examination shows that she is suffering from an incurable cancer with few months to live
and with great suffering before her. Despite the fact that the woman has specifically asked
to be told exactly what she is facing, the physician informs her that the results of the
examination are not conclusive and that he will see her weekly as an outpatient. Mrs. R.
feels better after the appointment.
Is the decision of doctor correct one?

Case 2
Mrs. B is about to have a life-or-death operation as a result of a car accident, in which one
of her children has died. Mrs. B asks the physician about her children and he lies to her,
saying that “the children are worried about her”. The physician decides to hide this
information from her because he thinks that, in her condition, knowing the truth could kill
her.
Is the decision of doctor good one?

Case 3

informed Consent: http://depts.washington.edu/bioethx/topics/consntd1.html

A 64-year-old woman with MS (Multiple sclerosis (MS) is a demyelinating disease of the

central nervous system, causing impairment in sensation, movement, cognition, or other
functions depending on which nerves are involved) is hospitalized. The team feels she may
need to be placed on a feeding tube soon to assure adequate nourishment. They ask the
patient about this in the morning and she agrees. However, in the evening (before the tube
has been placed), the patient becomes disoriented and seems confused about her decision
to have the feeding tube placed. She tells the team she doesn't want it in. They revisit the
question in the morning, when the patient is again lucid. Unable to recall her state of mind
from the previous evening, the patient again agrees to the procedure.

Is this patient competent to decide? Which preference should be honored?

35
Case 4

A 55-year-old man has a 3-month history of chest pain and fainting spells. You feel his
symptoms merit cardiac catheterization (Cardiac catheterization is the insertion of a
catheter into a chamber or vessel of the heart.). You explain the risks and potential benefits
to him, and include your assessment of his likely prognosis without the intervention. He is
able to demonstrate that he understands all of this, but refuses the intervention.

Can he do that, legally? Should you leave it at that?

Chapter 4
Bioethics in practical medicine
Practical Medicine is the art and science of healing (the word medicine is derived
from the Latin ars medicina, meaning the art of healing) It encompasses a range of health
care practices evolved to maintain and restore health by the prevention and treatment of
illness. Contemporary medicine applies health science, biomedical research, and medical
technology to diagnose and treat injury and disease, typically through medication,
surgery, or some other form of therapy. Though medical technology and clinical expertise
are pivotal to contemporary medicine, successful face-to-face relief of actual suffering
continues to require the application of ordinary human feeling and compassion, known in
English as bedside manner.

36
 Any tip of practice (including Medical, Bioethical etc.) is a coherent and complex
set of activities, socially constructed. It has distinctive goals and standards of excellence
that help make the practice what it is, and that cannot be fully under stood apart from it.
These defining goals and standards develop through time. This development is not plain
and easy, it consists of many periods and moments of uncertainly. Nowadays in medical
practice also there are some issues on which the consensus is not achieved. These issues
are bioethical problems related to life and death (euthanasia), problems of reproduction,
and moral problems of genetic.

4.1. Euthanasia

Euthanasia : http://www.bbc.co.uk/ethics/euthanasia/infavour/infavour_1.shtml#h8

Euthanasia (literally "good death" in Old Greek) refers to the practice of ending a
life in a painless manner. Euthanasia can be several types.

A. Euthanasia by consent
Euthanasia may be conducted with consent (voluntary euthanasia) or without
consent (involuntary euthanasia). Involuntary euthanasia is conducted where an
individual makes a decision for another person incapable of doing so. The decision can be
made based on what the incapacitated individual would have wanted, or it could be
made on substituted judgment of what the decision maker would want were he or she in
the incapacitated person's place, or finally, the decision could be made by assessing
objectively whether euthanasia is the most beneficial course of treatment. In any case,
euthanasia by proxy consent is highly controversial, especially because multiple proxies
may claim the authority to decide for the patient and may or may not have explicit
consent from the patient to make that decision.
B. Euthanasia by means
Euthanasia may be conducted passively, non-actively, and actively. Passive
euthanasia entails the withholding of common treatments (such as antibiotics, pain
medications, or surgery) or the distribution of a medication (such as morphine) to relieve
pain, knowing that it may also result in death (principle of double effect). Passive
euthanasia is the most accepted form, and it is a common practice in most hospitals.
Non-active euthanasia entails the withdrawing of life. Active euthanasia entails the use of
lethal substances or forces to kill and is the most controversial means.

37
 Assisted suicide is the process by which an individual, who may otherwise be
incapable, is provided with the means (drugs or equipment) to commit suicide. In some
cases, the terms aid in dying or death with dignity are preferred. These terms are often
used to draw a distinction from suicide; in some legal jurisdictions, "suicide" (whether
assisted or not) remains illegal, while "aid in dying" is permitted.

History

The term euthanasia comes from the Greek words "eu"-meaning good and
"thanatos"-meaning death, which combined means “well-death” or "dying well".
Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400
and 300 B.C. The original Oath states: “To please no one will I prescribe a deadly drug
nor give advice which may cause his death.” Despite this, the ancient Greeks and Romans
generally did not believe that life needed to be preserved at any cost and were, in
consequence, tolerant of suicide in cases where no relief could be offered to the dying or,
in the case of the Stoics and Epicureans, where a person no longer cared for his life.
English Common Law from the 1300s until the middle of the last century made
suicide a criminal act in England and Wales. Assisting others to kill themselves remains
illegal in that jurisdiction. However, in the 1500s, Thomas More, in describing a utopian
community, envisaged such a community as one that would facilitate the death of those
whose lives had become burdensome as a result of "torturing and lingering pain".

A. Modern history

Since the 19th Century, euthanasia has sparked intermittent debates and activism in
North America and Europe. According to medical historian Ezekiel Emanuel, it was the
availability of anesthesia that ushered in the modern era of euthanasia. In 1828, the first
known anti-euthanasia law in the United States was passed in the state of New York, with
many other localities and states following suit over a period of several years. The first
major effort to legalize euthanasia in the United States arose as part of the eugenics
movement in the early years of the twentieth century. In an article in the Bulletin of the
History of Medicine, Brown University historian Jacob M. Appel documented extensive
political debate over legislation to legalize physician-assisted suicide in both Iowa and
Ohio in 1906. Appel indicates social activist Anna S. Hall was the driving force behind
this movement. In his book A Merciful End, Ian Dowbiggen has revealed the role that
leading public figures, including Clarence Darrow and Jack London, played in advocating
for the legalization of euthanasia.
Euthanasia societies were formed in England in 1935 and in the U.S.A. in 1938 to
promote aggressive euthanasia. Although euthanasia legislation did not pass in the U.S. or

38
England, in 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as
the person ending the life has nothing to gain. During this period, euthanasia proposals
were sometimes mixed with eugenics. While some proponents focused on voluntary
euthanasia for the terminally ill, others expressed interest in involuntary euthanasia for
certain eugenic motivations (e.g., mentally "defective"). During this same era, meanwhile,
U.S. court trials tackled cases involving critically ill people who requested physician
assistance in dying as well as “mercy killings”, such as by parents of their severely
disabled children.
Prior to and during World War II, the Nazis carried out an involuntary euthanasia
program, largely in secret. In 1939, Nazis, in what was code-named Action T4, killed
children under three who exhibited mental retardation, physical deformity or other
debilitating problems which they considered gave the disabled child "life unworthy of
life”. This program was later extended to include older children and adults.. Inmates of
mental asylums in Germany and Austria would be transported to an intermediate facility,
from where they would be retransported to one of six killing centers’ at Brandenburg near
Berlin (January 1940 - September 1940), Grafeneck near Stuttgart (January 1940 -
December 1940), Hartheim near Linz in Austria (January 1940 - December 1944),
Sonnenstein/Pirna near Dresden (April 1940 - August 1943), Bernburg near Magdeburg
(September 1940 - April 1943), Hadamar near Koblenz (January 1941 - August 1941).
Religious protest especially but not limited to Catholic prelates caused Hitler to order the
official cancellation of T4 but postwar investigation made it clear that the practice
continued in institutes where personnel were sympathetic to eugenic policies.
The T4 program of the Nazis was extended to killing of concentration camp inmates
when Philipp Bouhler,the head of the T4 program, allowed Heinrich Himmler to utilize T4
doctors, staff and facilities to kill concentration camp prisoners who were "most seriously
ill" in a program designated "14f13".

B. Post-War history

Due to outrage over Nazi euthanasia, in the 1940s and 1950s there was very little
public support for euthanasia, especially for any involuntary, eugenics-based proposals.
Catholic Church leaders, among others, continued speaking against euthanasia as a
violation of the sanctity of life. (Nevertheless, owing to its principle of double effect,
Roman Catholic moral theology did leave room for shortening life with pain-killers and
what could be characterized as passive euthanasia.) On the other hand, judges were often
lenient in mercy-killing cases. By the 1960s, advocacy for a right-to-die approach to
voluntary euthanasia increased. A key turning point in the debate over voluntary
euthanasia (and physician assisted dying), at least in the United States, was the public
furor over the case of Karen Ann Quinlan. The Quinlan case paved the way for legal
39
protection of voluntary passive euthanasia. In 1977, California legalized living wills and
other states soon followed suit.
In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to
assist terminal patients with six months or less to live to end their lives. The U.S. Supreme
Court allowed such laws in 1997. The Bush administration failed in its attempt to use drug
law to stop Oregon in 2001, in the case Gonzales v. Oregon. In 1999, non-aggressive
euthanasia was permitted in Texas.
In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002,
restrictions were loosened. During that year, physician-assisted suicide was approved in
Belgium. Belgium's at the time most famous author Hugo Claus, suffering from
Alzheimer's disease, was among those that asked for euthanasia. He died in March 2008,
assisted by an Antwerp doctor. Australia's Northern Territory approved a euthanasia bill in
1995, but that was overturned by Australia’s Federal Parliament in 1997.
In November 2008, Washington Initiative 1000 made Washington the second U.S.
state to legalize physician-assisted suicide.
As of 2008, some forms of euthanasia are legal in Belgium, Luxembourg, The
Netherlands, Switzerland, the U.S. states of Oregon and Washington the Autonomous
Community of Andalusia (Spain), and Thailand.
Euthanasia can be accomplished either through an oral, intravenous, or
intramuscular administration of drugs. In individuals who are incapable of swallowing
lethal doses of medication, an intravenous route is preferred. The following is a Dutch
protocol for parenteral (intravenous) administration to obtain euthanasia: Intravenous
administration is the most reliable and rapid way to accomplish euthanasia and therefore
can be safely recommended. A coma is first induced by intravenous administration of 20
mg/kg sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then
a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given,
such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide
(Norcuron). The muscle relaxant should preferably be given intravenously, in order to
ensure optimal availability. Only for pancuronium bromide (Pavulon) are there
substantial indications that the agent may also be given intramuscularly in a dosage of 40
mg.

Arguments for and against voluntary euthanasia

Since World War II, the debate over euthanasia in Western countries has centered
on voluntary euthanasia (VE) within regulated health care systems. In some cases, judicial
decisions, legislation, and regulations have made VE an explicit option for patients and
their guardians. Proponents and critics of such VE policies offer the following reasons for
and against official voluntary euthanasia policies:

Reasons given for voluntary euthanasia:

40
 Choice: Proponents of VE emphasize that choice is a fundamental principle for
liberal democracies and free market systems.
 Quality of Life: The pain and suffering a person feels during a disease, even with
pain relievers, can be incomprehensible to a person who has not gone through it.
Even without considering the physical pain, it is often difficult for patients to
overcome the emotional pain of losing their independence.
 Economic costs and human resources: Today in many countries there is a shortage
of hospital space. The energy of doctors and hospital beds could be used for people
whose lives could be saved instead of continuing the life of those who want to die
which increases the general quality of care and shortens hospital waiting lists. It is a
burden to keep people alive past the point they can contribute to society, especially
if the resources used could be spent on a curable ailment.

Reasons given against voluntary euthanasia:

 Professional role: Critics argue that voluntary euthanasia could unduly compromise
the professional roles of health care employees, especially doctors. They point out
that European physicians of previous centuries traditionally swore some variation of
the Hippocratic Oath, which in its ancient form excluded euthanasia: "To please no
one will I prescribe a deadly drug nor give advice which may cause his death."
However, since the 1970s, this oath has largely fallen out of use.
 Moral: Some people consider euthanasia of some or all types to be morally
unacceptable. This view usually treats euthanasia to be a type of murder and
voluntary euthanasia as a type of suicide, the morality of which is the subject of
active debate.
 Theological: Voluntary euthanasia has often been rejected as a violation of the
sanctity of human life. Specifically, some Christians argue that human life
ultimately belongs to God, so that humans should not be the ones to make the
choice to end life. Orthodox Judaism takes basically the same approach, however, it
is more open minded, and does, given certain circumstances, allow for euthanasia to
be exercised under passive or non-aggressive means. Accordingly, some theologians
and other religious thinkers consider voluntary euthanasia (and suicide generally) as
sinful acts, i.e. unjustified killings.
 Feasibility of implementation: Euthanasia can only be considered "voluntary" if a
patient is mentally competent to make the decision, i.e., has a rational understanding
of options and consequences. Competence can be difficult to determine or even
define.
 Necessity: If there is some reason to believe the cause of a patient's illness or
suffering is or will soon be curable, the correct action is sometimes considered to
attempt to bring about a cure or engage in palliative care.
 Wishes of Family: Family members often desire to spend as much time with their
loved ones as possible before they die.
 Consent under pressure: Given the economic grounds for voluntary euthanasia
(VE), critics of VE are concerned that patients may experience psychological
pressure to consent to voluntary euthanasia rather than be a financial burden on their
41
 families. Even where health costs are mostly covered by public money, as in various
European countries, VE critics are concerned that hospital personnel would have an
economic incentive to advise or pressure people toward euthanasia consent.

Euthanasia and religion

Catholic teaching condemns euthanasia as a "crime against life". The teaching of the
Catholic Church on euthanasia rests on several core principles of Catholic ethics,
including the sanctity of human life, the dignity of the human person, concomitant human
rights, due proportionality in casuistic remedies, the unavoidability of death, and the
importance of charity. The Church's official position is the 1980 Declaration on
Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith. In Catholic
medical ethics official pronouncements strongly oppose active euthanasia, whether
voluntary or not, while allowing dying to proceed without medical interventions that
would be considered "extraordinary" or "disproportionate." The Declaration on
Euthanasia states that:

"When inevitable death is imminent... it is permitted in conscience to take the

decision to refuse forms of treatment that would only secure a precarious and burdensome
prolongation of life, so long as the normal care due to a sick person in similar cases is not
interrupted." The Declaration concludes that doctors, beyond providing medical skill, must
above all provide patients "with the comfort of boundless kindness and heartfelt charity".
Although the Declaration allows people to decline heroic medical treatment when death is
imminently inevitable, it unequivocally prohibits the hastening of death and restates
Vatican II's condemnation of "crimes against life 'such as any type of murder, genocide,
abortion, euthanasia, or willful suicide'".

Jewish medical ethics have become divided, partly on denominational lines, over
euthanasia and end of life treatment since the 1970s. Generally, Jewish thinkers oppose
voluntary euthanasia, often vigorously, though there is some backing for voluntary passive
euthanasia in limited circumstances. Likewise, within the Conservative Judaism
movement, there has been increasing support for passive euthanasia (PAD) In Reform
Judaism response, the preponderance of anti-euthanasia sentiment has shifted in recent
years to increasing support for certain passive euthanasia (PAD) options.

Islam categorically forbids all forms of suicide and any action that may help another
to kill themselves. It is forbidden for a Muslim to plan, or come to know through self-will,
the time of his own death in advance. The precedent for this comes from the Islamic
prophet Muhammad having refused to bless the body of a person who had committed
suicide. If an individual is suffering from a terminal illness, it is permissible for the

42
individual to refuse medication and/or resuscitation. Other examples include individuals
suffering from kidney failure who refuse dialysis treatments and cancer patients who
refuse chemotherapy.

