Bioethics Midterm 1

Other Responses to Criticism of Utlitarianism

If we construe the cases properly, many would actually agree that following the act utilitarian's advice is the right thing to do. But in most cases, worse results would occur if we sacrifice one to save many

Universal Law

Imagine a world in which everybody follows that maxim anytime it applies

Ad Hoc Committee of Harvard Med to Examine Definition of Death

In response to 2 reasons: Creation of life-supporting technology, which sometimes created a burden for hospitals and families Obsolete criteria causing controversy in organ obtainment--Dead Donor Rule

Cardiopulmonary Death

Irreversible loss of cardiopulmonary function (heart and lungs) Cardiopulmonary death is always brain death

Do/Do Allow Distinction

Is there a moral difference between actively causing death (killing) versus merely allowing death to occur when everything is equal: intentions, motives, and consequences The medical and legal community agree that removing life support is a permissible allowing of death to occur Allowing to die is actually permissible killing

Are organs public or private goods?

It is a private matter whether we choose to donate or not But if we donate, we are required to donate them as public goods, available for the general distribution "curious mix of choice and conscription" No other goods are treated in this way

What are the problems with substituted judgement?

It is suppose to reflect what the patient should have wanted, but that is easily confused with what the family member wants Family members are under a lot of stress and emotional duress, so they may not be the best party to undertake such difficult decisions

Problems with advanced directives

Problem of personal identity--are you the same now as you will be in the case that you are incapcitated

Constraints

Prohibitions Examples: Constraints against harming, killing, lying etc.

Undue Influence

Prospect of great benefit if one does what another wants

Physician Assisted Suicide

Providing assistance so that one may commit suicide themselves

Maxim

Reason for action in this situation Example: Even when it would be more fun to get out of the commitment, keep your promise

California Right to Die Law

Requirements include: 2 doctors must agree that patient has a terminal diagnosis (less than 6 months to live) One meeting must be private--between doctor and patient Patients must have the mental capacity to make medical decisions Must be able to swallow pills themselves Must reaffirm that they will take the pill within 48 hours

Oregon Death with Dignity Act

Requirements: Informed consent must be documented Patient must have terminal diagnosis Patient must be a resident Doctor prescribes patient lethal dose Patient must administer the medication

Substituted Judgement Principle

Requires surrogate to use their knowledge of the patient to make decisions that the patient would have made when they were competent Used when the patient doesn't have an advanced directive

Four Major Principles of Morality

Respect for autonomy Nonmaleficence Beneficence Justice Not listed in order of importance

Tuskegee Syphilis Experiments

Resulted in U.S. federal requirement that all research on humans (receiving federal funding) be reviewed through Institutional Review Boards (IRBs Brought awareness to concerns about vulnerable populations in research; the use of deception Need for informed consent to research Resulted in a long-standing suspicion of medical research by many African Americans

How are decisions about treatment made when a person is considered incompetent?

There is a hiearchy of decsion making standards: (1) Advanced Directive/Expressed desire about treatment (2) Substituted Judgement (3) Best Interest Standard--for those who have never had the ability to make judgments

Moderate Deontology

There is a threshold at which the good to be done by harming someone outweighs the wrongness of harming them Therefore it is okay for one to harm one person to help many Ad hoc, or arbitrary and not very simple

Problems with Utilitarianism

There is no fundamental moral distinction for them between committing harms to achieve that goal or merely failing to do good You may sometimes kill or harm in order to bring about greater good An enormous harm to one person is acceptable if it leads to a larger number of small benefits for other people

What is distinct about PAS, Suicide, and Euthanasia?

They are not the same as refusal of life-saving treatment Also, legally distinct from removing life support

What about people who lack the capacity to consent (not competent)?

They cannot consent to medical treatment or research Includes: infants and young children, neurologically damaged adult What matters or is in the best interest of each of these people varies widely BUT, children of older ages can assent, rather than consent

Coercion

Threat of harm if one fails do to what another wants

What does it mean to treat them as an end in themselves?

To see that they have their own projects and desires, that they are autonomous, and that they are rational

What does it mean to treat someone as a means?

To treat them as an instrument to you achieving your ends Example: Tuskegee Syphilis Experiments

What are the issues surrounding organ donation as highlighted by Richards?

