1.

Introduction to ethics

1
Introduction ….
 At one time, health care ethics was the domain of
health care professionals
 Doctors, nurses, and the other care givers in the allied
health care professions made most of the decisions
that pertained to the ethics of their occupations
 While patients were often consulted about some of
the medical decisions which affected them, they were
usually passive insofar as ethical decisions were
concerned

2
Introduction ….
 Today, however, the situation has changed
considerably
 Because of the technical revolution in both
information and in the provision of health care,
patients are now an integral part of the medical
decision-making process
 Moreover, and perhaps more significantly, the ethical
questions to which science, medicine, and health care
give rise, affect the present and future well-being of
people, whether they are sick or not

3
Introduction ….
 For example, the manner in which health care is
financed and provided now concerns everyone
 The escalation of health care costs is fundamentally
an ethical issue, as is the need to provide health care
based upon human need rather than upon consumer
ability to pay
 Many situations arise in the practice of medicine and
in medical research that present problems requiring
moral decisions
 A few of these can be illustrated by the following
questions
4
Introduction ….
 Should a parent have a right to refuse immunization
for his or her child?
 Is basic health care a right or a privilege?
 Does public safety supersede an individual’s right?
 Who dictates client care – the client, the physician, the
attorney, or the medical insurance carrier?
 Should children with serious birth defects be kept
alive?
 Should a woman be allowed an abortion for any
reason?
5
Introduction ….
 Should everyone receive equal treatment in medical
care?
 Should people suffering from a genetic disease be
allowed to have children?
 Should individuals be allowed to die without
measures being taken to prolong life?
 None of these questions has an easy answer, and one
hopes never to have to deal with them
 The decision for these issues is subjective, hence need
to refer legal and ethical standards
6
Introduction …
 ethics is a very personal concept and personal decision
 Blanchard and Peale developed three questions to serve as an “ethics
check” that is a useful tool for persons facing an ethical dilemma
1. is it legal or in accordance with institutional or company policy?
2. does it promote a win–win situation with as many individuals
(client/employee/employer) as possible?
3. how would I feel about myself were I to read about my decision or
action in the daily newspaper? how would my family feel? can I look
myself in the mirror?
 If the answer to any one of the three questions is no, the action is
unethical
 If the answer to all three questions is yes, the action is ethical

7
Introduction …
 Coach Thee suggests that leaders, managers, health services
providers and students ask and answer the following eight
questions to test the rightness or wrongness of their actions
1. is it legal?
2. does it comply with my/our rules and guidelines?
3. is it in sync with my personal and organizational values?
4. will I be comfortable and guilt free if I do it?
5. does it match my commitments and promised guarantees?
6. would I do it to my family or friends?
7. would I be perfectly okay with someone doing it for me?
8. would the most ethical person I know do it?

8
Ethics and Morality

 No matter what our social, cultural, economic or professional

backgrounds are, we are all in the business of practicing ethics
on a daily basis.
 We have certain values (things we think are important for their
own sake) and beliefs (views about the nature of existence and
the way we understand the world to be)
 For example, we hold values such as charity and generosity
 Ethics is about carefully studying the values that actually do
guide our attitudes and behaviors in given contexts, and it is
about exploring what values ought to guide our attitudes and
behaviors

9
Ethics and Morality …
 ethics refers to standards of behavior that tell us how
human beings ought to act in the many situations in
which they find themselves as friends, parents,
businesspeople, professionals…
 Ethics is:
 A moral Principle
 What is good and bad
 What is right and wrong
 Based on value system

10
Ethics and Morality …

 Ethical norms are not universal – depends on the

sub culture of the society
 Ethics is not following the law
 Ethics is not following culturally accepted norms
 Ethics is not science

11
Ethics and Morality …
 Morality: is conformity to ideals of right human conduct
 Morality is the quality of being in accord with standards
of right or good conduct
 Morality is looking at how good or bad our conduct is,
and our standards about conduct
 Ethics is used to refer to the formal study of those
standards or conduct
 Morals are the concepts of what is “good” and what is
“bad” and how one should behave
 Ethics is primarily a matter of knowing whereas morality
is a matter of doing