Palliative care

Many think palliative care as a proper alternative to euthanasia. Palliative care is

physical, emotional and spiritual care for a dying person when cure is not possible. It
includes compassion and support for family and friends. Competent palliative care may
well be enough to prevent a person feeling any need to contemplate euthanasia. You
matter because you are you. You matter to the last moment of your life and we will do all
we can to help you die peacefully, but also to live until you die. The key to successful
palliative care is to treat the patient as a person, not as a set of symptoms, or medical
problems. The World Health Organization states that palliative care affirms life and
regards dying as a normal process; it neither hastens nor postpones death; it provides relief
from pain and suffering; it integrates the psychological and spiritual aspects of the patient.
Making things better for patient, family and friends.

4. 2. Bioethics and reproduction

Within the framework of WHO's definition of health as a state of complete
physical, mental and social well-being, and not merely the absence of disease or
infirmity. And reproductive health, or sexual health/hygiene, is a component of this
state of well being. It addresses the reproductive processes, functions and system at all
stages of life. Reproductive health, therefore, implies that people are able to have a
responsible, satisfying and safe sex life and that they have the capability to reproduce
and the freedom to decide if, when and how often to do so. Implicit in this are the right
of men and women to be informed of and to have access to safe, effective, affordable
and acceptable methods of fertility regulation of their choice, and the right of access to
appropriate health care services. The freedom to decide coupled with technological
advance in reproductive sphere give rise of some ethical debates concerning forms of (A)
reproducing on one hand and (B) abortion on the other hands.

A. Advanced methods of reproduction and ethical debates

Children are flowers of life and appearance of a new life is the motive of happiness
while infertility is a cause of distress. Today’s technologies offer the chance to reduce this
distress by means In vitro fertilization (IVF) and Surrogacy
43
 In vitro fertilization (IVF) is a process by which egg cells are fertilized by sperm
outside of the womb, in vitro. The term in vitro, from the Latin root meaning in glass, is used,
because early biological experiments involving cultivation of tissues outside the living
organism from which they came, were carried out in glass containers such as beakers, test
tubes, or petri dishes. Today, the term in vitro is used to refer to any biological procedure
that is performed outside the organism it would normally be occurring in, to distinguish it
from an in vivo procedure, where the tissue remains inside the living organism within
which it is normally found. Initially IVF was developed to overcome infertility due to
problems of the fallopian tube, but it turned out that it was successful in many other
infertility situations as well. The introduction of intracytoplasmic sperm injection (ICSI)
addresses the problem of male infertility to a large extent.
For IVF to be successful it may be easier to say that it requires healthy ova, sperm that can
fertilize, and a uterus that can maintain a pregnancy. In the simplest case, a woman is
given a course of hormone treatments to cause her ovaries to produce multiple eggs. The
eggs are surgically removed just prior to ovulation, either under general anesthesia through
the abdomen (laparoscopy) or under local anesthesia through the wall of the vagina
(transvaginal retrieval). They are then placed in a culture dish with the father’s sperm.
During the next few days, the dish is periodically examined to see if fertilization has
occurred. In approximately 48 hours, when the embryos reach the eight-cell stage, those
that appear healthy and that are growing normally are transferred into the uterus, where, it
is hoped, some will implant and develop full term. A woman may have to undergo several
treatment cycles before she becomes pregnant.
Surrogacy is a method of reproduction whereby a woman agrees to become pregnant
and deliver a child for a contracted party. A surrogate mother is the woman who is
pregnant with the child and intends to relinquish it after birth. The word surrogate, from
Latin subrŏgare (to substitute), means appointed to act in the place of. The intended
parent(s) is the individual or couple who intends to rear the child after its birth.
In traditional surrogacy (aka the Straight method) the surrogate is pregnant with her
own biological child, but this child was conceived with the intention of relinquishing the
child to be raised by others; by the biological father and possibly his spouse or partner,
either male or female. The child may be conceived via home artificial insemination using
fresh or frozen sperm or impregnated via IUI (intrauterine insemination) which is
performed at a fertility clinic.
In gestational surrogacy the surrogate becomes pregnant via embryo transfer with a
child of which she is not the biological mother. She may have made an arrangement to
relinquish it to the biological mother or father to raise, or to a parent who is themselves
unrelated to the child (e. g. because the child was conceived using egg donation, sperm
donation or is the result of a donated embryo). The surrogate mother may be called the
gestational carrier.
44
 Altruistic surrogacy is a situation where the surrogate receives no financial reward
for her pregnancy or the relinquishment of the child (although usually all expenses related
to the pregnancy and birth are paid by the intended parents such as medical expenses,
maternity clothing, and other related expenses).
Commercial surrogacy is a form of surrogacy in which a gestational carrier is paid to
carry a child to maturity in her womb and is usually resorted to by well off infertile
couples who can afford the cost involved or people who save and borrow in order to
complete their dream of being parents. This procedure is legal in several countries
including in India where due to excellent medical infrastructure, high international demand
and ready availability of poor surrogates it is reaching industry proportions. Commercial
surrogacy is sometimes referred to by the emotionally charged and potentially offensive
terms "wombs for rent", "outsourced pregnancies" or "baby farms".

Ethical problems of reproduction

After Mary Carrington Coutts. Ethical Issues in In Vitro Fertilization http://bioethics.georgetown.edu

Sue A. Meinke. Surrogate Motherhood: Ethical and Legal Issues
http://bioethics.georgetown.edu/publications/scopenotes/sn6.pdf

Infertility may have profound psychological effects. Partners may become more
anxious to conceive, ironically increasing sexual dysfunction. Marital discord often
develops in infertile couples, especially when they are under pressure to make medical
decisions. Women trying to conceive often have clinical depression rates similar to
women who have heart disease or cancer. Even couples undertaking IVF face
considerable stress. Emotional stress and marital difficulties are greater in couples where
the infertility lies with the man. In many cultures, inability to conceive bears a stigma. In
closed social groups, a degree of rejection (or a sense of being rejected by the couple)
may cause considerable anxiety and disappointment. Some respond by actively avoiding
the issue altogether; middle-class men are the most likely to respond in this way.

If the infertility arise the social, psychological and health problems the advanced
methods of reproduction arise ethical issues.

 At a basic level, some believe that society should not allow any of the reproductive
technologies (artificial insemination, surrogate motherhood, sex preselection, in
vitro fertilization, etc.) because they separate the conjugal act from the procreative
act. This is seen as both unnatural and a threat to the unity of the family and the
dignity of the human person.

 Others would argue that the world is already overpopulated and that those
unfortunate couples not able to conceive naturally should adopt a child rather than
struggle to conceive their own biological child.
45
  A related question is whether it is right to expend the significant economic resources
required to create just one child through IVF when our health care resources are
already overburdened.

 High-cost treatments are out of financial reach for some couples.

 At a more specific level, there are ethical quandaries surrounding the retrieval of the
eggs, and their subsequent treatment. The doctors involved in the IVF procedure
must strike a delicate balance between retrieving and fertilizing enough eggs to
establish a pregnancy, but not implanting so many preembryos that they are faced
with a high occurrence of multiple pregnancies; these usually result in low birth
weight babies, which have a statistically higher risk of neonatal problems and death.
When doctors do have too many fertilized embryos to transfer back to the mother,
they must decide what to do with the “spare embryos.” There are several possible
alternatives: 1) discard them; 2) donate them to a recipient who is either unable to
produce eggs, or whose genetic background makes it inadvisable for her to use her
own egg, 3) freeze the embryos for later transfer, should no pregnancy occur in the
current cycle; or 4) donate the embryos to a research project. All of these options
have stimulated the debate on the significance of the human embryo. For some
people involved in IVF, the decision to discard a spare embryo is a pragmatic one;
the embryos discarded are usually those that are not developing properly in the
culture dish, and thus may not be healthy enough to implant themselves if they were
transferred to the womb. The early disposal of these embryos is merely carrying out
what nature would probably do herself. For others, the moral significance of the
embryo is much too important to permit its disposal. They make anti-abortion
opposition to the destruction of embryos not transferred in vivo.

Ethical issues abound surrogacy:

 Many argue that surrogate arrangements depersonalize reproduction and create a
separation of genetic, gestational, and social parenthood.
 Others argue that there is a change in motives for creating children: children are not
conceived for their own sakes, but for another’s benefit. Much is unknown.
 Other says that nobody knows: What is the degree of stress on the couple and
especially on the surrogate mother? What are the possible adverse psychological
effects on the child? What identity crisis might ensue, and will there be a desire on
the part of the child to know his/her gestational mother? Will surrogate
arrangements be used not only by infertile couples but also for the sake of
convenience, or by single men or women? Should the surrogate be paid? Would
this lead to commercialization of surrogacy and expose the surrogate mother to
possible exploitation? What happens when no one wants a handicapped newborn?

Legal Questions

Many countries have special frameworks for dealing with the ethical and social issues
around fertility treatment.
46
  One of the best known is the HFEA - The UK's regulator for fertility treatment and
embryo research. This was set up on 1 August 1991 following a detailed
commission of enquiry led by Mary Warnock in the 1980s

 A similar model to the HFEA has been adopted by the rest of the countries in the
European Union. Each country has its own body or bodies responsible for the
inspection and licensing of fertility treatment under the EU Tissues and Cells
directive

 Regulatory bodies are also found in Canada and in the state of Victoria in Australia

B. Abortion

http://en.wikipedia.org/wiki/Abortion_debate

An abortion is the termination of a pregnancy by the removal or expulsion of an

embryo or fetus from the uterus, resulting in or caused by its death. An abortion can
occur spontaneously due to complications during pregnancy or can be induced. Abortion
as a term most commonly refers to the induced abortion of a human pregnancy, while
spontaneous abortions are usually termed miscarriages. A pregnancy can be intentionally
aborted in many ways. The manner selected depends chiefly upon the gestational age of
the embryo or fetus, in addition to the legality, regional availability, and doctor-patient
preference for specific procedures. Reasons for procuring induced abortions are typically
characterized as either therapeutic or elective. An abortion is medically referred to as
therapeutic when it is performed to:

 save the life of the pregnant woman;

 preserve the woman's physical or mental health;
 terminate pregnancy that would result in a child born with a congenital disorder that
would be fatal or associated with significant morbidity; or
 selectively reduce the number of fetuses to lessen health risks associated with
multiple pregnancy.
 Any abortion that is not therapeutic is by definition elective.

Abortion debate

In the history of abortion, induced abortion has been the source of considerable
debate. Abortion debates, especially pertaining to abortion laws, are often spearheaded
by advocacy groups belonging to one of two camps. Most often those in favor of greater
legal restrictions on, or even complete prohibition of abortion, describe themselves as
pro-life while those against legal restrictions on abortion describe themselves as pro-
choice. Generally, the pro-life position argues that a human fetus is a human being with
47
the right to live making abortion tantamount to murder. The pro-choice position argues
that a woman has certain reproductive rights, especially the choice whether or not to
carry a pregnancy to term. In both public and private debate, arguments presented in
favor of or against abortion focus on either the moral permissibility of an induced
abortion, or justification of laws permitting or restricting abortion. Mare famous debates
are as fellow:
 Fetal pain debate. Many researchers in the area of fetal development
believe that a fetus is unlikely to feel pain until after the sixth month of pregnancy.
Developmental neurobiologists suspect that the establishment of thalamocortical
connections (at about 26 weeks) may be critical to fetal perception of pain. However,
legislation has been proposed by anti-abortion advocates requiring abortion providers to
tell a woman that the fetus may feel pain during an abortion procedure. Wendy Savage
Press officer, Doctors for a Woman’s Choice on Abortion, considers the question to be
irrelevant. She noted that the majority of surgical abortions in Britain are already
performed under general anesthesia which affects the fetus, and considers the discussion
"to be unhelpful to women and to the scientific debate."
 Fetal personhood debate. Although the two main sides of the abortion
debate tend to agree that fetuses are biologically and genetically human (that is, of the
human species), they often differ in their view on whether or not a fetus is, in any of
various ways, a person. Pro-life supporters argue that abortion is morally wrong on the
basis that a fetus is an innocent human person or because a fetus is a potential life that
will, in most cases, develop into a fully functional human being. Others reject this
position by drawing a distinction between human being and human person, arguing that
while the fetus is innocent and biologically human, it is not a person with a right to life. In
support of this distinction, some propose a list of criteria as markers of personhood. For
example, Mary Ann Warren suggests consciousness (at least the capacity to feel pain),
reasoning, self-motivation, the ability to communicate, and self-awareness. According to
Warren, a being need not exhibit all of these criteria to qualify as a person with a right to
life, but if a being exhibits none of them (or perhaps only one), then it is certainly not a
person. Warren concludes that as the fetus satisfies only one criterion, consciousness
(and this only after it becomes susceptible to pain), the fetus is not a person and abortion
is therefore morally permissible. Critics of this typically argue that the proposed criteria
for personhood would disqualify two classes of born human beings – reversibly comatose
patients, and human infants – from having a right to life, since they, like fetuses, are not
self-conscious, do not communicate, and so on. Critics may see such concessions as an

48
indication that the right to life cannot be adequately defined by reference to developed
psychological features.
 Arguments in favor of the right to abortion. An argument first presented by
Judith Jarvis Thomson states that even if the fetus has a right to life, abortion is morally
permissible because a woman has a right to control her own body. Thomson's variant of
this argument draws an analogy between forcing a woman to continue an unwanted
pregnancy and forcing a person's body to be used as a dialysis machine for another
person suffering from kidney failure. It is argued that just as it would be permissible to
"unplug" and thereby cause the death of the person who is using one's kidneys, so it is
permissible to abort the fetus (who similarly, it is said, has no right to use one's body
against one's will). Critics of this argument generally argue that there are morally relevant
disanalogies between abortion and the kidney failure scenario. For example, it is argued
that the fetus is the woman's child as opposed to a mere stranger; that abortion kills the
fetus rather than merely letting it die; and that in the case of pregnancy arising from
voluntary intercourse, the woman has either tacitly consented to the fetus using her
body, or has a duty to allow it to use her body since she herself is responsible for its need
to use her body. Some writers defend the analogy against these objections, arguing that
the disanalogies are morally irrelevant or do not apply to abortion in the way critics have
claimed.
 Sexual emancipation and equality. Some argue that women's freedoms are
limited until they can have the right to abortion on demand and to walk away from
parenthood like men can. Governments that ban abortion arguably burden women with
certain duties that men (who, too, are responsible for the pregnancy) are not also held
accountable to, therefore, creating a double standard. Margaret Sanger wrote: "No
woman can call herself free until she can choose consciously whether she will or will not
be a mother." Denying the right to abortion can be construed from this perspective as a
form of female oppression under a patriarchal system, perpetuating inequality between
the sexes. Among pro-choice advocates, sexual-equality discussion often involves the
additional debate regarding to what degree the potential father should have a choice in
deciding whether or not to abort the developing child.
 Arguments against the right to abortion. Argument of Discrimination.
According to this argument, those who deny that fetuses have a right to life do not value
all human life, but instead select arbitrary characteristics (such as particular levels of
physical or psychological development) as giving some human beings more value or
rights than others. In contrast, philosophers who define the right to life by reference to
particular levels of physical or psychological development typically maintain that such

49
characteristics are morally relevant, and reject the assumption that all human life
necessarily has value (or that membership in the species Homo sapiens is in itself morally
relevant).

Public opinion

An individual's position on the complex ethical, moral, philosophical, biological,

and legal issues of abortion is often related to his or her value system. Opinions of
abortion may be best described as being a combination of beliefs on its morality, and
beliefs on the responsibility, ethical scope, and proper extent of governmental
authorities in public policy. Religious ethics also has an influence upon both personal
opinion and the greater debate over abortion.
A number of opinion polls around the world have explored public opinion
regarding the issue of abortion. Results have varied from poll to poll, country to country,
and region to region, while varying with regard to different aspects of the issue.
A May 2005 survey examined attitudes toward abortion in 10 European countries,
asking polltakers whether they agreed with the statement, "If a woman doesn't want
children, she should be allowed to have an abortion". The highest level of approval was
81% (in the Czech Republic); the lowest was 47% (in Poland).
In North America, a December 2001 poll surveyed Canadian opinion on abortion,
asking Canadians in what circumstances they believe abortion should be permitted; 32%
responded that they believe abortion should be legal in all circumstances, 52% that it
should be legal in certain circumstances, and 14% that it should be legal in no
circumstances. A similar poll in January 2006 surveyed people in the United States about
U.S. opinion on abortion; 33% said that abortion should be "permitted only in cases such
as rape, incest or to save the woman's life", 27% said that abortion should be "permitted
in all cases", 15% that it should be "permitted, but subject to greater restrictions than it is
now", 17% said that it should "only be permitted to save the woman's life", and 5% said
that it should "never" be permitted. A November 2005 poll in Mexico found that 73.4%
think abortion should not be legalized while 11.2% think it should.
Of attitudes in South and Central America, a December 2003 survey found that
30% of Argentines thought that abortion in Argentina should be allowed "regardless of
situation", 47% that it should be allowed "under some circumstances", and 23% that it
should not be allowed "regardless of situation". A March 2007 poll regarding the abortion
law in Brazil found that 65% of Brazilians believe that it "should not be modified", 16%
that it should be expanded "to allow abortion in other cases", 10% that abortion should
be "decriminalized", and 5% were "not sure". A July 2005 poll in Colombia found that
50
65.6% said they thought that abortion should remain illegal, 26.9% that it should be
made legal, and 7.5% that they were unsure.