Traditional values focus on respect for bodies of donors, with less emphasis on interests of potential recipients Not enough organs to go around There should be a presumption in favor of organ donation and against policies that hinder it

Total Disability

Universal and irreversible disability

Characterisitics of a Permanently Non-functioning Brain

Unreceptivity + unresponsivity No movements or breathing No reflexes Flat EEG

The Categorical Imperative (Kantianism)

Various formulations that Kant claims are all derivable from one another Includes: Formula of Universal Law and Formula of Humanity

Dead Donor Rule

Vital organs may be only taken from a person who is declared dead Brain dead people are the perfect donors

The View of Persons (Definition of Death)

We are both part organism and part person These two are distinct entities We are our minds, and our human organism can survive though a person dies So a PVS patient is one whose organism is alive though their person is not

Welfarism (What is "Welfare?")

Well being, happiness

Paternalism

When a clinician decides what is best for the patient without looking for informed consent; the opposite of autonomy

Descriptive Statement

describe the world; they can be empirically verified Can be true or false

Justice

fairness The other 3 occur at the bedside of the patient, so to speak, while the justice condition is about fair access to resource it occurs at the population level—across people

What do advanced directives typically do?

Appoint decision makers State patient values Dictate preferences for life-prolonging treatments Body/tissue donation

Why is understanding and appreciation of information the most complex of the three conditions of informed consent?

Because we don't know how are clinicians suppose to ensure understanding and we don't know what information is necessary for understanding

Why is it good to have an advanced directive?

Better assures that you will receive the kind of care you want instead of the default (life-prolonging treatment at great cost) Takes the burden of decision-making off your family For those who reject life-prolonging treatment at great cost, expresses to health care providers this value

Brain Death and the Dead Donor Rule

Brain death is the gerrymandering of the boundaries of life and death Are brain dead people actually still alive--their bodily organism is This can make it a violation of the Dead Donor Rule, which would lead in a sharp decline in organ donation

John Arras's Assessment

Casuistry is a very valuable tool Can be supplemented with appeal to higher ethical theory How aspirational or conservative it is depends on who is using it and what their values are

What is in the bioethics terrain?

Clinical Practice Research Technology Public Health/Resource Allocation

Principlism

Common morality can serve as action guides in our deliberation of different moral situations Crosscultural Product of human history and experience, learned and transmitted through generations Method for thinking about bioethical problems when we cannot agree on what moral theory to use A top-down approach

What are the conditions for informed consent?

Competence Understanding and appreciation of information Voluntariness

Criticisms of Kantianism

Concern for only intentions, but not results is problematic Is Kantianism moderate or absolute? Both have their criticisms What about beings that are not fully autonomous or autonomous at all? (animals, infants, mentally incompetent humans)

Beneficence

Contribute to people's welfare Help/aid/assist them Requires actions Positive obligations Connected to 2 other principles: positive beneficence and utility

How does Armstrong and Miller's view effect the Dead Donor Rule?

Dead Donor Rule would be obsolete--we could take organs when a patient is totally disabled and not necessarily dead --PVS patients and brain dead patients are fair game

Armstrong and Miller

Death itself is not bad, the badness of death is total disability Total disability is the same as death

Manipulation

Deception

Autonomy

Defined as a person choosing their own life plans without having them imposed on them from the outside- by others or circumstances. Informed consent to treatment is necessary to respect autonomy

Why physician assistance?

Hard to commit suicide painlessly, successfully, aesthetically Hard or impossible to do if one is very ill or disabled

Rule Utilitarianism

Hare developed this form of utilitarianism in response to criticism that states: We cannot know with certainty in most cases what will bring about the most utility. We should stick with the best rules. The best rules won't advocate sacrificing one to save many in most cases

Karen Ann Quinlan

Higher brain destroyed after a combo of drugs and alcohol suppressed her breathing Respirator was used to keep her breathing Family desired to take her off, but doctors feared legal ramifications Stayed on life support for 10 more years and died of Pneumonia

Casuistry Method

(1) Describe a case in rich detail and categorize the case (2) Fit it into a taxonomy of other cases (3) Locate the present case on the spectrum, from unacceptable to acceptable conduct (4) Draw a conclusion * When we have moral certainty it comes from cases, not the abstract

How did O'Neill respond to the criticism that Kantianism cares only about intentions and not results?

(1) It is rare for good intentions to have bad results (2) Critique against Utilitarianism because it is very hard to predict what the results of actions are going to be, so it is not very accurate or valid

Jahi McMath

13 year old declared brain dead after tonsillectomy complications Parents wanted to continue ventilation and feeding, cited their religion Doctors say its unethical to treat a dead person Makes us question the definition of death

Marlise Munoz

33 year old diagnosed brain dead after blood clot in lungs; 14 weeks pregnant Husband and family want to remove her life support Doctors refuse citing Texas law prohibiting removal of life support from a pregnant patient But if she is dead, she can't be a patient

Casuistry

A bottom-up approach where we start with real, concrete cases and derive principles/norms from them Much like common law tradition Casuistry requires one to become an expert in case studies

Removal of Life Support

A permissible way of allowing someone to die of the underlying causes

What information is necessary for understanding?