12
What is Health Ethics?
 Health ethics is the branch of ethics that deals with
ethical issues in health, health care, medicine and
science
 It involves discussions about treatment choices and
care options that individuals, families, and health care
providers must face
 It requires a critical reflection upon the relationships
between health care professionals and those they
serve, as well as the programs, systems, and
structures developed to improve the health of a
population
13
What is Health Ethics?...

 few specific examples of health ethics issues include:

 Making decisions about end-of-life care
 Determining whether to allocate funds to the
treatment of disease or the promotion of health
 Critically examining the discrepancies in health
status between populations and our ethical
obligations to ensure equitable access to health
services
 Ensuring ethical conduct in health research

14
health ethics and the law

 Laws are societal rules or regulations that are advisable or

obligatory to observe
 Ethics is a set of moral standards and a code for behavior that
govern an individual’s interactions with other individuals and
within society
 Laws are mandatory rules to which all citizens must adhere or
risk criminal liability
 Ethics often relate to morals and set forth universal goals that
we try to meet,
 However, there is no temporal penalty for failing to meet the
goals as there is apt to be in law

15
health ethics and the law…

 Both ethics and law are normative frameworks, i.e. they

define how people ought to act
 Ethics and law are often complementary; for example, a
legal decree might require a person to do what is ethically
required (such as refrain from harming others)
 However, something can be legal and yet conflict with
ethical standards and vis-versa
 For instance, there are no laws prohibiting countries from
investing vast public resources in the development of
medical interventions of minor public health significance,
such as a cure for male pattern baldness

16
health ethics and the law…

 It is not ethical to devote their resources to minor public health

significance rather than reducing the burden of life threatening
disease
 disrespectfully to one’s parents may be considered unethical,
even though it is not against the law
 It is also possible that individual laws may themselves violate
important ethical principles
 Ethical analysis of the law can stimulate important reform
efforts or acts of civil disobedience
 while ethics and law are different, ethics remains a foundation
for law, and often provides a justificatory basis for legal norms

17
 Rationale of Health Ethics
 Nowadays, conflicts of interests between the
government and medical institutions, between medical
institutions and medical personnel, between physicians
and patients are getting more and more serious and
complex
 High technologies not only brought us hopes of cure
but have also created a heavy economic burden
 The ethical dilemmas of high technology medicine-
brain death, organ transplantation, and concerns about
quality of life-have become increasingly prominent

18
Rational…
 The attainment of highest possible level of health is
highly dependent, among other things, on the
regulation of health service delivery and the
application of suitable ethical principles
 Ethics is and always has been an essential component
of medical practice
 Ethical principles such as respect for persons,
informed consent and confidentiality are basic to the
physician-patient relationship

19
Rational…
 The study of ethics prepares public health
professionals, health and medical practitioners and
students to recognize difficult situations and to deal
with them in a rational and principled manner
 Ethics is also important in professionals’ interaction
with society and their colleagues and for the conduct
of medical research
 It provides standards of behavior for health workers

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Fundamental ethical principles

 Four fundamental principles of ethics have

usually been recognized and widely discussed
in moral literature:
1. Autonomy,
2. Beneficence,
3. Non-maleficence,
4. Justice

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Autonomy
 Two Greek words: autos (“self”), and nomos (“rule”),
giving it the literal meaning of “self-rule” or “self-
governance”.
 Implies an individual who is master of himself or herself
and can act, make free choices and take decisions
without the constraint of another
 Respect for Persons:
 autonomous agents,

 persons with diminished autonomy are entitled to

protection
 Respect for autonomy is the basis for informed consent
22
Autonomy…
 The application starts with the respect for a person’s right by
providing them with adequate and relevant information
 The process of informed consent is begun when initial
contact is made with a prospective subject and continues
throughout the course of the study – in research
 Pre-conditions of autonomy are
 Competence (the capacity to be a moral agent)
 Liberty or freedom
 Individual autonomy may be diminished or completely absent,
as in the case of minor children, mentally handicapped or
incapacitated persons, prisoners, etc.