Abortion law

Current laws pertaining to abortion are diverse. Religious, moral, and cultural
sensibilities continue to influence abortion laws throughout the world. The right to life,
the right to liberty, the right to security of person, and the right to reproductive health
are major issues of human rights that are sometimes used as justification for the
existence or absence of laws controlling abortion. Many countries in which abortion is
legal require that certain criteria be met in order for an abortion to be obtained, often,
but not always, using a trimester-based system to regulate the window of legality:

 In the United States, some states impose a 24-hour waiting period before the
procedure, prescribe the distribution of information on fetal development, or require
that parents be contacted if their minor daughter requests an abortion.
 In the United Kingdom, as in some other countries, two doctors must first certify
that an abortion is medically or socially necessary before it can be performed.
Other countries, in which abortion is normally illegal, will allow one to be
performed in the case of rape, incest, or danger to the pregnant woman's life or health. A
few nations ban abortion entirely: Chile, El Salvador, Malta, Ireland and Nicaragua,
although in 2006 the Chilean government began the free distribution of emergency
contraception. In Bangladesh, abortion is illegal, but the government has long supported
a network of "menstrual regulation clinics", where menstrual extraction (manual vacuum
aspiration) can be performed as menstrual hygiene.
In places where abortion is illegal or carries heavy social stigma, pregnant women
may engage in medical tourism and travel to countries where they can terminate their
pregnancy. In the USA, it is not unusual for women to travel from one state to another
for reasons of termination of pregnancy.

4.3. Bioethics and genetic

GeneticEngineeringDebates http://library.thinkquest.org/C004367/be10.shtml

51
Nowadays significant advanced is done in genetics or in genetic engineering. Application
of them in practice is the subject of large debates. Some of them are related with following
subjects.

Genetically Modified Foods

One major application of genetic engineering techniques is in the realm of food

production. With the world population expanding and synthetic pesticides decreasing in
effectiveness, novel solutions are increasingly in demand. Genetically modified foods are
one such solution. Genetic modification of organism involves the insertion or deletion of
genes. In the process of cisgenesis, genes are artificially transferred between organisms
that could be conventionally bred (genes are only transferred between closely related
organisms). In the process of transgenesis, genes from a different species are inserted,
which is a form of horizontal gene transfer. Transgenesis is the process of introducing an
exogenous gene – called a transgene – into a living organism so that the organism will
exhibit a new property and transmit that property to its offspring. This techniques can:
increase plants' resistance to pesticides and herbicides, thereby decreasing the need for
these pollutant chemicals; allow plants to manufacture their own pesticides to ward off
insects; increase the yields of many staple crops and thereby ward off starvation in many
areas of the world; and allow plants to grow under adverse weather conditions or in poor
soil, thereby increasing the amount of arable land on the planet.
However, despite these undeniable benefits, critics argue that genetically engineered crops
might transmit their novel genes to wild populations, possibly creating organisms against
which humans have no defense. Critics also argue that genetic diversity of plant
populations could decrease, thus making crops more susceptible to decimation by as-yet-
unknown pathogens. A third argument centers on food consumption, and states that people
with food allergies or dietary restrictions might inadvertently eat foods that contain a
dangerous compound due to modification.
The debate also is concerning to label or not genetically modified food. According to
the US Food and Drug Administration, food coming from cloned animals is safe to eat. In
addition the FDA stated that cloned food does not require special labeling. Both meat
and milk from cloned animals such as swine, goats and cattle have no differences from
the conventionally bred animals. Joseph Mendelson, legal director of the Center for Food
Safety, said that cloned food still should be labeled due to the fact that safety and ethical
issues of it remain questionable.

Gene Therapy

52
Another application of genetic engineering techniques is in the area of gene therapy, or
treatment of genetic diseases through genetic modifications. Gene therapy is the insertion
of genes into an individual's cells and tissues to treat a disease. For example, if a person
had a disease caused by a defective gene, a healthy gene could be added to the affected
cells to treat the disorder. The technique researchers are currently experimenting is viruses.
Viruses are good at injecting their DNA payload into human cells and reproducing it. By
adding the desired DNA to the DNA of non-pathogenic virus, a small amount of virus will
reproduce the desired DNA and spread it all over the body.
Proponents of this method argue that gene therapy is the most reasonable and cost-
effective way to treat most genetic diseases, because the ideal treatment would only need
to be administered once - after that, the modification would be incorporated into the
person's genome. Gene therapy techniques promise to end or at least curb a vast amount of
human suffering due to painful, debilitating, and sometimes fatal genetic diseases.

Opponents of gene therapy cite the unknown and unpredictable results of inserting genes
at random into the genes in a person's cells. They argue that playing with the genome
could cause, or at least be a contributing factor, to many types of cancer; they state that
curing a person of a genetic disease only to give him terminal cancer is unthinkably
inhumane. They also maintain that gene therapy on humans, especially at this stage when
we know so little about gene regulation, would amount to unethical experimentation on
human subjects.

Some of the problems of gene therapy mentioned is as following:

 Immune response - Anytime a foreign object is introduced into human tissues, the
immune system has evolved to attack the invader. The risk of stimulating the
immune system in a way that reduces gene therapy effectiveness is always a
possibility. Furthermore, the immune system's enhanced response to invaders it has
seen before makes it difficult for gene therapy to be repeated in patients.
 Problems with viral vectors - Viruses, while the carrier of choice in most gene
therapy studies, present a variety of potential problems to the patient --toxicity,
immune and inflammatory responses, and gene control and targeting issues. In
addition, there is always the fear that the viral vector, once inside the patient, may
recover its ability to cause disease.
 Multigene disorders - Conditions or disorders that arise from mutations in a single
gene are the best candidates for gene therapy. Unfortunately, some of the most
commonly occurring disorders, such as heart disease, high blood pressure,
Alzheimer's disease, arthritis, and diabetes, are caused by the combined effects of
variations in many genes. Multigene or multifactorial disorders such as these would
be especially difficult to treat effectively using gene therapy.
 Chance of inducing a tumor (insertional mutagenesis) - If the DNA is integrated in
the wrong place in the genome, for example in a tumor suppressor gene, it could
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 induce a tumor. This has occurred in clinical trials for X-linked severe combined
immunodeficiency (X-SCID) patients, in which hematopoietic stem cells were
transduced with a corrective transgene using a retrovirus, and this led to the
development of T cell leukemia in 3 of 20 patients.
 Religious concerns - Religious groups and creationists may consider the alteration
of an individual's genes as tampering or corrupting God's work.

Germ-Line Therapy

An even more controversial subset of gene therapy is germ-line therapy, or the

removal or replacement of faulty genes, not in a person's body cells, but in his gametes.
The distinguishing characteristic of somatic engineering mention in previous paragraph is
that it is non-inheritable, e.g. the new gene would not be passed to the recipient’s
offspring. Germline engineering would change genes in eggs, sperm, or very early
embryos. This type of engineering is inheritable, meaning that the modified genes would
appear not only in any children that resulted from the procedure, but in all succeeding
generations. Proponents argue that germ-line therapy would be a great boon to mankind
because it would eliminate destructive and costly genetic diseases. They often state that it
would be inhuman to allow children to be born with fatal genetic diseases when the
capability exists to remove those genes from the population once and for all. They
generally see it as an extremely effective way to curb human suffering, as well as a
practical measure against the high costs of conventional treatment for generations of
people afflicted with a given disease.
The potential of genetic engineering to cure medical conditions opens the question
of exactly what such a condition is. Some view aging and death as medical conditions and
therefore potential targets for engineering solutions. They see human genetic engineering
potentially as a key tool in this. The difference between cure and enhancement from this
perspective is merely one of degree. Theoretically genetic engineering could be used to
drastically change people's genomes, which could enable people to regrow limbs and other
organs, perhaps even extremely complex ones such as the spine. It could also be used to
make people stronger, faster, smarter, or to increase the capacity of the lungs, among other
things. Strength, speed, endurance and so on can be enhanced. The baby can be made
taller, more beautiful; the changes possible are really up to the imagination, and the ability
of the techniques employed by future gene manipulators. If a gene exists in nature, it could
be brought over to a human cell. In this view, there is no qualitative difference (only a
quantitative one) between, for instance, a genetic intervention to cure muscular dystrophy,
and a genetic intervention to improve muscle function even when those muscles are
functioning at or around the human average (since there is also an average muscle function
for those with a particular type of dystrophy, which the treatment would improve upon).

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 Opponents of germ-line gene therapy generally argue that it would be extremely
inadvisable at this time, when so little is known about gene regulation or the mechanisms
of embryological development; they claim that the premature use of such techniques could
have results even worse than the diseases they were trying to cure. Opponents also express
concern that not only diseases will be culled from the population, but also relatively
insignificant problems like myopia, racial variations like skin color, and even normal
variations like height; they generally argue that germ-line therapy is a slippery slope that
will plunge humanity into eugenic policies and practices. Individuals may benefit from
non-therapeutic genetic engineering, but some claim that there may be adverse social
implications. Few resources – particularly those related to medicine and health care – are
available to everyone, and allowing the most privileged to engineer themselves or their
children to have special capabilities could lead to what some call a genetic aristocracy.
Numerous enhancements via genetic engineering have been proposed, including increased
memory, intelligence, and less need for sleep, in addition to some peoples’ desires to alter
their physical appearance. The advantages created by genetic engineering, either real or
perceived, could lead to new forms of inequality between those with genetic enhancements
and those without while also exacerbating current inequalities between the rich and poor.
Others feel that there is an important distinction between using genetic technologies to
treat those who are suffering and to make those who are already healthy superior to the
average. Though theory and speculation suggest that genetic engineering could be used to
make people stronger, faster, smarter, or to increase lung capacity, opponents say there is
little evidence that this can currently be done without very unsafe and therefore unethical
human experiments. Because different cells have different tasks, changing one cell to do a
different job will not only affect that one task, it can affect many others too.
In addition, opponents claim that reduction of genetic diversity in the human gene pool
could increase our collective susceptibility to newly emerging diseases. Some people also
cite religious or ethical objections to this particular method of "playing God".

Cloning

Cloning in biology is the process of producing populations of genetically-identical

individuals that occurs in nature when organisms such as bacteria, insects or plants
reproduce asexually. Cloning in biotechnology refers to processes used to create copies of
DNA fragments (molecular cloning), cells (cell cloning), or organisms. The term clone is
derived from κλών, the Greek word for "twig, branch", referring to the process whereby a
new plant can be created from a twig.
Organism cloning refers to the procedure of creating a new multicellular organism,
genetically identical to another. Reproductive cloning of organism uses "somatic cell
nuclear transfer" (SCNT). This process entails the transfer of a nucleus from a donor adult
55
cell (somatic cell) to an egg which has no nucleus. If the egg begins to divide normally it is
transferred into the uterus of the surrogate mother. Dolly (1996-07-05 – 2003-02-14), a
Finn Dorsett ewe, was the first mammal to have been successfully cloned from an adult
cell, though the first actual thing to be cloned, was a tadpole in 1952. She was cloned at
the Roslin Institute in Scotland and lived there until her death when she was six. Dolly
was publicly significant because the effort showed that the genetic material from a
specific adult cell, programmed to express only a distinct subset of its genes, could be
reprogrammed to grow an entire new organism. Before this demonstration, there was no
proof for the widely spread hypothesis that differentiated animal cells can give rise to
entire new organisms. Cloning Dolly the sheep had a low success rate per fertilized egg;
she was born after 277 eggs were used to create 29 embryos, which only produced three
lambs at birth, only one of which lived. Seventy calves have been created from 9,000
attempts and one third of them died young. Notably, although the first clones were frogs,
no adult cloned frog has yet been produced from a somatic adult nucleus donor cell.
Human cloning is the creation of a genetically identical copy of an existing or
previously existing human. The term is generally used to refer to artificial human cloning;
human clones in the form of identical twins are commonplace, with their cloning
occurring during the natural process of reproduction. There are two commonly discussed
types of human cloning: therapeutic cloning and reproductive cloning. Therapeutic
cloning involves cloning cells from an adult for use in medicine and is an active area of
research: while reproductive cloning would involve making cloned human beings. Such
reproductive cloning has not been performed and is illegal in many countries.

Ethical debates over reproductive human cloning

The ethical status of cloning humans has been a hotly debated issue, touched off by the
controversy over Dolly, the first cloned mammal. Proponents of cloning argue that it is no
more unnatural than binary fission, the process by which bacteria reproduce to produce
identical copies of themselves; they go on to state that cloning is no more unethical than
growing a plant from a cutting or giving birth to identical twins, both of which involve two
separate and distinct organisms with identical genomes. Since identical twins have the
exact same genome, but still grow up with different personalities, clones raised in entirely
different time periods and social contexts will be entirely individual despite identical
genes. In this view, cloning is just another scientific topic and will become just another
reproductive option, and those who wish to research cloning or to be cloned should not be
stopped.
There is a small group of people who oppose cloning - or at least propose a moratorium on
it for the time being - for practical, not moral or ethical, reasons. These people argue that
56
cloning is ethically acceptable, but practically unsound because of the resultant decrease in
the genetic diversity of the human gene pool. They also advise more extensive
experiments on the effects of cloning on animals before human beings are cloned.
Finally, a large majority of people argue that cloning humans is both unnatural and
unethical. They cite fears that include: people's individuality being impaired or ruined due
to cloning technologies; aggressor nations creating armies of cloned soldiers to assault
other nations; overpopulation due to sudden ease of reproduction; depletion of the human
gene pool; and a number of concerns about the moral status of clones. Some go so far as to
postulate a stratified society divided into the cloned and the uncloned, and fears about
eugenics or of reserving cloning technology to the "genetically desirable" generally
surface. Many religions also object to cloning, again by claiming that it is "playing God".

4.4. Study cases

Comment the cases!
Euthanasia – Case Studies
http://www.rsrevision.com/Alevel/ethics/euthanasia/Euthanasia_Case_Studies.pdf

Case of Dax Cowart

Dax Cowart was very badly burnt after a gas explosion engulfed his car. He said “I was
burned so severely and in so much pain that I did not want to live even in the early
moments following the explosion.” Dax repeatedly asked his doctors, family and friends to
help him end his suffering, which lasted through 10 years of agonising treatment. Dax is
blind and cannot use his hands, but is otherwise healthy and currently works as an
attorney. He still believes it was wrong to deny his request for euthanasia. An interactive
CD ROM of this case has been produced, with interviews from Dax, his doctors and
friends and family.

Case of Dr Jack Kevorkian

Kevorkian earned the name 'Dr Death' by photographing the eyes of dying patients. Later
in his career (starting in 1987) he began to advertise his services as a physician offering
'death counselling'. When terminally ill patients learned that he was helping people to die,
more and more people came to him. Despite several failed court cases, Kevorkian helped
over 130 people to die.
Kevorkian believed that helping people was not enough, and actually killed Thomas Youk,
filmed himself doing so and showed the film on 60 Minutes. He left the studio in
handcuffs, and, defending himself unsuccessfully in court, was sentenced to 10-25 years in
prison. In 2006 Kevorkian became terminally ill with Hepatitis C and asked to be
pardoned.

