Intro To Philosophy

THE HIPPOCRATIC OATH

- very old - template for modern code - before 1960s no informed consent -------> only keep medical info in medical field - only written code of ethics to survive - small group *Do No Harm - do no unnecessary harm ----> surgery ex, side effects - anti euthanasia - influences convo today - act in best interest of patient (paternalism) - treat everyone equally - keeping confidentiality - patients are silent in hippocratic oath, voices aren't heard = doctors thought they had a privileged moral opinion - end all be all make decisions and choices

THE FUNDAMENTAL QUESTION

•What constitutes a moral act: •Conformity with traditional authority •Conformity with rational principles •Practical wisdom—Phronesis—The "art" of choosing and doing the right thing—is concerned with universals (the good) and particulars, ends and choosing the best means for achieving the ends. - morality - acting on a basis of enlightened self - others suggest it goes beyond self interest

MODERN MEDICAL ETHICS

•What differentiates classical and modern medical ethics? The scope of the discussion. •What was once an internal dialogue within the medical profession is now a dialogue with an interested and concerned public that is prepared to hold medical decision-making up to ethical scrutiny. •"The Principles of Biomedical Ethics"—Tom Beachampand James Childress—1979—Written for a course in Medical Ethics at Georgetown University Medical School *tech advances exploded to public concern

LIMITS OF VIRTUE ETHICS

•What is a good person? •Is it possible to derive "rules" and "priniciples" from "human nature." The need for "liminal" constructs. --- who decides the virtues of a good person -- is the culture up for grabs? what is our culture? and just bc something is normative and ppl accept it, is it right? who's to say?

PROBLEMS AND POSSIBILITIES OF MORAL RELATIVISM

•Whether in considered in individualistic or cultural sense, it lacks a rational foundation and results in intractable disagreement associated with "differences in perspective." The operative assumption is that all morality is a function of power—"might makes right" a la Thrasymachus in Plato's "Republic." •Strengths of relativism is that it calls attention to the fact that moral decision-making is never a matter of solving abstract problems...doing the right thing in the right way for the right reasons in reference to concrete possibilities for realizing the "good."

DIFFERENCE BETWEEN ETHICS AND LAW

Law = differentiated account of public morality -> not necessarily amoral -> just subjective Ethics = reflection on that public morality considers other possibilities -> critically reflect on assumptions made by law Just bc P/A suicide was voted no, doesn't mean that the ethical debate stopped

FOUNDATIONAL PRINCIPLES OF MEDICAL ETHICS

•Non-Maleficence—do no unnecessary harm •Beneficence—act in the best interest of the other (patient) •Autonomy—self-determination, the patient as moral age, the "Patient as Person" •Justice—distributive justice

PRINCIPLES AND MODES OF MORAL AND THE PHYSICIAN/PATIENT RELATIONSHIP

•Paternalism—primacy of beneficence •Informative model—radical autonomy—the practitioner as technical consultant •Interpretive model—values clarification—finding the balance in deference to autonomy •Deliberative model—finding the balance in deference to beneficence.

FACTORS IN THE RISE OF MODERN MEDICAL ETHICS

•Professional Misconduct in Medical Research—the "Nazi Doctors"--the Nuremburg Code, 1947. TuskeegeeSyphilis Study, Willowbrook School, Jewish Chronic Disease Hospital Case, etc. •Technological Advances—transplants, cardio-pulmonary resuscitation, diagnosis of fetal abnormalities, genetic engineering, in vitro fertilization, etc. (organ transplant system) •1960's—Critique of "Functional Elites"—professionals subject to criticism as members of the "hidden hierarchy (C. Gilb)" Ivan Illych, "Medical Nemesis" •1970's—The "Health Care Crisis"—the spiraling cost of health care—distribution of a "scarce resource." •Waning of a "normative culture"—White, anglo-saxon, Protestant elites. •Postmodernism--general distrust of grand theories and ideologies as well as a problematical relationship with any notion of "art."

PULLMAN VS. DECKER (Part 1 In CDB)

•Pullman—critique of moral relativism—the quest for foundational values/beliefs/ principles. Absolute principles? Generally acknowledged principles? Principle of respect for human dignity - he is a light deontologist - categorical imperitive - one can't earn or lose human dignity - crimes against humanity presupposes universal acceptance of human dignity - there's a difference between Basic Dignity and Social Dignity - without universalism there is no possible way to understand each other across cultures •Decker—moral relativism as an invitation to dialogic negotiation of value and meaning. - it is hard to define human dignity across groups - influenced by social context - there are moral determinations outside of human dignity - lacks stable foundation - too many disagreements - he says basic dignity stems from our uncomfortability with not having stagnant truths - we want the confidence that we are making the "right decisions" Universalism - ideas and practices can / are universal Particularism - circumstances dictate Moral relativism is the view that moral truths are true relative to something, like a time or a place or a community or a speaker. Moral particularism is the view that the correct answer to moral questions can't be captured by any single overarching moraltheory, because the answer depends on the specifics of the case.