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Informed consent
 The application of autonomy is seen in the informed consent
process
 Informed consent in ethics usually refers to the idea that a
person must be fully informed about and understand the
potential benefits and risks of their choice of treatment
 Uninformed person is at risk of mistakenly making a choice
not reflective of his or her values or wishes
 Patients can elect to make their own medical decisions, or can
delegate decision-making authority to another party
 The value of informed consent is closely related to the values
of autonomy and truth telling
 "informed consent" correlates to informed refusal

24
Beneficence
 The term beneficence refers to actions that promote the
well being of others
 Beneficence, or doing good, involves promoting
another’s welfare,
 In the medical context, this means acting in an
individual's best interest and in a manner which benefits
others
 doctors must take positive steps to help people and not
merely refrain from harm
 However, uncertainty surrounds the precise definition of
which practices do in fact help patients
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Non-maleficence
 the concept of non-maleficence is embodied by the
phrase, "first, do no harm," or the Latin, primum non
nocere
 Many consider that should be the main or primary
consideration (hence primum): that it is more important
not to harm your patient, than to do them good
 This is partly because enthusiastic practitioners are prone
to using treatments that they believe will do good,
without first having evaluated them adequately to ensure
they do no (or only acceptable levels of) harm

26
Non-maleficence…
 Much harm has been done to patients as a result, as in the
saying, "The treatment was a success, but the patient died“
 It is not only more important to do no harm than to do good; it
is also important to know how likely it is that your treatment
will harm a patient
 In practice, however, many treatments carry some risk of harm
 In some circumstances, e.g. in desperate situations the
outcome without treatment will be grave,
 Hence, risky treatments that stand a high chance of harming
the patient will be justified, as the risk of not treating is also
very likely to do harm

27
Non-maleficence…
 So the principle of non-maleficence is not absolute, and balances
against the principle of beneficence (doing good), as the effects
of the two principles together often give rise to a double effect
 Double effect refers to two types of consequences that may be
produced by a single action, and in medical ethics it is the
combined effect of beneficence and non-maleficence
 Depending on the cultural consensus conditioning (expressed by
its religious, political and legal social system) the legal definition
of non-maleficence differs
 Violation of non-maleficence is the subject of medical
malpractice litigation
 Regulations therefore differ over time, per nation

28
Justice
 Justice is “fairness” or “entitlement”
 we have an obligation to treat all people equally, fairly, and
impartially
 Justice requires that “equals be treated equally and un-equals
unequally”
 Implies that human beings as moral equals should be treated
equally unless there is a reasonable justification for treating
them differently
 The general moral idea underlying the principle of justice is
that which states:
“Do unto others as you would have them do unto you if you
were in their place and they in yours”

29
Justice…
 The principle of justice demands
 fairness in the treatment of individuals and communities
 the equitable distribution of the burdens and benefits of
research
 Has important implications for such issues as
 choice of study population,
 recruitment into study,
 study and post-study benefits, etc.

30
 Conflicts between autonomy and beneficence
or non-maleficence
 Autonomy can come into conflict with beneficence when
patients disagree with recommendations that healthcare
professionals believe are in the patient's best interest
 When the patient's interests conflict with the patient's welfare,
different societies settle the conflict in a wide range of manners
 In general, Western medicine defers to the wishes of a mentally
competent patient to make their own decisions, even in cases
where the medical team believes that they are not acting in
their own best interests

31
Conflicts between autonomy and….

 However, many other societies prioritize beneficence over

autonomy
 Examples include when a patient does not want a treatment
because of, for example, religious or cultural views
 in the case of euthanasia, the patient, or relatives of a patient,
may want to end the life of the patient
 Also, the patient may want an unnecessary treatment, as can be
the case with cosmetic surgery; here, the practitioner may be
required to balance the desires of the patient for medically
unnecessary potential risks against the patient's informed
autonomy in the issue

32
Conflicts between autonomy and….

 A doctor may want to prefer autonomy because refusal to

the patient's self-determination would harm the
doctor-patient relationship.
 individuals' capacity for informed decision-making may
come into question during resolution of conflicts between
autonomy and beneficence
 The role of surrogate medical decision makers is an
extension of the principle of autonomy

33
Fundamental ethical…
 The four fundamental principles of ethics are equally
relevant and important within all possible contexts and
perspectives

 They are cross-culturally valid, although the emphasis

given to each and the way they are operationalised may
differ slightly from culture to culture, from place to
place, from context to context, and even from time to
time within the same context