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Chapter 5
Social problems of bioethics: socio-philosophical analysis. Rights and
obligations in the biomedical world.
5.1. Ethics and sex: transexualism.
The Diagnostic and Statistical Manual of Mental Disorders accepts the expression
of desire to be of the opposite sex, or assertion that one is of the sex opposite from the one
with which one was assigned at birth, as sufficient for being transsexual. Transsexualism
is a condition in which a person identifies with a physical sex different from the one with
which they were born. A medical diagnosis can be made if a person experiences
discomfort as a result of a desire to be a member of the opposite sex, or if a person
58
experiences impaired functioning or distress as a result of that gender identification. Many
transsexual people believe that gender is hard-wired in the brain before birth, arguing that
being transsexual is an intersex condition, a congenital birth issue unseen by others due to
its location in the brain: a mis-match in the sex of a person between that of the brain and
that of the body. The main symptom of this condition is a unique type of depression,
anxiety or even psychological pain: Gender Dysphoria. Commonly, transsexual people
assert that their brain-based inner perception of their sexual self is their true identity and so
change their physical sex in an effort to align their inner and outer self. If untreated,
Gender Dysphoria can lead to mental and emotional problems, and sometimes suicide.
Most transsexual men and women desire to establish a permanent social role as a member
of the gender with which they identify. Many transsexual people also desire various types
of medical alterations to their bodies. These physical alterations are collectively referred to
as sex reassignment therapy and often include hormone replacement therapy and surgery.
The entire process of switching from one physical sex and social gender presentation to
the other is often referred to as transition, and usually takes several years. There is no
conclusive evidence that sex change operations improve the lives of transsexuals, with
many people remaining severely distressed and even suicidal after the operation, according
to a medical review conducted exclusively for Guardian Weekend tomorrow.
The review of more than 100 international medical studies of post-operative transsexuals
by the University of Birmingham's aggressive research intelligence facility (Arif) found no
robust scientific evidence that gender reassignment surgery is clinically effective. Against
the statistic above indicating that 1% to 2% of post-operative persons have serious regrets,
the Report itself states: Paradoxically, a growing number of post-operative transsexuals are
scathing about their medical care. International research suggests that 3-18% of them
come to regret switching gender.

Sex reassignment therapy raise also social and ethical issue as it is unfolded in
article below.

Technology on the Social and Ethical, Aspects of Transsexual Surgery

By Janice G. Raymond Assistant Professor of Medical Ethics and

Women's Studies, Hampshire College/University of Massachusetts Amherst,
Massachusetts, June, 1980. http://www.susans.org/reference/usts1-9.html

That the transsexual is a person who is trapped in the body of the wrong sex. Thus
we have the popular definition of a transsexual as a "female mind in a male body." This
results in the perception of transsexualism as a disease or as disease-like and thus a
medical problem. In many cases, a "cure" can only be affected through radical

59
intervention such as specialized hormonal treatments and sex conversion surgery. That it
is a therapeutic necessity and a reasonable and humane treatment to perform surgery on
those individuals who have undergone rigorous preoperative psychological evaluations
and who can truly "pass" as members of the opposite sex. Furthermore, proof of the
surgery's efficacy is that over 90% of those who have undergone transsexual operations
report that their lives are healthier and happier.
The aim of this paper is to analyze these assumptions and, in so doing, to address
the much-neglected social and ethical issues surrounding transsexual surgery.
Transsexualism is an important medical ethical issue that raises questions that go far
beyond the transsexual context -- questions of bodily mutilation and integrity, medical
priorities, unnecessary surgery, the inevitable issue of the medical model in general, as
well as definitions of maleness and femaleness, and the boundaries of such. Scholars will
also find that transsexualism touches the parameters of many of the academic disciplines
in such a way as to raise fundamental questions about the territorial imperatives of
biology, psychology, medicine, and the law, to name but a few. Questions about the
causes of transsexualism and the proper methods of treatment have been hitherto
restricted to the domains of psychology and medicine. But as an ethicist, I would
maintain that these issues of causation and treatment are often embedded with social
values and philosophical beliefs -- values and beliefs about the so-called natures of
women and men, for example.
Historically, one could say that some people have always felt "trapped" in the
wrong body, in the wrong skin, and in the wrong period of time. But this feeling never
certified them as members of the "right" body, skin, or period of time. For example,
persons who felt "trapped" in black skin were never encouraged to undergo a
pigmentation change. Ultimately, it was recognized that such "trapped" feelings were
encouraged by a society that oppressed and discriminated against black people, and that
it was the society that needed changing, not the individual black. In the same way, to
acknowledge that a man who feels trapped in his native-born body is a transsexual (and
ultimately, through hormonal and surgical intervention, a woman), is to ignore the social
causes and ramifications that surround the issue. Indeed, one must ask why it is possible
in this society that persons could even talk about a "female mind in a male body."
If transsexualism is a disease, then does desire qualify as disease? As Thomas Szasz
has asked, does the old person who wants to be young suffer from the "disease" of being
a "transchronological" or does the poor person who wants to be rich suffer from the
"disease" of being a "transeconomical?" Thus, there is an absence of those objective
diagnostic tests normally available to confirm or indicate the presence of pathological

60
illness or disease. The doctor, or so it seems, can only assess the validity of the potential
transsexual's claims in relation to his/ her actions and when compared with the behaviour
and statements of previously 'diagnosed' 'sufferers'. This problem is further compounded
by the variety of theories outlined, which suggest possible causes for transsexuality
ranging from the biological to the cultural, and from psychosis to upbringing. Selection is
made by matching the claims of existing clients to those of past clients for whom
reassignment was successful. Not only is this an unsatisfactory method of diagnosis
(though not perhaps of selection) it implies that ultimately, radical surgery is performed
on the strength of the patient's self-diagnosis.
Transsexualism as disease raises many deeper issues about the medical model in
general and the ways in which transsexualism has come to the defined as legitimate
medical territory. Within the last century, more and more areas of life have come to be
defined as medical and technical problems. This is most evident, of course, in the mental
health realm where all sorts of behaviors have been categorized as diseases, and then
treated by drugs, surgery, and other medical-technical means. My point here is to affirm
that more and more personal, moral, and now social problems are defined as medical
problems when they are actually human and social conflicts. Approaching these conflicts
from a diagnostic and disease perspective prevents the person who is dissatisfied with his
sex from seeing the issue in an alternative framework. Specifically, persons who think
they are transsexuals are not encouraged presently to see this desire as arising from the
social constraints of masculine and feminine role-defined behavior. Thus a man who
wishes to be emotional or non-aggressive is encouraged to think of himself as a woman
instead of as a man who is trying to break out of the masculine role.
The ultimate effect of defining transsexualism as a disease, and as a medical
problem, is to encourage persons to view other persons (especially children) who do not
live out proper and appropriate sex role behavior as potential transsexuals. Thus, for
example, for the boy who likes to play with dolls or the girl who wants to be a truck
driver, these behaviors can be interpreted as transsexual behavior instead of as non-
stereotypical behavior that helps to break down sex roles. Thus the classification of
transsexualism as a disease or as a therapeutic category relegates non-stereotypical sex-
role behavior to the medical realm.
It is important to understand that doctors here are not curing a disease. They are
actually engaged in the political and social shaping of masculine and feminine behavior.
Several facts bear out this contention. Here especially, I note the role of the so-called
gender identity clinics and private therapists who foster and reinforce stereotyped
behavior. Persons wishing to change sex come to these clinics or go to individual
therapists to receive counseling and ultimately to be referred for treatment and surgery.
It is a primary requirement of these centers that men who wish to be transsexed must

61
prove that they can "pass" as "true women" in order to qualify for treatment and
surgery. "Passing" requirements evaluate everything from an individual's feminine dress,
to feminine body language, to so-called feminine positions in intercourse. Most clinics
require candidates for surgery to live out opposite sex-roles and rigidly defined
stereotypical behavior for periods of six months to two years. Thus the role of these
clinics and clinicians in reinforcing sex-role stereotypes is significant and, as I have tried
to show above, one that has consequences that reach far beyond the transsexual issue. I
would suggest that what we are witnessing here is a "benevolent" form of behavior
control and modification. It is not inconceivable that gender clinics, in the name of
therapy, could become potential centers of sex-role control for non-transsexuals--e.g.
children whose parents have strong ideas about the kind of masculine or feminine
children they want their offspring to be.
The ultimate effect of viewing the desire to live as a member of the opposite sex
as a disease or as a medical category is that a social and ethical issue becomes
transformed into a therapeutic and medical-technical problem to be solved by "passing"
requirements, hormone therapy, and sex conversion surgery. Medicine focuses on the
surgical construction of desired genitalia. Artifacts of silicone breasts, artificial vaginas,
and the like come to incarnate the essence of femaleness which the transsexual so
desperately desires. Since the general result of sex conversion surgery is that the
transsexual becomes an agreeable participant in a society which encourages conformity
to rigid sex role behavior, then ultimately the medical solution becomes a "social
tranquilizer." Sexism, and its foundation of sex-role stereotyping, is reinforced.
Transsexual surgery also enables doctors to gain medical knowledge about the
manipulation of human sexuality that probably could not be acquired by any other
medical procedures. In what other medical situation could a penectomy be done upon a
healthy penis and an artificial vagina inserted into a chromosomal male? What we also
witness in the transsexual context is a number of medical specialties combining to create
transsexuals -- urologists, gynecologists, endocrinologists, plastic surgeons, and the like.
The proliferation of treatments that has been generated to take care of the "disease" is
remarkable. These range from the initial and basic operative procedures undergone by all
transsexuals to highly specialized forms of secondary cosmetic surgery such as eye, nose,
and chin operations. Not coincidentally, hormone therapy and surgery are expensive.
Finally, treating transsexualism as a disease and making it medical territory have
also masked the fact that a unique group of medical consumers has been created by
medicine itself. The terminology of transsexualism disguises the reality that transsexuals
prove they are "real" transsexuals by conforming to the canons of a medical institution

62
that evaluates them on the basis of their being able to pass as stereotypically masculine
or feminine, and that ultimately grants surgery on this basis. Once sex-role dissatisfaction
is given the name of transsexualism, institutionalized in gender identity clinics, and
treated by hormone therapy and surgery, the category of transsexualism functions to
explain and order very valid dissatisfactions with sex-role stereotypes.
The terminology of transsexualism raises the inevitable question of is it possible to
change sex, i.e., to transsex? To answer this, it is necessary to discuss various meanings of
the word SEX, a word that has both a dismaying multiplicity and ambiguity of meanings.
John Money has distinguished various definitional levels of the word SEX that are helpful
in assessing whether it is biologically possible to cross sex. Chromosomal sex determines
biological maleness or femaleness, contrary to popular opinion that anatomical sex is
determinative. Normal males have a chromosomal pattern of XY with normal females
being XX. There are some individuals who are born with chromosomal anomalies in
which surgery is often used to bring the anomalous person in line with the anatomical
characteristics that become most dominant, or else the developing anatomical
characteristics are altered in line with the sex in which the child has been reared. The
pattern of sex chromosomes is present and unchangeable in every body cell, including
blood cells. Chromosomal sex can, however, conflict with anatomical sex.
Anatomical sex refers to primary and secondary sex characteristics. Primary
characteristics include the testes in the male and the ovaries in the female. Secondary
anatomical sex characters include the penis, scrotum, prostate, hair distribution, and a
deeper voice in the male; and the clitoris, vulva, uterus, vagina, breasts, a wide pelvis,
female voice, and hair distribution in the female. Transsexual surgery alters anatomical
sex through hormonal and operative procedures. Genital or Gonadal sex is the collective
term for the tests in the male or the ovaries in the female. Legal sex is designated most
often by genital sex, although this is not actually defined in the codes. It is in this area
that errors of sex do occur, since the obstetrician or mid-wife may be deceived by the
apparent genital sex. Endocrine or Hormonal sex is determined by androgen in the male
and estrogen in the female, supplied by not only the sex glands, but also by the pituitary
or adrenal glands. Endocrine sex is mixed to certain extents since, for example, the testes
as well as male adrenals, produce certain amounts of estrogen. Psychological sex or the
word gender are terms used in much of the literature to designate attitudes, traits,
characteristics, and behavior that are said to accompany biological maleness or
femaleness. I would prefer the term psychosocial sex to indicate the all-important factor
that such attitudes, traits, characteristics, and behavior are socially influence and
orchestrated. Historical sex is a term that I would add to this already lengthy list of

63
distinctions. History is important, in this context, because there is a certain constellation
of events that attend the sex into which one is born. For example, menstruation for a girl
is a biological happening, but it is also a historical event around which cluster a certain
set of very different yet also very similar collective female experiences. Men do not have
a history of menstruation nor the experiences which surround its onset, its monthly
occurrence, or its demise. What significance does this delineation of the various
terminologies of sex have in answering the question of is it possible to change sex?
Beginning in order with the list of sex distinctions, the most important reality is that it is
biologically impossible to change chromosomal sex. If chromosomal sex is taken as the
bottom line of maleness or femaleness, the male who undergoes sex conversion surgery
is NOT female.
Anatomically, transsexualism does take place, but anatomical changes also
happen in what is commonly termed plastic surgery. Transsexual surgery alters genital or
gonadal sex most intrinsically. For example, it is possible to remove a woman's ovaries or
a man's testes through this surgery, and it is also possible to construct an artificial vagina
in a man whose penis and testes have been removed. The question then becomes how
much value one would give to this kind of alteration in terms of changing the totality of a
person's sex. George Burou, a Casablancan physician who has operated on over 700
American men who wanted to become women, expressed the superficiality of changing
genital sex in this way: "I don't change men into women. I transform male genitals into
genitals that have a female aspect. All the rest is in the patient's mind." Furthermore, a
change in genital sex does not make reproduction possible.
Endocrine or hormonal sex is the most susceptible to alteration, but this is done
without surgical intervention. Hormonal intake of opposite-sex hormones have certain
anatomical effects resulting in, for example, breast for men or a redistribution of body
hair for both women and men. Hormonal treatments must be lifelong, however, for most
of the anatomical effects to be prolonged.
In law, it is possible to transsex; that is, it is possible to change one's legal sex.
However, the whole area of legal sex has been one of contention for the transsexual who
wishes to have sex conversion surgery validated by a corresponding change of sex on
official papers such as birth certificates, social security, drivers' licenses, and the like.
If it is impossible to change basic chromosomal structure, then it is necessary to
take a more in-depth look at not only the terminology but also the reality of
transsexualism? Can we call a person a transsexual, biologically speaking, whose
anatomical structure and hormonal balance have changed, but who is still genetically XY

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and XX? If chromosomal sex is not the bottom line, what are we really talking about when
we say that a person is a biological male or female?
Is there any such enduring reality as biological maleness or femaleness?
Obviously, there is more to maleness or femaleness than chromosomal make-up.
Feminists have been arguing this for years, and I am not re-affirming the biology is
destiny argument. In fact, it is transsexuals and defenders of the surgery who are
asserting a new form of biology is destiny. For what they are ultimately saying is that it is
impossible to change male or female behavior, traits, characteristics, and the like UNLESS
one also changes one's body. Transsexuals define themselves by exclusive reference to
the body of the sex they want to be. This is a new variation on the theme of biology is
destiny. What transsexuals and those who support the surgery affirm is that persons are
irrevocably determined by what body they are born with. In the transsexual context,
persons desiring the surgery become enfettered by both the unwanted body of their
chromosomal sex (which they reject) and the body of the opposite sex for which they are
willing to undergo painful and mutilating surgery. Ultimately, the transsexual and the
medical community which supports surgery give the message that the body is all-
important, that it does guide one's destiny, and that all else is body-bound.
Chromosomal sex is the enduring reality which determines biological maleness or
femaleness. This can never change. What is more significant in determining the totality of
maleness or femaleness, however, is what I have called historical sex. No man can have
the history of being born and located in any culture as a woman. He can have the history
of wishing to be a woman and of acting like a woman, but this is the history of one who
DESIRES to be a woman, not of one who is a woman. Surgery may confer the artifacts of
outer and inner female organs, but it cannot confer the history of being born a woman in
this society.
History, of course, is not static. All of us make changes in both our personal and
social history. I am not advocating that history should determine the boundaries, life, and
location of the self. However, there are aspects of anyone's personal and social history
that cannot be changed. For example, a person who is born into a particular class cannot
change that history. He can change his class attitudes, habits, and complex of behaviors
that accompany a certain class typology. Likewise, in the transsexual context, a man
cannot change his history of having grown up male. Men who want to change masculine
attitudes, habits, and complex of behaviors should not take on the bodies of women but
rather should try to change their unwanted history in their own bodies.