PROBLEMS WITH DEONTOLOGICAL ETHICS

•Resolving conflicting maxims. Example: Nazi SS officers ask, "Are you hiding Jews in you basement." •"Clean hands is no hands"—"Axe murderer at the door." •Challenges with "triage" situations. •Adjudication of values/principles when several are at issue if moral principles must, by definition be a priori •W.D. Ross—Prima Facie Principles --- which principle is most important when you are dealing with many

RIGHTS-BASED APPROACHES

•Roots in natural law theory—but idea that persons have moral claims/entitlements by virtue of being human was developed by Enlightenment thinkers—Grotius, Pufendorf, Locke MODERN Types of rights •Civil rights - moral claim by virtue of their membership to a certain sociohistoric community •Natural/human rights - rights by virtue of being a human being rights --- possession of moral claim / entitlement in relation to other persons - benefit of contradicting majoritarian

NATURAL LAW IN CONTRAST TO UTILITARIANISM AND DEONTOLOGY

•Similar to utilitarianism because both are teleological (oriented to end/outcomes)—concerned with the human good. •Similar to Kant because natural law theorists do not think happiness can be reduced to what is "pleasant" or "desireable." - similar to deontology bc it takes into account the moral subject (person)

CONTRIBUTIONS OF NATURAL LAW THEORY TO MEDICAL ETHICS

•The Doctrine of "Double Effect" •The Doctrine of "Proportionality"

PROPORTIONALITY & TOTALITY

•The good effect is sufficiently desireable to compensate for the bad effect (Kind of utilitarian) •Example—Administration of morphine to address intractable pain even though side-effect will be to hasten death through suppression of cardio-pulmonary functioning •Totality—Preservation of what is highest/most distinctly human—justification for amputation, voluntary organ donation, etc.

NATURAL LAW THEORY

•The intelligibility of the universe cannot be reduced to cause and effect. Material—Efficient—Formal—Final Causes. •Final causes—that for the sake of which entities exist. Presupposes that there is a "human good" that is articulated in terms of a normative understanding of what constitutes being human. •That act is moral that is congruent with human nature -- presumes existence of moral rules that are invariant -- anything contrary to our nature as human beings is immoral Aristotle 4 causes to a thing 1. material cause (biology) 2. Efficient cause of a thing (carpenter, parents, etc) 3. Formal causes - that which makes something what it is and not something else (formal definitions) (our capacity for reasons and capacity for moral order makes us human beings) 4. Final - for the sake of which a thing exists (live in accordance with our nature)

TYPES OF UTILITARIANISM AND THE "STATUS OF RULES"

•Utilitarianism does not reject the existence of moral "rules" or "principles." The issue is the status of the rules relative to the primary concern to maximize happiness Internal debate on rules and how they should hold •Act-Utilitarianism—rules as "rules of thumb" that can be disgarded if their application interferes with the optimization of happiness in any give circumstance (what is good right now) •Rule-Utilitarianism—rules may be applicable even if in the immediate circumstance, happiness is not optimized. (what is good long term) For example: Killing one person to give organs to 5 dying people - act --> yes bc overall happiness increases - rule --> no bc although immediate happiness is granted if everyone in society went around doing that then overall happiness would be distraught

RIGHTS-BASED APPROACHES IN COMPARISON TO DEONTOLOGY AND UTILITARIANISM

•Utilitarianism tends to be "majoritarian" (disregards persons ability to be self - determined (Autonomous)) •Similar to Kantian ethics/deontology in its emphasis on "autonomy of the subject"—that act is moral which instances rational self-determination Kant moral subject --- capacity to choose in accordance with rational principle not self-determination RB - subject can choose within their moral authenticity - no accountability

BASIC TENETS OF DEONTOLOGICAL ETHICS

•An act is moral insofar as it is a matter of rational duty, not concern for outcome or consequence. Presupposes that there are some actions that are obligatory regardless of the consequence. Kant rejects the premise that pain is intrinsically bad and happiness is intrinsically good •Universalizability—"Categorical Imperative"--Act only according to that maxim whereby you can, at the same time, will that it should become a universal law. E.g., truth-telling, cheating, etc. -- can this rule be used by everybody and be good? ----> an unconditional moral obligation which is binding in all circumstances and is not dependent on a person's inclination or purpose. •Second formulation of the categorical imperative: Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end. --- respect for human dignity is exceptionless (pullman) - you should never use people as pawns --follow rules of conduct in order to respect another person's autonomy, not to make anyone happy, although you do have a duty to help others and yourself become more rational in order to choose the right maxims consistently. •The person as "autonomous" moral agent - impossible to determine exceptions to a principle (if you only sometimes tell the truth how do we know you are telling the truth)