34
4 ethical rules
 Veracity – truth telling, informed consent, respect for
autonomy
 Fidelity – loyalty, maintaining the duty to care for all no
matter who they are or what they may have done
 Privacy – a persons right to remain private or one is not
observed or disturbed by others during service delivery
 Confidentiality – only sharing private information on a
‘need to know basis ”_disclose patient information based
on need

35
Ethical Theories
 Ethical theories provide a system of rules or principles as a
guide in making decisions about what is right/wrong and
good/bad in a specific situation
 Applied consistently to determine whether an action is right or
wrong
 Allow a person to present a persuasive, logical argument as to
why certain actions should or should not be allowed
 Allow an executive branch to enforce conduct, i.e. to penalize
persons for actions that are not allowed

36
Ethical theories …

 There are many ethical theories

 Consequentialism
 Deontology
 Virtue Ethics
 Natural Law
 Relativism
 Divine Command Ethics
 Principilism

37
Ethical theories …
 There are three main approaches to ethics:
 Consequence-based approaches
 Rule-based approaches
 Character-based approaches
 The first two approaches address the question of how
we should act (CONDUCT)
 The third approach responds to the question of what
kind of person we should be (CHARACTER)
Ethical theories …

on the basis of
How should consequences
people act?
Fundamental by following rules
Question and thus doing our
duty
What kind of person
we should be?
develop character
and virtues

39
Ethical theories …

 There are two basic ways of answer the question,

“How should people act?”

Consequentialism:
Act-oriented • Look at the consequences and
choose the action that has the best
approaches consequences
Deontology:
• Look at the rules and follow the
rules (ten commandments, duty,
human rights, justice).

40
Consequentialism theory
 The rightness or wrongness of an action is
determined by its consequences
 Consequentialists maintain that whether an action is
morally right or wrong depends on the action's
consequences
 In any situation, the morally right thing to do is
whatever will have the best consequences
 Consequentialist theories are sometimes called
teleological theories

41
Consequentialism …

 What Kind of Consequences?

 Pleasure/pain
 Happiness
 Preferences/satisfaction
 For whom the consequence is?
 For the individual/me
 For my group
 For all human being
Consequentialism…
 Based on the consequence to whom,
consequentialism can be classified as:
a. Utilitarianism
 The right action is the one that promotes the
greatest happiness of the greatest number
(maximizes social utility)
 the choice that yields the greatest benefit to the
most people is the one that is ethically correct
 Bentham (1748-1832) and Mill (1806-1873)

43
Consequentialism…
 There are two types of utilitarianism,
 Act utilitarianism
 An action is right or wrong to the extent that it increases or
decreases the total happiness of affected members of
society
 Rule utilitarianism
 Adopt moral rules which, if followed by everyone, will
lead to the greatest total happiness of society
 Principle of utility applied to moral rules, not individual
actions

44
Consequentialism…
b. Ethical egoism - the ethics of self- interest
 The right action is the one that promotes the greatest
happiness of the agent (maximizes the agent’s utility)
 everyone ought always to do those acts that will best serve
his or her own best self-interest
 morally right actions are those that maximize the best
interest of oneself, even when it conflicts with the interests
of others
 Two Ethical Egoists - Benjamin Tucker (1854-1939) and
Ayn Rand (1905-1982)

45
Consequentialism…

c. Altruism - show concern for best interests of others

 Altruistic acts involve putting other people’s
interests ahead of our own
 The ethics of altruism prescribes that we sacrifice
our interests and lives for the good of others
 Ethical egoist theorists are strongly against to the
ethics of altruism

46
Deontology
 Deontology theories are rule oriented
 The duty ethics theory, proposed by Immanuel Kant
(1724-1804)
 The rightness/wrongness of an action is determined by
inherent features of the action itself, or by an inherently
valid rule
 If an action is of the wrong kind, it is forbidden, no matter
how good its consequences are
 Rejects both Utilitarianism and Ethical Egoism
 “The end doesn’t justify the means”
47
Deontology…
 The ethical action is one taken from duty, that is, it is done
precisely because it is our obligation to perform the action
 Behaving ethically by meeting our duties
 Ethical obligations are the same for all rational creatures
(they are universal)
 For Kant, choosing to obey the universal moral law is the
very nature of acting ethically
 Duties such as, ‘being honest’, ‘not cause suffering of
others’, ‘being fair to others, keeping promises’ etc. are
ethical and right actions must be universalizable