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 To summarize, it is impossible to change sex, i.e., to transsex, because it is
impossible to change not only the chromosomes of one's native-born sex but also much
of the personal and social history that accompanies biological maleness and femaleness.
Proponents of transsexual surgery claim that the only way of treating those
individuals who find themselves to be born into "the wrong sex," and who have
undergone rigorous preoperative screening procedures, is ultimately through sex
conversion surgery. It is emphasized that many persons who think they might be
candidates for surgery are weeded out through these stringent evaluations, and only
those who can truly "pass" as women (or men) are referred for surgery. For this small
number of individuals, transsexual surgery is not only a therapeutic necessity but a
reasonable and humane treatment. Furthermore, the majority of postoperative reports
of transsexuals testify that the surgery has been proven effective and efficacious and is
therefore no longer experimental. They cite the fact that 90% of those persons who have
undergone surgery report that their lives are happier and healthier. These reports,
however, do not explore the deeper social issues, nor do they question a satisfaction that
is achieved at the expense of never investigating the underlying social and ethical issues.
They do not state that after surgery the transsexual fits into a role-defined world better
than most native-born women who live out their feminine roles.
Critics of this position maintain that it would be an overwhelming burden on both
the transsexual and the therapist to attack so large a problem as sex-role socialization in
the therapeutic, never mind social, context. Therefore, it is easier, to confront the
problem within role limits, making use of a ready-made social structure that created
transsexualism initially. While proponents of transsexual surgery may admit that it would
be preferable to modify society's attitudes toward masculine and feminine behavior, they
emphasize that in the immediacy of the therapeutic moment, the task of social change is
impossible. Faced with the personal crisis of a gender-disturbed individual, they opt for
ignoring or relegating the social effects to a secondary place. However, in the name of
dealing with an individual crisis, it is important to note that this kind of therapy does not
foster genuine individualism. Current transsexual therapy and surgery promote an
individualism that serves a role-defined society. Thus, it is more accurate to say that
these are solutions that promote the values of social conformity. To use another
example: Many oppressed people use heroin to make life tolerable in intolerable
conditions. Heroin usage is a highly effective yet dangerous treatment for dissatisfaction
and despair. Recently, black leaders have drawn attention to heroin as a pacifier of black
people. The contentment and euphoria produced by the drug diffuses the critical
consciousness of the users. Although there are many real differences between the users

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of heroin and the recipients of transsexual surgery, the analogy is appropriate in at least
one significant way. Transsexual surgery produces satisfaction and relief for the
transsexual at the expense of muting his or her critical consciousness of the ways in
which such surgery reinforces sex role behavior. Thus transsexuals are not encouraged to
ask how their own socialization conditioned not only their choice of surgery, but also
their motivation to choose.
It is in this sense that transsexual surgery can be said to be experimental surgery.
Transsexuals are seeking surgery to relieve gender discomfort and dissatisfaction. Within
the context of a role defined society, the surgery is narrowly successful at doing this for
some transsexuals. But there is no evidence to prove that the surgery "cures" the deeper
problems which lead many persons to seek the surgery. In other words, sex conversion
surgery cannot bestow upon the transsexual the sense of self that he or she lacks.
Furthermore, there is evidence, at least in some postoperative cases, which transsexuals
themselves have come to realize this, but too late. Meyer and Hoopes, as early as 1974,
noted that a group of their patients had reacted self-destructively after surgery. These
reactions included multiple and serious suicide attempts, drug abuse, and serious
physical complications. Randall in an earlier study, reported on four cases (out of 29) in
which postoperative adjustment was worse than before the operation. The behavior
included suicide, suicidal impulse, moral depravity, and a wish to reverse the effects of
the operation.
One of the first well-known physicians to work in the areas was Charles Ihlenfeld,
an endocrinologist, who was a co-worker and protege of Harry Benjamin. Ihlenfeld left
the field after helping one hundred or more transsexuals change sex because as he
reported to have said: "Whatever surgery did, it did not fulfill a basic yearning for
something that is difficult to define. This goes along with the idea that we are trying to
treat superficially something that is much deeper." Finally, Johns Hopkins terminated
transsexual surgery in 1979 after conducting a study of fifty transsexuals which showed
that there was no significant difference in successful life adjustment between those who
underwent transsexual surgery and those who did not. The study was the first to
compare postoperative transsexuals with an unoperated group of persons who wanted
the surgery. The study, initially reported in the ARCHIVES OF GENERAL PSYCHIATRY and in
the press release issued by Johns Hopkins which appeared in newspapers across the
country said, among other things: "Physicians have to ask themselves if transsexual
surgery is medically necessary. To say that this type of surgery cures psychiatric
disturbance is incorrect. We now have objective evidence that there is no real difference

67
in the transsexual's adjustment to life in terms of jobs, educational attainment, marital
adjustment, and social stability."
On physical grounds alone, there is a substantial amount of evidence to confirm that sex
conversion surgery is experimental. Transsexual treatment is far from established as a safe
medical procedure. In some instances, it has been known to cause cancer. In 1968, W.
Symmers reported two cases of carcinoma of the breast in which the transsexuals died. He
suggested that the malignance was entirely due to the hormonal imbalance created by
castration plus the massive doses of estrogen received. There are several other studies that
have investigated the correlation between male-to=constructed female transsexualism and
cancer. One might also ask why initial long term research with a control group was not
undertaken. Without such studies it is difficult to see how the patient can be informed
about the potential outcome of his/her operation. Within the context of transsexuality, the
radical nature of the surgery itself poses several ethical questions. Most obvious is that of
gaining fully informed consent. It is reported that the majority of patients selected for the
operation are at best intermittently depressed and at worst simultaneously suffering from
psychiatric illness. In either case, judgement may be impaired. Furthermore, the research
results given suggest that post-operative euphoria declines over the years, meaning that
complete long-term adjustment cannot be inferred from early apparent success.
This paper has argued that the issue of transsexualism is an ethical one that has
profound social and moral ramifications. Transsexualism itself is a deeply moral question
rather than a medical technical answer. In concluding, I would list some suggestions for
change that address the more social and ethical arguments I have raised in the preceding
pages. While there are many who feel that morality must be built into law, I believe that
the elimination of transsexualism is not best achieved by legislation prohibiting
transsexual treatment and surgery but rather by legislation that limits it and by other
legislation that lessens the support given to sex-role stereotyping, which generated the
problem to begin with. Any legislation should be aimed at the social conditions that
initiate and promote the surgery as well as the growth of the medical-institutional
complex that translates these stereotypes into flesh and blood. More generally, the
education of children is one case in point here. Images of sex roles continue to be
reinforced, at public expense, in school textbooks. Children learn to role play at an early
age.
Nonsexist counseling is another direction for change that should be explored. The
kind of counseling to "pass" successfully as masculine or feminine that now reigns in
gender identity clinics only reinforces the problem of transsexualism. It does nothing to
develop critical awareness, and makes transsexuals dependent upon medical-technical
solutions. What I am advocating is a counseling that explores the social origins of the

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transsexual problem and the consequences of the medical technical solution. It would
raise questions such as the following: is individual gender suffering relieved at the price
of role conformity and the perpetuation of role stereotypes on a social level? In changing
sex, does the transsexual encourage a sexist society whose continued existence depends
upon the perpetuation of these roles and stereotypes? These and similar questions are
seldom raised in transsexual therapy at present. I am not so naive as to think that these
measures would make transsexualism disappear overnight, but they would at least pose
the existence of a real alternative to be explored and tried. Given encouragement to
cultural definitions of both masculinity and femininity, persons considering transsexual
surgery might not find it as necessary to resort to sex conversion surgery.
Public education must also be emphasized. Up to this point, the transsexual and
the transsexual professionals have been the sources of information for the general
public. The mere existence of the postoperative transsexual, moreover, and the fact of
the surgery's availability permit people to restrict their thinking about sex role
dissatisfaction to these medical-surgical boundaries. One way in which education about
transsexualism has reached the general public is through the media. Famous transsexual
personages such as Jan Morris or Renee Richards appear in widely circulated magazines
and on television talk shows. Thus transsexualism becomes "media-ized" in certain
prejudicial ways, which contribute to public opinion that surgery is indeed the solution to
gender dissatisfaction. Different perspectives on the issues of transsexualism need to
receive more attention and publicity. We need to hear more from those men and women
who, at one time, thought they might be transsexuals but decided differently -- persons
who successfully overcame their gender crises without resorting to medicine and surgery.
We need to hear more also from professionals such as endocrinologist Charles
Ihlenfeld who, after helping many to change sex, left the field. Finally, we need to listen
to persons, such as feminists, who have experienced sex role dissatisfaction but did not
become transsexuals.
In the final analysis, it is important to remember that transsexualism is merely one
of the most obvious forms of gender dissatisfaction and sex-role playing in a role-defined
society. It is one of the most obvious because, in the transsexual situation, we have the
stereotypes on stage, so to speak, for all to see and examine in an alien context. What
can be overlooked, however, is that these same stereotypical behaviors are lived out
every day in "native" bodies. The issues that this paper has highlighted should by no
means be confined to the transsexual context. Rather they should be confronted in the
"normal" society that spawned the problem of transsexualism to begin with.

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 5.2. Ethical issues in mental disorder patients.
The definition and classification of mental disorder is a key issue for the mental
health professions and for users and providers of mental health services. Most
international clinical documents use the term "mental disorder" rather than "mental
illness". There is no single definition and the inclusion criteria are said to vary depending
on the social, legal and political context. In general, however, a mental disorder has been
characterized as a clinically significant behavioral or psychological pattern that occurs in
an individual and is usually associated with distress, disability or increased risk of
suffering. The term "serious mental illness" (SMI) is sometimes used to refer to more
severe and long-lasting disorder. A broad definition can cover mental disorder, mental
retardation, personality disorder and substance dependence. The phrase "mental health
problems" may be used to refer only to milder or more transient issues. There is often a
criterion that a condition should not be expected to occur as part of a person's usual
culture or religion. Nevertheless, the term "mental" is not necessarily used to imply a
distinction between mental (dys) functioning and brain (dys)functioning, or indeed
between the brain and the rest of the body.
There are currently two widely established systems that classify mental disorders -
Chapter V of the International Classification of Diseases (ICD-10), produced by the World
Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list
categories of disorder and provide standardized criteria for diagnosis. Some approaches
to classification do not employ distinct categories based on cut-offs separating the
abnormal from the normal. They are variously referred to as spectrum, continuum or
dimensional systems. There is a significant scientific debate about the relative merits of a
categorical or a non-categorical system. There is also significant controversy about the
role of science and values in classification schemes, and about the professional, legal and
social uses to which they are put.

Disorders

There are many different categories of mental disorder, and many different facets
of human behavior and personality that can become disordered.

The state of anxiety or fear can become disordered, so that it is unusually intense
or generalized over a prolonged period of time. Commonly recognized categories of

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anxiety disorders include specific phobia, Generalized anxiety disorder, Social Anxiety
Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Post-traumatic
stress disorder. Relatively long lasting affective states can also become disordered. Mood
disorder involving unusually intense and sustained sadness, melancholia or despair is
known as Clinical depression (or Major depression), and may more generally be
described as Emotional dysregulation. Milder but prolonged depression can be diagnosed
as dysthymia. Bipolar disorder involves abnormally "high" or pressured mood states,
known as mania or hypomania, alternating with normal or depressed mood. Whether
unipolar and bipolar mood phenomena represent distinct categories of disorder or
whether they usually mix and merge together along a dimension or spectrum of mood is
under debate in the scientific literature.
The fundamental characteristics of a person that influence his or her cognitions,
motivations, and behaviors across situations and time - can be seen as disordered due to
being abnormally rigid and maladaptive. Categorical schemes list a number of different
personality disorders, such as those classed as eccentric (e.g. Paranoid personality
disorder, Schizoid personality disorder, Schizotypal personality disorder), those described
as dramatic or emotional (Antisocial personality disorder, Borderline personality disorder,
Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-
related (Avoidant personality disorder, Dependent personality disorder, Obsessive-
compulsive personality disorder).
There may be an emerging consensus that personality disorders, like personality
traits in the normal range, incorporate a mixture of more acute dysfunctional behaviors
that resolve in relatively short periods, and maladaptive temperamental traits that are
relatively more stable. Other disorders may involve other attributes of human
functioning. Eating practices can be disordered, at least in relatively rich industrialized
areas, with either compulsive over-eating or under-eating or binging. Categories of
disorder in this area include Anorexia nervosa, Bulimia nervosa, Exercise Bulimia or Binge
eating disorder. Sleep disorders such as Insomnia also exist and can disrupt normal sleep
patterns. Sexual and gender identity disorders, such as Dyspareunia or Gender identity
disorder or ego-dystonic homosexuality. People who are abnormally unable to resist
urges, or impulses, to perform acts that could be harmful to themselves or others, may
be classed as having an impulse control disorder, including various kinds of Tic disorders
such as Tourette's Syndrome, and disorders such as Kleptomania (stealing) or Pyromania
(fire-setting). Substance-use disorders include Substance abuse disorder. Addictive
gambling may be classed as a disorder. Inability to sufficiently adjust to life circumstances
may be classed as an Adjustment disorder. The category of adjustment disorder is usually

71
reserved for problems beginning within three months of the event or situation and
ending within six months after the stressor stops or is eliminated. People who suffer
severe disturbances of their self-identity, memory and general awareness of themselves
and their surroundings may be classed as having a Dissociative identity disorder, such as
Depersonalization disorder or Dissociative Identify Disorder itself (which has also been
called multiple personality disorder, or "split personality".). Factitious disorders, such as
Munchausen syndrome, also exist where symptoms are experienced and/or reported for
personal gain.
Disorders appearing to originate in the body, but thought to be mental, are known
as somatoform disorders, including Somatization disorder. There are also disorders of the
perception of the body, including Body dysmorphic disorder. Neurasthenia is a category
involving somatic complaints as well as fatigue and low spirits/depression, which is
officially recognized by the ICD-10 but not by the DSM-IV. Memory or cognitive disorders,
such as amnesia or Alzheimer's disease exist.
Some disorders are thought to usually first occur in the context of early childhood
development, although they may continue into adulthood. The category of Specific
developmental disorder may be used to refer to circumscribed patterns of disorder in
particular learning skills, motor skills, or communication skills. Disorders which appear
more generalized may be classed as pervasive developmental disorders (PDD) also known
as autism spectrum disorders (ASD); these include autism, Asperger's, Rett syndrome,
childhood disintegrative disorder and other types of PDD whose exact diagnosis may not
be specified. Other disorders mainly or first occurring in childhood include Reactive
attachment disorder; Separation Anxiety Disorder; Oppositional Defiant Disorder;
Attention Deficit Hyperactivity Disorder.

Causes

Numerous factors have been linked to the development of mental disorders. In

many cases there is no single accepted or consistent cause currently established. A
common view held is that disorders often result from genetic vulnerabilities combining
with environmental stressors (Diathesis-stress model). An eclectic or pluralistic mix of
models may be used to explain particular disorders. The primary paradigm of
contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS)
model - incorporating biological, psychological and social factors - although this may not
be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing
on "organic" or "hardware" pathology of the brain. Psychoanalytic theories have been
popular but are now less so. Evolutionary psychology may be used as an overall
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explanatory theory. Attachment theory is another kind of evolutionary-psychological
approach sometimes applied in the context for mental disorders. A distinction is
sometimes made between a "medical model" or a "social model" of disorder and related
disability.
Genetic studies have indicated that genes often play an important role in the
development of mental disorders, via developmental pathways interacting with
environmental factors. The reliable identification of connections between specific genes
and specific categories of disorder has proven more difficult.
Environmental events surrounding pregnancy and birth have also been implicated.
Traumatic brain injury may increase the risk of developing certain mental disorders.
There have been some tentative inconsistent links found to certain viral infections, to
substance misuse, and to general physical health.
Abnormal functioning of neurotransmitter systems has been implicated, including
serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been
found in the size or activity of certain brains regions in some cases. Psychological
mechanisms have also been implicated, such as cognitive and emotional processes,
personality, temperament and coping style.
Social influences have been found to be important, including abuse, bullying and
other negative or stressful life experiences. The specific risks and pathways to particular
disorders are less clear, however. Aspects of the wider community have also been
implicated, including employment problems, socioeconomic inequality, lack of social
cohesion, problems linked to migration, and features of particular societies and cultures.