DOUBLE EFFECT

•An act is permitted if •The bad effect is not intended though it may be forseen •The act is not intrinsically wrong •The good effect is the result of the action and not the bad effect

VIRTUE ETHICS

•Character, Decisions and Community •Good choices make good persons. Participation in good communities enables/cultivates good persons who make good choices. •"the virtuous person knows how to react and act in the right way, at the right time, in the right manner an for the right reasons..." •Virtue as habit. •What makes a good professional? - not just what's right, timing, delivery, intention EX counter-transference (reason / meaning matters) Fundamental regard for good of another person Resembles Moral philosophy in early days What makes a good person? - fights utilitarian and deontological ---- these two talk about the moral decision and VE talks about who is making the choice

MEDICAL ETHICS IN HISTORICAL PERSPECTIVE

•Classical Medical/Professional Ethics •Hippocratic Oath (circa 700-300 B.C.E.) •Medical Ethics as a "Code Morality"—specific to practitioners. No specific effort to establish validity of prescriptions and prohibitions to the public Hippocratic oath - very static way of thinking --> only used to be internal convos - made public discourse now (post ww2) - too important to only leave to physicians (Physicians used to lie and say condition was worse so if patient died, not their fault and if they were healed then practitioner was amazing)

BASIC TENETS OF UTILITARIANISM A LA MILL

•Consequentialism •Maximization—"The greatest good for the greatest number" •Theory of "value": Mill moves beyond Bentham's simple pleasure/pain calculus, differentiates between "lower" (pleasure/pain) and "higher" (cultural/social) goods. •A "scope-of-morality" premise: What beings happiness matters? - often we forgot lower good for the sake of higher good

PROBLEMS WITH UTILITARIANISM

•Consequentialism—is it really possible to anticipate the full range of consequences of any given decision? Complicates possibly relevant distinctions—"killing" and "allowing to die"—Consequentialists may say they are equivalent insofar as both may result in a "desireable death." •Maximization—Bentham claims that the happiness of each being is one unit (counts equally) and as such all are equal. Challenging example: Who gets the transplant? •Theory of "Value": What precisely is happiness and is "happiness" the same for everyone? How do we compare different accounts of happiness and are some accounts of happiness better than others? •Moral responsibility—Do the ends justify the means? (Ref. ethical issues in research) •Utilitarianism, in its social application, tends to be majoritarian. Discriminates against persons at the margins.

DEONTOLOGY

•Immanuel Kant (1724-1804) •Deontos—Duty •Kant is a modern proponent of rational duty. Fundamental assumption is that morality is a distinctly human possibility and, as such, is consistent with what is expressive of that humanity—the capacity to act on the basis of reason, not instinct or pleasure/pain •Precursors •Confucianism •Bhagavad Gita

PROBLEM WITH RIGHTS-BASED APPROACHES

•Is there a limit to "self-determination?"—Ex.—DaxCowart Physicians know that, if treated, he will recover. -- kant believes fundamentally flawed --- may be authentic decision but not moral unless you choose to act in rational principle

UTILITARIANISM

•Jeremy Bentham (1748-1832)and John Stuart Mill (1806-1863). •Bentham precedes Mill-decides that a surer foundation for a rational morality is provided by the natural tendency to seek pleasure and avoid pain. Bentham, in fact, works out a complicated calculus for weighing benefit and risk of any given moral choice. Mill expands and develops the theory.

Medical Ethics

•Medical Ethics—Applied Ethics—Avails itself of foundational frameworks developed in moral philosophy to address questions arising in the field of medicine and medical practice +applied ethical discipline -- foundations for good decision making

Moral Philosophy

•Moral Philosophy—a sub-discipline of philosophy which focuses on establishing the foundations of good decision-making—Concerns itself with why is one mode of ethical reflection better than another

THE MAJOR OPTIONS

•Moral Relativism •Utilitarianism •Deontology •Natural Law •Rights-based •Virtue Ethics

MORAL RELATIVISM

•Moral Relativism/Contextualism—is actually a post-modern option. Presupposes that there are no universal moral principles. Precursor in David Human—"moral sentiments", Schiller and "fellow feeling." •Nietzche—provides systematic expression to this viewpoint in "Geneology of Morals" after debunking the Enlightenment in the "The Gay Science." In the end, it is all a matter of the "war of poetry", "Will to Power." (Nihilist) If it is congruent with your beliefs it is good

WHAT IS ETHICS?

•Morality is what people believe to be right and good, while ethics is a critical reflection about morality. •Ethics as a reflective enterprise arises from a natural and spontaneous desire of human beings to give an account of what they do and why they do it. All choices are moral choices (even going to class b/c they are morally embedded) Both deal with right and wrong but moral is within oneself and ethics are environmentally dependent