48
Virtue Ethics
 The rightness or wrongness of an action is determined by the
character traits it expresses
 Emphasize what kind of person you should be
 The qualities that one should develop in oneself are called
virtues (ex. honesty, fairness, kindness, prudence, faithfulness,
generosity, integrity, bravery, etc.)
 ethics should be concerned with the whole of a person’s life,
not with the individual discrete actions a person may perform
in any given situation
 Aristotle (384-322 BCE) Confucius (551-479 BCE)

49
Ethical Relativism
 This theory holds that morality is relative to the norms of
one's culture
 states that before decisions are made, the context of the
decision must be examined
 there are no absolute truths in ethics and that what is
morally right or wrong varies from person to person or
from society to society
 variances in culture and society influence whether an act
is moral
 Unlike deontology, this theory believes that what is right
for one group may not be right for another; this theory
believes there is no “universal truth”
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Divine Command Ethics

 What makes an action right is the fact that God

commands it
 They are religious oriented approach
 10 Commandments
 Islamic Sharia
Principilism theory
 Principilism attempts to have both ways of deontological and
consequentialist
 Now the dominant theory in medical ethics
 It is a base for the development of the four fundamental
Principles of ethics
1. Autonomy
2. Beneficence
3. Non-maleficence
4. Justice
 1 & 4 are deontological
 2 & 3 are consequentialist
Early records on ethics
 The Hippocratic Oath (400 BC)
 is probably the earliest document that alludes to morals and
code of medical conduct for physicians.
 It appears to be designed for the swearing in of a person at
the beginning of a medical practice
 It is the origin of ethics in health care
 Thomas Parcival (1803)
 His writing is probably the earliest statement directing to
peer-review: “Before proceeding with therapeutic
innovation, a physician ought to consult with peers”

53
 Early records…

 Parcival went further to identify the concept of

vulnerable groups in the statement:
 “for the poor-who being the most numerous class of
society, are the greatest beneficiaries of the healing
art … But in the accomplishment of the salutary
purpose, the gentlemen of the faculty should be
governed by sound reason, just analogy, or well
authenticated facts
 and No such trials should be instituted, without a
previous consultation of the physicians or surgeons,
according to the nature of the case”
54
Early records…
 In between the Hippocrates and Parcival times:
 much unethical research seems to have taken place with very
poor documentation of the details.
 Uncontrolled, unscientific human experiments which were
purely empirical were done
 vivisection was common without consent;
 experiments on condemned criminals and underprivileged;
 prisoners could be offered pardons on participation in
“inoculations”
 the famous inoculation of cowpox to an 8 Yrs. old boy by Jenner
happened during this period (1796)

55
 Early records…
 William Beaumont (1833)
 records what some consider to be the oldest American
document dealing with research ethics
 Beaumont identified key issues which may be summarized as
follows:
 Experimentation is needed;
 Investigator must be conscientious and responsible;
 Investigations must have good methodological approach
 Voluntary consent is necessary;
 Discontinuation of experiment when it causes distress to the
subject or the subject objects or becomes dissatisfied

56
 Early records…
 1900 - Prussian Directive
 Is response to public debate on human subject
experimentation.
 Prohibited experiments in minors and those not fully
competent
 Unequivocal consent required after explanation of the
experiment and possible adverse consequences
 Only certain people were allowed to do the research
and must keep written records

57
Early records…
Prussian Directive…
 For the first time in history, informed consent, the
research process, and explicit clarification of personal
responsibility for the experiment were required to be
included in the medical record
 In addition, issues of written research plans with a
risk-benefit assessment, and the need for previous
animal experimentation were raised
 Ethical issues are required to be assessed by peers on
institutional review boards

58
Research History and Tragedies
 Much of what we have as ethical codes and guideline
have been influenced by tragic events which cause
public concerns.
 During the 1900, accounts of many atrocities in the
name of biomedical research are documented
 Experiments were liberally done on underprivileged
children, the poor and prisoners.
 Cases of vivisection have been reported
 Genetic, racial hygiene experiments were conducted,
and in all cases, there is little doubt that the subjects
were not volunteers
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The Nazi Experiments (WW-II 1939-1944)
 Prisoners in Nazi concentration camps were forced
to undergo experiments that included exposing them
to extreme temperatures, mutilating surgery, and
lethal pathogens