Laws and policies

Three quarters of countries around the world have mental health legislation.
Compulsory admission to mental health facilities (also known as Involuntary commitment
or sectioning), is a controversial topic. From some points of view it can impinge on
personal liberty and the right to choose, and carry the risk of abuse for political, social and
other reasons; from other points of view, it can potentially prevent harm to self and others,
and assist some people in attaining their right to healthcare when unable to decide in their
own interests. All human-rights oriented mental health laws require proof of the presence
of a mental disorder as defined by internationally accepted standards, but the type and
severity of disorder that counts can vary in different jurisdictions. The two most often
utilized grounds for involuntary admission are said to be serious likelihood of immediate
or imminent danger to self or others, and the need for treatment. Applications for someone
to be involuntarily admitted may usually come from a mental health practitioner, a family
member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that
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independent medical practitioners or other accredited mental health practitioners must
examine the patient separately and that there should be regular, time-bound review by an
independent review body. An individual must be shown to lack the capacity to give or
withhold informed consent (i.e. to understand treatment information and its implications).
Legal challenges in some areas have resulted in Supreme Court decisions that a person
does NOT have to agree with a psychiatrist's characterization of their issues as an
"illness", nor with a psychiatrist's conviction in medication, but only recognize the issues
and the information about treatment options.
Proxy consent (also known as substituted decision-making) may be given to a
personal representative, a family member or a legally appointed guardian, or patients may
have been able to enact an advance directive as to how they wish to be treated. The right to
supported decision-making may also be included in legislation. Involuntary treatment laws
are increasingly extended to those living in the community, for example outpatient
commitment laws (known by different names) are used in New Zealand, Australia, United
Kingdom and most of the United States.
The World Health Organization reports that in many instances national mental
health legislation takes away the rights of persons with mental disorders rather than
protecting rights, and is often outdated. In 1991, the United Nations adopted the Principles
for the Protection of Persons with Mental Illness and the Improvement of Mental Health
Care, which established minimum human rights standards of practice in the mental health
field. In 2006 the UN formally agreed the Convention on the Rights of Persons with
Disabilities to protect and enhance the rights and opportunities of disabled people,
including those with psychosocial disabilities. The term insanity, sometimes used
colloquially as a synonym for mental illness, is often used technically as a legal term.

Perception and discrimination

Stigma

The social stigma associated with mental disorders is a widespread problem. Some
people believe those with serious mental illnesses cannot recover, or are to blame for
problems. The US Surgeon General stated in 1999 that: "Powerful and pervasive, stigma
prevents people from acknowledging their own mental health problems, much less
disclosing them to others. Employment discrimination is reported to play a significant part
in the high rate of unemployment among those with a diagnosis of mental illness. Efforts
are being undertaken worldwide to eliminate the stigma of mental illness. Their methods
and outcomes have sometimes been criticized as counterproductive.
A study by Baylor University researchers found that clergy often deny or dismiss
the existence of the mental illness. In a study published in Mental Health, Religion and

74
Culture, researchers found that in a study of 293 Christian’s church members, more than
32 percent were told by their church pastor that they or their loved one did not really have
a mental illness. The study found these church members were told the cause of their
problem was solely spiritual in nature, such as a personal sin, lack of faith or demonic
involvement. Baylor researchers also found that women were more likely than men to
have their mental disorders dismissed by the church. All of the participants in both studies
were previously diagnosed by a licensed mental health provider as having a serious mental
illness, like bipolar disorder and schizophrenia, prior to approaching their local church for
assistance.

Media and general public

Media coverage of mental illness comprises predominantly negative depictions, for

example, of incompetence, violence or criminality, with far less coverage of positive
issues such as accomplishments or human rights issues. Such negative depictions,
including in children's cartoons, are thought to contribute to stigma and negative attitudes
in the public and in those with mental health problems themselves, although more
sensitive or serious cinematic portrayals have increased in prevalence. In the United
States, The Carter Center has created fellowships for journalists in South Africa, the U.S.,
and Romania, to enable reporters to research and write stories on mental health topics.
Former U.S. First Lady Rosalynn Carter began the fellowships not only to train reporters
in how to sensitively and accurately discuss mental health and mental illness, but also to
increase the number of stories on these topics in the news media. The general public has
been found to hold a strong stereotype of dangerousness and desire for social distance
from individuals described as mentally ill.

Violence

People with mental disorders are often afraid of violence against them. Over a quarter of
individuals diagnosed with "severe mental illness" accessing community mental health
services in a US inner-city area were found to have been victims of at least one violent
crime in a year, a proportion eleven times higher than the inner-city average. The
proportion is many times greater in every category of crime, including rape/sexual assault,
other violent assaults, and personal and property theft. Findings consistently indicate that it
is many times more likely that people diagnosed with a serious mental illness living in the
community will be the victims rather than the perpetrators of violence.
However, fear of unpredictable violent acts by people with mental illness is also
common. One US national survey indicated that a far higher percentage of Americans
rated individuals described as displaying the characteristics of a mental disorder (for
example Schizophrenia or Substance Use Disorder) as "likely to do something violent to
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others" compared to those described as being 'troubled'. Research indicates, on balance, a
higher than average number of violent acts by some individuals with certain diagnoses,
notably antisocial or psychopathic personality disorders, but conflicting findings about
specific symptoms (for example links between psychosis and violence in community
settings) - but the mediating factors of such acts are most consistently found to be mainly
socio-demographic and socio-economic factors such as being young, male, of lower socio-
economic status and, in particular, substance abuse (including alcohol). For the most
serious crimes, such as homicide, some diagnoses are over-represented in
arrests/convictions; however, although high-profile cases have leaded to fears that this has
increased due to deinstitutionalization, this does not reflect the evidence. Violence related
to mental disorder (in either direction) typically occurs in the context of complex social
interactions, often in a family setting rather than between strangers. It is also an issue in
health care settings and the wider community.

5.3. Suicide

Suicide (Latin suicidium, from sui caedere, to kill oneself) is the act of terminating
one's own life. Many dictionaries also note the metaphorical sense of "willful destruction
of one's self-interest". The World Health Organization noted that someone commits
suicide every 39 seconds, making it one of the leading causes of death in the world. There
are an estimated 10 to 20 million non-fatal attempted suicides every year. Self-sacrifice
for others is not usually considered suicide, as the goal is not to kill oneself but to save
another.
The predominant view of modern medicine is that suicide is a mental health
concern, associated with psychological factors such as the difficulty of coping with
depression, inescapable suffering or fear, or other mental disorders and pressures.
Suicide is sometimes interpreted in this framework as a "cry for help" and attention, or to
express despair and the wish to escape, rather than a genuine intent to die. Most people
who attempt suicide do not complete suicide on a first attempt; those who later gain a
history of repetitions have a significantly higher probability of eventual completion of
suicide.

Epidemiology

According to official statistics, about a million people die by suicide annually, more
than those murdered or killed in war. According to 2005 data, suicides in the U.S.
outnumber homicides by nearly 2 to 1 and ranks as the 11th leading cause of death in the
country, ahead of liver disease and Parkinson's disease. http://en.wikipedia.org/wiki/Suicide -
cite_note-7 According to a 2008 report from the Johns Hopkins Bloomberg School of Public
76
Health’s Center for Injury Research and Policy, the rate of suicide in the United States is
increasing for the first time in a decade. The increase in the overall suicide rate between
1999 and 2005 was due primarily to an increase in suicides among whites aged 40-64,
with white middle-aged women experiencing the largest annual increase. Worldwide
suicide rates have increased by 60% in the past 50 years, mainly in the developing
countries. Most suicides in the world occur in Asia, which is estimated to account for up to
60% of all suicides. According to the World Health Organization, China, India and Japan
may account for 40% of all world suicides.
Gender and suicide: In the Western world, males die much more often by means of
suicide than do females, although females attempt suicide more often. This pattern has
held for at least a century. Some medical professionals believe this stems from the fact that
males are more likely to end their lives through effective violent means (guns, knives,
hanging, etc.), while women primarily use more allure-prone methods such as overdosing
on medications. Others ascribe the difference to inherent differences in male/female
psychology. Greater social stigma against male depression and a lack of social networks of
support and help with depression are often identified as key reasons for men's
disproportionately higher level of suicides, since suicide as a "cry for help" is not seen by
men as an equally viable option. Typically males die from suicide three to four times more
often as females and not unusually five or more times as often. Excess male mortality from
suicide is also evident from data from non-western countries. In 1979–81, 74 territories
reported one or more cases of suicides. Two of these reported equal rates for both sexes:
Seychelles and Kenya. Three territories reported female rates exceeding male rates: Papua
New Guinea, Macau, and French Guiana. The remaining 69 territories had male suicide
rates greater than female suicide rates.
Ethnic groups and suicide: In the USA, Asian-Americans are more likely to die by
suicide than any other ethnic group. Caucasians die by suicide more often than African
Americans do. This is true for both genders. Non-Hispanic Caucasians are nearly 2.5 times
more likely to kill themselves than are African Americans or Hispanics.
Age and suicide: In the USA, males over the age of seventy die by suicide more
often than younger males. There is no such trend for females. Older non-Hispanic
Caucasian men are much more likely to kill themselves than older men or women of any
other group.
Season and suicide: People die by suicide more often during spring and summer.
The idea that suicide is more common during Christmas is a common misconception.
There is also potential risk of suicide in some people experiencing Seasonal affective
disorder. Some studies have found that elderly people are more likely to commit suicide
around their birthdays.

Impact of suicide
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 It is estimated that each suicide in the United States leaves an average of six
people intimately affected by the death, either as a spouse, parent, significant other,
sibling, or child of the deceased person. These people are referred to as survivors. Of
course, this estimate does not represent the total number of people who may be
affected by an individual suicide. For example, the suicide of a child may leave not only
his/her immediate family to make sense of the act, but also his/her extended family,
school and entire community. As with any death, family and friends of a suicide victim
feel grief associated with loss. However, suicide deaths leave behind a unique set of
issues for the survivors. Suicide survivors are often overwhelmed with psychological
trauma that vary depending on the factors comprising the event, including discovery of
the body. The survivor's trauma can leave him/her feeling guilty, angry, remorseful,
helpless, and confused. It can be especially difficult for survivors because many of their
questions as to the victim's final decision are left unanswered, even if a suicide note is left
behind (the "why" questions). Moreover, survivors often feel that they should have
intervened in some way to prevent the suicide, even if the suicide comes as a surprise
and there are no obvious warning signs. Along with this sense of regret and failure, there
is sometimes relief if the survivor's relationship with the victim was difficult, strained, or
otherwise complicated. Given this complex and conflicting set of emotions associated
with a loved one's suicide, survivors usually find it difficult to discuss the death with
others, even with those who have also faced the death of a loved one, but by some other
means. These feelings cause survivors to feel isolated from their network of family and
friends as well as often making them reluctant to form new relationships. Fortunately,
"survivor support groups" can offer counseling and help bring many of the issues
associated with suicide out into the open. They can also help survivors reach out to their
own friends and families who may be feeling similarly and thus begin the healing process.
In addition, counseling services and therapy can provide invaluable support to the
bereaved. Some such groups can be found online, providing a forum for discussion
amongst survivors of suicide. Economic impact. In the United States, deaths and injuries
from suicidal behavior represent $25 billion each year in direct costs, including health
care services, funeral services, autopsies and investigations, and indirect costs like lost
productivity. These costs may be counterbalanced by economic gains. Expenditure on
those who would have continued living is reduced, including pensions, social security,
health care services for those with brain disorders ("mentally ill"), as well as other normal
budgetary expenditure per head of living population.

Views on suicide

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 A. Medical

Modern medicine treats suicide as a mental health issue. Overwhelming or

persistent suicidal thoughts are considered an emotional crisis. Mental health
professionals advise that people who have expressed plans to kill themselves be
encouraged to seek help. This is especially relevant if the means (weapons, drugs, or
other methods) are available, or if the person has crafted a detailed plan for executing
the suicide. Medical personnel and mental health professionals frequently receive special
training to look for suicidal signs in those designated "as at risk" within that system.
Individuals suffering from depression are considered a high-risk group for suicidal
behavior. Suicide hotlines are widely available for people seeking help anonymously.
http://en.wikipedia.org/wiki/Suicide - cite_note-38 In the United States, individuals who express the
intent to harm themselves are automatically determined to lack the present mental
capacity to refuse treatment, and can be transported to the emergency department
against their will. An emergency physician will determine whether inpatient care at a
mental health care facility is warranted. This is sometimes referred to as being
"committed". A court hearing may be held to determine the individual's competence. In
most states, a psychiatrist may hold the person for a specific time period without a
judicial order. If the psychiatrist determines the person to be a threat to himself or
others, the person may be admitted involuntarily to a psychiatric treatment facility. This
period is usually of three days duration. After this time the person must be discharged or
appear in front of a judge. As in any judicial proceeding this person has a right to legal
counsel.

B. Criminal

In some jurisdictions, an act or incomplete act of suicide is considered to be a

crime. More commonly, a surviving party member who assisted in the suicide attempt
will face criminal charges. In Brazil, if the help is directed to a minor, the penalty is
applied in its double and not considered as homicide. In Italy and Canada, instigating
another to suicide is also a criminal offense. In Singapore, assisting in the suicide of a
mentally handicapped person is a capital offense. In India, abetting suicide of a minor or a
mentally challenged person can result in a possible death penalty, otherwise a maximum
1 year prison term with a possible fine. In North Korea, suicide is considered treason
against the party and is punishable by death. Due to Kim Il Sung's decree that the seed of
class enemies should be destroyed to the third generation, families of persons who have
committed suicide are sent to labor camps with life sentences.

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In Germany, the following laws apply to cases of suicide:

 Active euthanasia (killing on request) is prohibited by article 216 of the StGB

(Strafgesetzbuch, German Criminal Code), punishable with six months to five years
in jail
 German law interprets suicide as an accident and anyone present during suicide may
be prosecuted for failure to render aid in an emergency. A suicide legally becomes
emergency when a suicidal person loses consciousness. Failure to render aid is
punishable under article 323c of the StGB, with a maximum one year jail sentence.
 Article 212 can be used sometimes against a person found guilty of persuading
someone to commit suicide, with a charge of indirect manslaughter punishable by
five to fifteen years in jail
 Unlike other countries, helping a suicidal person to obtain the materials or
medication needed to carry out the act is not usually viewed as a criminal offense

C. Religious and cultural

Views on suicide have been influenced by cultural views on existential themes such
as religion, honor, and the meaning of life. The Abraham, Christian and Islamic religions
consider suicide a dishonorable act; it was often regarded as a serious crime and an
offense towards God due to religious belief in the sanctity of life. However, Christianity
and other religions have a concept of martyrdom, which is considered a highly
meritorious act and separate to suicide. Japanese views on honor and religion led to
seppuku, one of the most painful methods of suicide, to be respected as a means to
atone for mistakes or failure, or as a form of protest during the samurai era. In the 20th
century, suicide in the form of self-immolation has been used as a form of protest, and in
the form of kamikaze and suicide bombing as a military or terrorist tactic. Sati is a Hindu
funeral practice in which the widow would immolate herself on her husband's funeral
pyre, either willingly, or under pressure from the family and in-laws.

C. Philosophical / ethical

Some see suicide as a legitimate matter of personal choice and a human right
(colloquially known as the right to die movement), and maintain that no one should be
forced to suffer against their will, particularly from conditions such as incurable disease,
mental illness, and old age that have no possibility of improvement. Proponents of this
view reject the belief that suicide is always irrational, arguing instead that it can be a
valid last resort for those enduring major pain or trauma. This perspective is most
popular in continental Europe, where euthanasia and other such topics are commonly
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discussed in parliament, although it has a good deal of support. A narrower segment of
this group considers suicide something between a grave but condonable choice in some
circumstances and a sacrosanct right for anyone (even a young and healthy person) who
believes they have rationally and conscientiously come to the decision to end their own
lives. Notable supporters of this school of thought include German pessimist philosopher
Arthur Schopenhauer, and Scottish empiricist David Hume. Hume rejects the thesis that
suicide violates our duties to self. Sickness, old age, and other misfortunes can make life
sufficiently miserable that continued existence is worse than death. As to worries that
people are likely to attempt to take their lives capriciously, Hume replies that our natural
fear of death ensures that only after careful deliberation and assessment of our future
prospects will we have the courage and clarity of mind to kill ourselves? In the end,
Hume concludes that suicide “may be free of imputation of guilt and blame.” His position
is largely utilitarian, allied with a strong presumption of personal liberty. Adherents of
this view often advocate the abrogation of statutes that restrict the liberties of people
known to be suicidal, such as laws permitting their involuntary commitment to mental
hospitals.

A counterargument of this position is the fact that suicide violates any moral duties
to others. No doubt the suicide of a family member or loved one produces a number of
harmful psychological and economic effects. In addition to the usual grief, suicide
“survivors” confront a complex array of feelings. Various forms of guilt are quite
common, such as that arising from (a) the belief that one contributed to the suicidal
person's anguish, or (b) the failure to recognize that anguish, or (c) the inability to
prevent the suicidal act itself. Suicide also leads to rage, loneliness, and awareness of
vulnerability in those left behind. Indeed, the sense that suicide is an essentially selfish
act dominates many popular perceptions of suicide (Fedden 1938, 209). Still, some of
these reactions may be due to the strong stigma and shame associated with suicide, in
which case these reactions cannot, without logical circularity, be invoked in arguments
that suicide is wrong because it produces these psychological reactions (Pabst Battin
1996, 68–69). Suicide can also cause clear economic or material harm, as when the
suicidal person leaves behind dependents unable to support themselves financially.
Suicide can therefore be understood as a violation of the distinctive “role obligations”
applicable to spouses, parents, and other caretakers.
The most vociferous opponent of suicide was Immanuel Kant. Kant's arguments,
though they reflect earlier natural law arguments, draw upon his view of moral worth as
emanating from the autonomous rational wills of individuals. (Cholbi 2000) For Kant, our
rational wills are the source of our moral duty, and it is therefore a kind of practical
81
contradiction to suppose that the same will can permissibly destroy itself. Given the
distinctive worth of an autonomous rational will, suicide is an attack on the very source of
moral authority. To annihilate the subject of morality in one's person is to root out the
existence of morality itself from the world as far as one can, even though morality is an
end in itself. Consequently, disposing of oneself as a mere means to some discretionary
end is debasing humanity in one's person…
Suicide also is criticize on the position of utilitarian too: Suicide would be morally
forbidden because general adherence to a rule prohibiting suicide would produce better
overall consequences than would general adherence to a rule permitting suicide (Brandt
1975)

5.4. Study Cases

Depression/Suicide Case Study
http://healthinmind.com/english/depressionexample.htm

Margaret B. was married to a tender and loving second husband who catered to both
Margaret and her son from her previous marriage. However, she became increasingly
unhappy and felt unworthy of both her husband and her son. She thought they deserved a
better wife and mother. Her misery led her husband to persuade her to seek psychiatric
help. Unfortunately for her, the psychiatrist she consulted was inflexible in his therapy
style and was unable to change Margaret's view of herself as ugly and inadequate,
although her friends saw her as unusually attractive and bright.

One of Margaret's friends, Vi, met Margaret because the same psychiatrist was treating
both of them. Vi was fond of Margaret because they had similar problems, and they visited
each other often. On one visit to Margaret's house, Vi found Margaret extremely active
and quite chipper, in contrast to her usual depressive and fatigued demeanor. Most people
might have regarded that as a great sign of progress, but the change was too radical, and
Vi was suspicious. Immediately after leaving Margaret's house, Vi went to the nearest pay
telephone and called Margaret's husband Burl to tell him that there was something strange
about Margaret's behavior. Burl rushed home from his office and found Margaret lying in
the bathtub with her wrists slashed, bleeding profusely. He applied tourniquets and called
an ambulance. Because Vi was astute and Burl was concerned and quick, Margaret
survived. Had he been 30 minutes later, she almost certainly wouldn't have.

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 After this incident, Margaret went to a different psychiatrist who prescribed medication
that significantly improved her mood. She still was not an unusually happy person, but her
mood was normal, and she did not repeat her suicide attempt.

Margaret's case occurred a long time ago. Nevertheless, it illustrates some facts about
depression better than a modern case could. First, it shows that the wrong psychotherapy
can be worthless, or worse. Second, it demonstrates the danger of suicide if effective
medications and therapy are not administered. Third, Margaret's sudden surprising
improvement in mood before her suicide attempt is typical, a sign that the depressed
person has made a decision and is relieved about it. That is one of several possible danger
signs that should not be ignored (see the discussion of suicide for other signs that should
arouse concern).http://en.wikipedia.org/wiki/Transexuality - cite_note-2

Chapter 6
Medical ethics - compartment of bioethics.
Medical ethics is domain which exists as long as medicine is. It subject matter is
related to norms designed to guide the relation of medicine and community, the relation
between physicians and patients, physicians and the patient family and the relation
between physicians (in medical team). The main categories of medical ethics are:
professional authority of physician, patient trust, confidentiality. In what will follow two
subjects are unfolded: patient – doctor relation and the problem of confidentiality.

6.1. Medical ethics: patient-doctor relation

MaryJo Ludwig, MD. Physician-Patient Relationship. 1998, University of Washington. Last date modified: April 11,
2008. http://depts.washington.edu/bioethx/topics/physpt.html

There is considerable healing power in the physician-patient alliance. A patient who

entrusts himself to a physician's care creates ethical obligations that are definite and
weighty. Working together, the potential exists to pursue interventions that can
significantly improve the patient's quality of life and health status. Fiduciary derives from
the Latin word for "confidence" or "trust". The bond of trust between the patient and the
physician is vital to the diagnostic and therapeutic process. It forms the basis for the
physician-patient relationship. In order for the physician to make accurate diagnoses and
provide optimal treatment recommendations, the patient must be able to communicate all
relevant information about an illness or injury. Physicians are obliged to refrain from

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divulging confidential information. This duty is based on accepted codes of professional
ethics which recognize the special nature of these medical relationships.
The historical model for the physician-patient relationship involved patient dependence
on the physician's professional authority. Believing that the patient would benefit from the
physician's actions, a patient's preferences were generally overridden or ignored. For
centuries, the concept of physician beneficence allowed this paternalistic model to thrive.
During the second half of the twentieth century, the physician-patient relationship has
evolved towards shared decision making. This model respects the patient as an
autonomous agent with a right to hold views, to make choices, and to take actions based
on personal values and beliefs. Patients have been increasingly entitled to weigh the
benefits and risks of alternative treatments, including the alternative of no treatment, and
to select the alternative that best promotes their own values (for further discussion, see the
topic page on Informed Consent).
Many patients appreciate a physician who brings a personal touch to the physician-
patient encounter. They may feel more connected to a physician whose extracurricular
activities and interests make her seem more alive. Physicians choose to share parts of their
life stories according to their level of comfort. However, it is essential that the patient, and
the patient's concerns, be the focus of every visit.
Occasionally, a physician may face requests for services, such as contraception or
abortion, which raise a conflict for the physician. Physicians do not have to provide
medical services in opposition to their personal beliefs. In addition, it is acceptable to have
a nonjudgmental discussion with a patient regarding her need for the service, and to ensure
that the patient understands alternative forms of therapy. However, it is never appropriate
to proselytize. While the physician may decline to provide the requested service, the
patient must be treated as a respected, autonomous individual. Where appropriate, the
patient should be provided with resources about how to obtain the desired service.
There may be many barriers to effective physician-patient communication. Patients may
feel that they are wasting the physician's valuable time; omit details of their history which
they deem unimportant; be embarrassed to mention things they think will place them in an
unfavorable light; not understand medical terminology; or believe the physician has not
really listened and, therefore, does not have the information needed to make good
treatment decisions. Several approaches can be used to facilitate open communication
with a patient. Physicians should:

- sit down

- attend to patient comfort

- establish eye contact

- listen without interrupting

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 - show attention with nonverbal cues, such as nodding

- allow silences while patients search for words

- acknowledge and legitimize feelings

- explain and reassure during examinations

- ask explicitly if there are other areas of concern

- What happens when physicians and patients disagree?

One third to one half of patients will fail to follow a physician's treatment
recommendations. Labeling such patients "noncompliant" implicitly supports an attitude
of paternalism, in which the physician knows best. Patients filter physician instructions
through their existing belief system; they decide whether the recommended actions are
possible or desirable in the context of their everyday lives. Compliance can be improved
by using shared decision making. For example, physicians can say, "I know it will be hard
to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will
create and try to solve them together." Or, "I can give you a medication to help with your
symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would
you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to
consider counseling yet. Would you be willing to take this information and find out when
the next support group meets?" Or, "Sometimes it's difficult to take medications, even
though you know they are important. What will make it hard for you to take this
medication?"
Competent patients have a right to refuse medical intervention. Dilemmas may arise
when a patient refuses medical intervention, but does not withdraw from the role of being
a patient. For instance, an intrapartum patient, with a complete placenta previa, who
refuses to undergo a cesarean delivery, often does not present the option for the physician
to withdraw from participation in her care (see the Maternal/Fetal Conflict topic page). In
most cases, choices of competent patients must be respected when the patient cannot be
persuaded to change them.
Physicians will sometimes encounter a patient whose needs, or demands, strain the
therapeutic alliance. Many times, an honest discussion with the patient about the
boundaries of the relationship will resolve such misunderstandings. The physician can
initiate a discussion by saying, "I see that you have a long list of health concerns.
Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most
urgent problem today and reschedule you for a longer appointment. That way, we can be
sure to address everything on your list." Or, "I know that it has been hard to schedule this
85
appointment with me, but using abusive language with the staff is not acceptable. What do
you think we could do to meet everybody's needs?"
There may be occasions when no agreeable compromise can be reached between the
physician and the patient. And yet, physicians may not abandon patients. When the
physician-patient relationship must be severed, the physician is obliged to provide the
patient with resources to locate ongoing medical care.
Under certain conditions, a physician should strongly encourage specific actions. When
there is a high likelihood of harm without therapy, and treatment carries little risk, the
physician should attempt, without coercion or manipulation, to persuade the patient of the
harmful nature of choosing to avoid treatment.

Court orders may be invoked to override a patient's preferences. However, such

disregard for the patient's right to noninterference is rarely indicated. Court orders may
have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself
or others; with concern for mental incompetence; or when the patient is a sole surviving
parent of dependent children. However, the use of such compulsory powers is inherently
time-limited, and often alienates the patient, making him less likely to comply once he is
no longer subject to the sanctions.

When can a patient be held for medical treatment against her will? This is a
controversial area in law, and the law varies by state. The ethical justification for treatment
of a patient against his will is based on balancing of the risk to the public versus respecting
the patient's personal freedom. If the magnitude of risk to the public is great, many states
allow for involuntary treatment. For example, a patient with active pulmonary tuberculosis
that is resistant to multiple anti-tuberculosis medications presents a grave risk to the public
if her condition is untreated. This arises in part because of the high infectivity of active
pulmonary tuberculosis and the relatively small risk to the patient from oral medications
for TB treatment. Other conditions for which non-treatment pose little or no threat to the
public, such as untreated acute leukemia, can rarely have involuntary treatment justified.

Advance Care Planning

Robert A. Pearlman, MD, MPH. Advance Care Planning. University of Washington School of Medicine. Last date
modified: April 11, 2008

http://depts.washington.edu/bioethx/topics/adcare.html

An arrangement for efficiency of care is advance care planning. Advance care planning is
a process aimed at extending the rights of competent adults to guide their medical care
through periods of decisional incapacity. The process, when accomplished
comprehensively, involves three steps: (1) thinking through one's values and preferences,
(2) talking about one's values and preferences with others, and (3) documenting them.
86
Advance care planning is the process. Advance directives usually are the written
documents that provide information about the patient's wishes and/or her designated
spokesperson. Verbal directives may be ethically valid, but most patients and health care
providers prefer written documentation in the form of official forms. If official forms are
not used, health care providers should document the result of their advance care planning
conversations in a medical record progress note. The goals of advance care planning are
four-fold. In the event of decisional incapacity, they are to:

- maximize the likelihood that medical care serves the patients goals,

- minimize the likelihood of over- or undertreatment,

- reduce the likelihood of conflicts between family members (and close friends) and
health care providers, and

- minimize the burden of decision making on family members or close friends.

As a health care provider who engages her patient in advance care planning, you can
expect to better understand your patient's views about the goals of medicine, his preferred
approach to end of life care, what makes life worth living, as well as his fears about
medical interventions and loss of dignity. In addition, you can expect to have a discussion
that clarifies misunderstandings. For example, patients often think that cardiopulmonary
resuscitation is successful 80% of the time, that mechanical ventilation is a fancy word for
nasal prongs, and that coma patients still have the ability to enjoy life.
You can also expect to have better communication with the patient's family members or
loved ones because there should be enhanced shared understanding of the patient's values
and wishes. Thus, you can expect to have fewer conflicts with family members about the
approach to end of life care.
Advance directives will not be the outcome of most advance care planning. At
minimum patients should become familiar with the concept and rationale for advance care
planning. Some patients will want to mull things over; others will want to discuss the topic
with their close friends or family and health care providers. Fewer will be ready to sign
documents and even fewer will be interested in personalizing their advance directives so
that they are clear and contain pertinent information with clinical relevance.
We usually think of doing advance care planning with patients who are at higher risk
for decisional incapacity. You should consider having a conversation about this with
patients with the following conditions:

- at risk for strokes (e.g., those with hypertension)

- experiencing early dementia

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 - engaging in risky behavior that is associated with head trauma and coma (e.g.,
motorcyclists, riding in cars without seat belts)

- experiencing severe, recurrent psychiatric illnesses

- terminal illness

It is unknown when or where advance care planning should ideally occur. It is generally
thought that this should occur initially in the outpatient setting, and then be reviewed upon
admission to and discharge from inpatient settings. It is also recommended that whenever
there is a significant change in a patient's social or health status, the patient's views about
advance care planning should be reviewed.
You can raise advance care planning as one of many health promotion activities. These
discussions are aimed at avoiding harms (over- and undertreatment), and promoting
benefits (treatments tailored to the patient's goals). You should reassure the patient that
raising this issue does not mean that there is something unspoken to worry about. You also
may tell the patient that this topic is difficult for many patients and that you will
understand if she does not want to come to any conclusions during this discussion.
When having a discussion about advance care planning, the following questions are
recommended:

- Who should speak on your behalf if you become so sick you can't speak for
yourself?

- Are there any circumstances that you've heard about through the news or TV where
you've said to yourself, "I would never want to live like that?" If so, what are they
and why do you feel this way about them?

- Are there any life-sustaining treatments that you would not want to receive under
any circumstances? If so, what are they and why do you feel this way about them?

- Some people have more concerns about the way they will die or dying than death
itself. Do you have any fears or concerns about this?

- In the event that you are dying, where do you want to receive medical care?

- Should your current preferences be strictly applied to future situations or serve as a

general guide to your family (or loved ones)?

- How should I advise a patient if she doesn't have anyone to name as a proxy? You
should inform the patient that the best course of action under these circumstances is
to write down her wishes and give a copy to her health care providers. She should

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 fill out a legal form, such as a living will, with as much detail as possible, and then
include a personalized statement to provide a better understanding of her wishes.

- How should I advise a patient if he believes that some family members will disagree
with his wishes? The patient should be informed that the best way to prevent
disagreements is to communicate with everyone ahead of time to let them know
who has been picked as a spokesperson and what kind of approach to medical care
he wants.