 The gruesome experiments that maimed and killed

helpless prisoners outraged the world and resulted in
criminal indictments against senior Nazi doctors, as
well as calls for international regulation of medical
experiments

60
The Nazi Experiments…
 Public outcry culminated in the 1946: Nuremberg
Doctors’ Trial
 They were found guilty of murder, torture, and
other atrocities
 During the trial at Nuremberg, the judges codified
fundamental ethical principles for the conduct of
research
 In 1947, the Nuremberg Code thus resulted with a
set forth 10 conditions to be met before research could
be deemed ethically permissible

61
The Nazi Experiments…
 Nuremberg Code became the first international
standard for the conduct of research and introduced
the modern era of protection for human research
participants
 In 1948, The Universal Declaration of Human Rights
was adopted by the United Nations
 The Universal Declaration asserted the principle that
each human being was entitled to certain rights and
freedoms

62
 Human Radiation Experiments
 The US government sponsored many radiation experiments
involving humans during the period 1944–1974
 In the majority of cases, the experiments were conducted to
advance biomedical science; however, some experiments were
conducted purely to advance national interests in defence or
space exploration
 Most of these studies involved radioactive tracers administered
in amounts not likely to cause physical harm
 Attention was not given to issues of fairness in the selection of
participants
 Further, research was conducted on participants without their
awareness or consent and on participants not likely to derive
direct medical benefit
63
The Jewish Chronic Disease Hospital Study
 In 1963, studies were undertaken at New York’s Jewish Chronic
Disease Hospital to understand whether the body’s inability to
reject cancer cells was due to cancer or debilitation
 These studies involved the injection of foreign, live cancer cells
into patients who were hospitalized with various chronic
debilitating diseases
 Consent had been given orally, but did not include a discussion
on the injection of cancer cells, and consent was not documented
 The researchers felt that documentation was unnecessary
because it was customary to undertake much more dangerous
medical procedures without the use of consent forms.

64
The Jewish Chronic Disease…
 Further, patients were not told that they would receive
cancer cells, because the researchers felt it would
unnecessarily frighten them
 Researchers defended this view with the assertion that
they had good cause to predict that the cancer cells
were going to be rejected
 Board of Regents of the State University of New York
found that the study had not been presented to the
hospital’s research committee and that the physicians
responsible for the patients’ care had not been consulted

65
The Willowbrook Study
 In a series of studies conducted from 1963 through
1966 at the Willowbrook State School, a New York
institution for “mentally defective” children

 In order to gain an understanding of the natural history

of infectious hepatitis under controlled circumstances,
newly admitted children were deliberately infected with
the hepatitis virus

66
The Willowbrook Study
 Researchers defended the deliberate injection
 the vast majority of them would acquire the infection
anyway while at Willowbrook, given the crowded and
unsanitary conditions, and
 only children whose parents had given consent were
included
 Parents found they were unable to admit their children to
Willowbrook unless they agreed to their participation in
the studies

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The Tuskegee Syphilis Study (1932-1972)
 Study of the natural evolution of syphilis infection in the
long-term
 Conducted at Tuskegee by the United States Public Health
Service
 More than 400 black men with syphilis participated, and
about 200 men without syphilis served as controls
 The men were recruited without informed consent and, in
fact, were misinformed that some of the procedures done
in the interest of research (e.g., spinal taps) were actually
“special free treatment”

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The Tuskegee Syphilis…

 As early as 1936, it was clear that many more infected

men than controls had developed complications,

 and 10 years later, a report of the study indicated that the

death rate among those with syphilis was about twice as
high as it was among the controls

 In the 1940s, penicillin was found to be effective in the

treatment of syphilis

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The Tuskegee Syphilis…
 This study continued, nonetheless, and the men were neither
informed nor treated with the antibiotic
 The first accounts of this study appeared in the national press in
1972 following the revelation of one of the participating nurse
called Rivers
 It was only in 1997 that a public acknowledgement of
Government responsibility was made by President Bill Clinton,
and the compensation of surviving participants and the families
of deceased participants continues

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