6.2. The problem of confidentiality

Kelly A. Edwards, M.A. Confidentiality. University of Washington, 1998

http://depts.washington.edu/bioethx/topics/confiden.html

Confidentiality is one of the core tenets of medical practice. Yet daily physicians face
challenges to this long-standing obligation to keep all information between physician and
patient private.
Where does the duty of confidentiality come from? Patients share personal information
with physicians. You have a duty as a physician to respect the patient's trust and keep this
information private. This requires the physician to respect the patient's privacy by
restricting access of others to that information. Furthermore, creating a trusting
environment by respecting patient privacy can encourage the patient to be as honest as
possible during the course of the visit. (See also Physician-Patient Relationship.)
The obligation of confidentiality both prohibits the physician from disclosing
information about the patient's case to other interested parties and encourages the
physician to take precautions with the information to ensure that only authorized access
occurs. Yet the context of medical practice does constrain the physician's obligation to
protect patient confidentiality. In the course of caring for patients, you will find yourself
exchanging information about your patients with other physicians. These discussions are
often critical for patient care and are an integral part of the learning experience in a
teaching hospital. As such, they are justifiable so long as precautions are taken to limit the
ability of others to hear or see confidential information. Computerized patient records pose
new and unique challenges to confidentiality. You should follow prescribed procedures for
computer access and security as an added measure to protect patient information.
What kinds of disclosure are inappropriate? Inappropriate disclosure of information can
occur in clinical settings. When pressed for time, the temptation to discuss a case in the
elevator may be great, but in that setting it is very difficult to keep others from hearing the
information exchanges. Similarly, extra copies of handouts from teaching conferences that
89
contain identifiable patients should be removed at the conclusion of the session. The
patient's right to privacy is not being respected in these sorts of cases.
Confidentiality is not an absolute obligation. Situations arise where the harm in
maintaining confidentiality is greater than the harm brought about by disclosing
confidential information. In general, two such situations that may give rise to exceptions
exist. In each situation, you should ask - will lack of this specific information about this
patient put a specific person you can identify at high risk of serious harm? Legal
regulations exist that both protect and limit your patient's right to privacy, noting specific
exceptions to that right. These exceptions follow.

Exception 1:

Concern for the safety of other specific persons. On the one hand, the law restricts access
to medical information and records. On the other, clinicians have a duty to protect
identifiable individuals from any serious threat of harm if they have information that could
prevent the harm. As mentioned above, the determining factor in justifying breaking
confidentiality is whether there is good reason to believe specific individuals (or groups)
are placed in serious danger depending on the medical information at hand. The most
famous case of this sort of exception is that of homicidal ideation, when the patient shares
a specific plan with a physician or psychotherapist to harm a particular individual. The
court has required that traditional patient confidentiality be breached in these sorts of
cases.

Exception 2:

Concern for public welfare. In the most clear cut cases of limited confidentiality, you are
required by state law to report certain communicable/infectious diseases to the public
health authorities. In these cases, the duty to protect public health outweighs the duty to
maintain a patient's confidence. From a legal perspective, the State has an interest in
protecting public health that outweighs individual liberties in certain cases. For instance,
reportable diseases in Washington State include (but are not limited to): AIDS and Class
IV HIV, hepatitis A and B, measles, rabies, tetanus, and tuberculosis. Suspected cases of
child, dependent adult and elder abuse are reportable, as are gunshot wounds. Local
municipal code and institutional policies can vary regarding what is reportable and
standards of evidence required. It is best to clarify institutional policy when arriving at a
new site.

What if a family member asks how the patient is doing? While there may be cases where
the physician feels compelled to share information regarding the patient's health and
prognosis with, for instance, the patient's inquiring spouse, without explicit permission
from the patient it is generally unjustifiable to do so. Except in cases where the spouse is at
90
 specific risk of harm directly related to the diagnosis, it remains the patient's, rather than
the physician's, obligation to inform the spouse.

6.3. Study cases

Case 1

Physician-Patient Relationship: http://depts.washington.edu/bioethx/topics/physptd1.html

During a visit to her family physician, a 35-year-old woman discloses that she suffers from
anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular
menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for
several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She
demonstrates a good understanding of the diagnosis and the recommended therapy for
anorexia. Despite receiving a variety of resource information, the patient refuses any
medical intervention. She continues to present to the family physician, offering a variety of
somatic complaints.

When a patient's preferences conflict with a physician's goal to restore health, which ethical
principle should prevail, patient autonomy or physician beneficence? Does the patient's
depression render her incompetent to refuse treatment for her anorexia?

Case 2

Advance Care Planning: http://depts.washington.edu/bioethx/topics/adcared1.html

An elderly woman told her daughters that if she ever ended up with dementia she wouldn't
want to live like that. Years later she developed senile dementia and her daughters had her
move into a nursing home. Although she did not recognize family or friends, she enjoyed
the company of others and the nursing home's cat. When she stopped eating, her daughters
were asked whether she should receive a feeding tube.

Should the daughters consider her previously stated wishes as an advance directive?

Case 3

Confidentiality:

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Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his
wife of the results and claims he is not ready to tell her yet.

What is your role legally? What would you say to your patient?

Chapter 7
Scientific research and clinical trials in the biomedical world from the
perspective of bioethics.
7.1. Ethical issues in human subjects research
After Timothy C. Callahan, PhD. Research Ethics. University of Washington School of Medicine.
http://depts.washington.edu/bioethx/topics/resrch.html

European Commotion.. European Textbook on Ethics in Research. Luxembourg: Publications Office of

the European Union, 2010

Scientific research is a systematic investigation designed to develop generalisable

knowledge. There are many reasons for holding that research is something to be
encouraged. Several reasons might be given for viewing research as a valuable activity:
• Research has brought a better quality of life and increased welfare.
We owe our present standard of living to the huge amount of research that has made it
possible – huge improvements in economic efficiency, health care and wellbeing only
exist because of research, and it is reasonable to expect that this will only continue.
• Huge numbers of lives have been saved.
If we think about medical research in particular, huge numbers of lives have been saved by
medical advances. Moreover, advances in our basic understanding of nutrition, sanitation
and the environment have had a profound impact on life expectancy and the quality of life.
• Knowledge may be good for its own sake.
Finally, even where new knowledge has no real world applications we may still think that
we are in some way enriched by understanding more about ourselves, the universe we live
in and our relationship
The ethical issues in human subjects’ research have received increasing attention over
the last 80 years; because of same public scandals arise as a result of abuse on humans in
scientific research. Among these scandals are Experiments carried out on concentration
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camp prisoners included involuntary sterilization, subjection to radiation, freezing to
induce hypothermia, infection of research subjects with malaria and tuberculosis (TB), and
many other unethical experiments, conducted without the consent of the research subjects,
and often leading predictably to extreme pain, mutilation and death.
The Milgram experiments, United States, 1961-63 designed to investigate people’s
obedience to authority. In these experiments the research subjects were deceived about the
nature of the research and led to believe that they (in the process of a different experiment)
were administering electric shocks to other research participants. The aim of the research,
which turned out to be very distressing for many of the subjects, was to see how far they
would be willing to go in risking harm to the other research participants. (10) Surprisingly,
the result was that most people (approximately 65 %) were willing to continue to the end
of the experiment, even though had the electric shocks been real they would have been
seriously endangering the other research participant. One observation that might be made
about this research is that science that is ethically questionable is not always scientifically
weak or unimportant, since from this research we learnt that people will often obey
authorities even if this involves behavior that they would normally judge to be unethical,
which has important implications for psychology, sociology and governance.
Tuskegee syphilis study, United States, 1932-72. This was a clinical study carried out
between 1932 and 1972 in Tuskegee, Alabama, by the US Public Health Service. About
400 mostly illiterate African-Americans with syphilis were recruited into the study as well
as two hundred healthy controls. The aim of the study was to observe the natural
progression of the disease when left untreated, and in particular to compare the
progression of the disease in African-Americans with the results of an earlier retrospective
study of the disease in Europeans. The participants were not told that they were in a
medical trial, and the tests were described as “special free treatments”. At the outset of the
trial there was no effective treatment for syphilis. However, by 1947 penicillin had
become the standard – effective – treatment for syphilis. The researchers blocked the study
subjects from receiving effective treatment, going so far as to prevent the subjects from
being conscripted into the armed forces since that would have necessitated them being
treated. At the end of the study only 74 subjects remained alive, 40 of their wives had been
infected and 19 children had been born with syphilis, some of which might have been
prevented if these men had been given treatment. The aftermath of Tuskegee led to the
formalization of ethics review in America, and was also influential on the 1975 revision of
the Declaration of Helsinki which introduced the requirement for the independent review
of all research.
International documents

Nowadays Institutional Review Boards for the Protection of Human Subjects (IRB's)
have been established at most institutions that undertake research with humans. These
committees are made up of scientists, clinical faculty, and administrators who review
research according to the procedures set out in nationals Regulations. The scientific
protocol is review accordingly to some principles mentioned in chapter 2: autonomy or
respect for person, beneficence and justice.

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 There are several ethical issues that must be considered when designing research that
will utilize participants who are human beings.
- The primary concern of the investigator should be the safety of the research
participant. This is accomplished by carefully considering the risk/benefit ratio,
using all available information to make an appropriate assessment and continually
monitoring the research as it proceeds.
- The scientific investigator must obtain informed consent from each research
participant. This should be obtained in writing (although oral consents are
sometimes acceptable) after the participant has had the opportunity to carefully
consider the risks and benefits and to ask any pertinent questions. Informed consent
should be seen as an ongoing process, not a singular event or a mere formality.

- The investigator must enumerate how privacy and confidentiality concerns will be
approached. Researchers must be sensitive to not only how information is protected
from unauthorized observation, but also if and how participants are to be notified of
any unforeseen findings from the research that they may or may not want to know.

- The investigator must consider how adverse events will be handled; who will
provide care for a participant injured in a study and who will pay for that care are
important considerations.

- In addition, before enrolling participants in an experimental trial, the investigator

should be in a state of "equipoise," that is, if a new intervention is being tested
against the currently accepted treatment, the investigator should be genuinely
uncertain which approach is superior. In other words, a true null hypothesis should
exist at the onset regarding the outcome of the trial.

Inform consent

For an informed consent to be ethically valid in research setting, the following components
must be present:

- Disclosure: The potential participant must be informed as fully as possible of the

nature and purpose of the research, the procedures to be used, and the expected
benefits to the participant and/or society, the potential of reasonably foreseeable
risks, stresses, and discomforts, and alternatives to participating in the research.
There should also be a statement that describes procedures in place to ensure the
confidentiality or anonymity of the participant. The informed consent document
must also disclose what compensation and medical treatment are available in the
case of a research-related injury. The document should make it clear whom to
contact with questions about the research study, research subjects' rights, and in case
of injury.
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 - Understanding: The participant must understand what has been explained and must
be given the opportunity to ask questions and have them answered by one of the
investigators. The informed consent document must be written in lay language,
avoiding any technical jargon.

- Voluntariness: The participant's consent to participate in the research must be

voluntary, free of any coercion or promises of benefits unlikely to result from
participation.

- Competence: The participant must be competent to give consent. If the participant is

not competent due to mental status, disease, or emergency, a designated surrogate
may provide consent if it is in the participant's best interest to participate. In certain
emergency cases, consent may be waived due to the lack of a competent participant
and a surrogate.

The potential participant must be given the opportunity to give full consideration
regarding the decision whether or not to participate in the research study without undue
influence from his or her physician, family, or the scientific investigator. No informed
consent may contain any exculpatory language by which the participant waives any legal
rights or releases the investigator or sponsor from liability for negligence.
As a general rule, deception is not acceptable when doing research with humans. Using
deception jeopardizes the integrity of the informed consent process and can potentially
harm your participants. Occasionally exploring your area of interest fully may require
misleading your participants about the subject of your study. For example, if you want to
learn about decision-making practices of physicians without influencing their practice-
style, you may consider telling them you are studying "communication behaviors" more
broadly. The IRB will review any proposal that suggests using deception or
misrepresentation very carefully. They will require an in-depth justification of why the
deception is necessary for the study and the steps you will take to safeguard your
participants.

7.2. Ethical issues in nonhuman subjects research

The scientific rationale underlying the use of animals in biomedical research is that a
living organism provides an interactive, dynamic system that can be observed and
manipulated experimentally in order to investigate mechanisms of normal function and of
disease. As a result, a greater understanding of living systems can be attained and this
knowledge can be generalized to other species including humans, facilitating the
development of effective therapies. One particular use of animals in research is in the
development and use of animal models of particular human physiological functions (e.g.,
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 immune response, cardiovascular function, vision) and diseases. These are commonly
used in all areas of biomedical research and have contributed significantly to medical
progress.

The use of animals in research must be done under some ethical request. Nuffield council
of bioethics elaborate guide for involving morally the animals in research. Accordingly
to this guide, animal experiments can only be carried out if the desired results cannot be
achieved by another method, and a range of replacement methods have been developed in
different areas of research. Report gives examples of replacement, methods called Three
Rs.

- Refinement: Improvement of all aspects of the lifetime experience of animals to

reduce suffering and improve welfare.
- Reduction: The use of fewer animals in each experiment without compromising
scientific output and the quality of biomedical research and testing, and without
compromising animal welfare.
- Replacement: The use of methods that permit a given scientific purpose to be
achieved without conducting experiments or other scientific procedures on living
animals.
See: http://www.nuffieldbioethics.org/sites/default/files/The%20ethics%20of%20research
%20involving%20animals%20-%20short%20guide.pdf

7.3. Study Cases.

Research Ethics: http://depts.washington.edu/bioethx/topics/resrchd1.html

Case 1

Mrs. Franklin, an 81-year-old Alzheimer's patient hospitalized under your care has been
asked to participate in a clinical trial testing a new drug designed to help improve memory.
You were present when the clinical investigator obtained a signed informed consent from
Mrs. Franklin a few days ago. However, when you visit Mrs. Franklin today and ask her if
she is ready to begin the study tomorrow, she looks at you blankly and seems to have no
idea what you are talking about.

What should you do?

Case 2

During the conduct of a large clinical trial of an investigational drug, preliminary analysis
of results show that there were three times as many participants in the experimental group
who experienced severe nausea and vomiting compared to the control group. Two of the
cases were severe enough to require that the participants be hospitalized. This is despite
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the fact that the preliminary analysis shows that there may be a moderate benefit with the
drug. What should be done?

References and Further Reading

1. Anscombe,Elizabeth “Modern Moral Philosophy,” Philosophy, 1958, Vol. 33,
reprinted in her Ethics, Religion and Politics (Oxford: Blackwell, 1981).

2. Aristotle, Nichomachean Ethics, in Barnes, Jonathan, ed., The Complete Works of

Aristotle (Princeton, N.J.: Princeton University Press, 1984).

3. Ayer, A. J., Language, Truth and Logic (New York: Dover Publications, 1946).

4. Baier, Kurt, The Moral Point of View: A Rational Basis of Ethics (Cornell University
Press, 1958).

5. Bentham, Jeremy, Introduction to the Principles of Morals and Legislation (1789), in

The Works of Jeremy Bentham, edited by John Bowring (London: 1838-1843).

6. Hare, R.M., Moral Thinking, (Oxford: Clarendon Press, 1981).

7. Hare, R.M., The Language of Morals (Oxford: Oxford University Press, 1952).

8. Hobbes, Thomas, Leviathan, ed., E. Curley, (Chicago, IL: Hackett Publishing

Company, 1994).

9. Hume, David, A Treatise of Human Nature (1739-1740), eds. David Fate Norton,
Mary J. Norton (Oxford; New York: Oxford University Press, 2000).

10.Kant, Immanuel, Grounding for the Metaphysics of Morals, tr, James W. Ellington
(Indianapolis: Hackett Publishing Company, 1985).

11.Locke, John, Two Treatises, ed., Peter Laslett (Cambridge: Cambridge University
Press, 1963).

12.MacIntyre, Alasdair, After Virtue, second edition, (Notre Dame: Notre Dame
University Press, 1984).

13.Mill, John Stuart, “Utilitarianism,” in Collected Works of John Stuart Mill, ed., J.M.
Robson (London: Routledge and Toronto, Ont.: University of Toronto Press, 1991).

14. Moore, G.E., Principia Ethica, (Cambridge: Cambridge University Press, 1903).

15.Ockham, William of, Fourth Book of the Sentences, tr. Lucan Freppert, The Basis of
Morality According to William Ockham (Chicago: Franciscan Herald Press, 1988).
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16.Plato, Republic, 6:510-511, in Cooper, John M., ed., Plato: Complete Works
(Indianapolis: Hackett Publishing Company, 1997).

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