A reasonable patient standard that includes information about: The nature of the procedure Risks of the procedure Alternatives to the procedure, if any Benefits of the procedure

Advanced Directive

A statement indicating treatment preferences in the case an individual becomes unable to make decisions some time in the future Respecting autonomy at the end of life Also called living will, durable power of attorney, and healthcare proxy Legally recognized documents, but not legally binding for physicans Provide physicians with legal immunity if they follow orders They don't override/surpass more general ethical requirements of care (no euthanasia and care/intervention you aren't eligible for)

Transparent Sophistry

A term coined by Brock that states that the distinction between removing life support which is labeled allowing to die, and euthanasia and PAS is not philosophically sound Allowing to die is really permissible killing

Principles

Abstract

Formula of Universal Law (FUL)

Act only in accordance with that maxim through which you can at the same time will it to become a universal law

Theory of Right Action

Act so that you bring about the most good A concept from Consequentialism/Resultism

Objections to PAS and Euthanasia

Against the Hippocratic Oath Gets doctors into the business of killing when they are in the business of curing Sanctity of life, religious concerns Slippery slope concerns--could lead to unethical killings Opposition from the left--concern that psychological issues and depression are the primary motivation for desire to end life, instead of pain, so doctors should focus on managing pain, suffering, and depression only

Persistent Vegetative State (PVS)

Alive but severely impaired consciousness Need supportive technology No awareness of the environment

Doctrine of Double Effect

An act that is wrong if one aims at it (killing) can be morally permissible if it is the unintended side-effect of aiming at some other good, even though it is foreseen Idea of collateral damage The aimed at good must be good enough to justify killing

Nuremberg Code

An ethical code, not legally binding Formed the basis for later ethical and legal documents Includes 10 points, with the most important being the concept of informed consent Also requires social benefit of the experiment, preclinical testing in animals, and doctor beneficence to research subjects

Rules

Derivable from principles; more specific

Nonmaleficence

Do no harm Requires an omission, that you abstain from harming Negative obligations BUT, not all harms are wrong Prima facie nature of principle requires justification for doing harm

How are organs procured?

Donation after cardiac death Donation after brain death

Where is PAS and Euthanasia legal?

Euthanasia: Legal in Belgium, Netherlands, Luxembourg, Colombia PAS: Switzerland, Canada, California, Oregon

Normative Statement

Evaluations, judgments or prescriptions

Advantages of Casuistry

Fits well with practical reasoning and medicine: doctors are familiar with case-based reasoning No need for deep theory Well-suited for consensus in a pluralistic society; the aim is to reach overlapping consensus Deciding cases at case level doesn't threaten people's deeply held higher level principles

The Trolley Problem

It seems that in some cases, we should kill one person to save five innocent lives (original trolley case), but in others (organ transplant case + the large man case) it is morally forbidden

Criticisms of Casuistry

It starts with judgements we already have and analogizes from them, so if the previous judgements were wrong, then we are still wrong Thus, casuistry is a conservative approach, doesn't often change

Euthanasia

Killing of another for merciful purposes

Deontology

Moral views that incorporate constraints on maximizing the good Promote the good without breaking any constraints Still consequentialist and welfarist Intuitive, closely resembles "common sense morality"

Formula of Humanity (FEH)

Never treat a person as a mere means only Always treat a person as an end

Common Morality

Norms about right and wrong human conduct that are so widely shared that they form a stable social compact Examples: Don't lie, kill, harm, and steal

Moral Dilemmas

Occur when it seems that the no matter which of the 2 (or more) actions a person takes, they act wrongly

What are the possible policies to reconsider?

Opt-in vs. Opt-out Donation Family Veto Directed Donation Compulsion and Reciprocity Paid Living Donation Overrule Dead Donor Rule

Coma

Patient is alive Could have brain stem responses, such as spontaneous breathing and spontaneous motor functions

What are the procedures for donation after brain death?

Patient is declared brain dead Ventilation is removed partway through donation surgery This allows for the donation of many tissues/organs

Brain Death

Patient is no longer alive; irreversible cessation of activity in both the brain and the brain stem Loss of involuntary functions needed to sustain life

What are the procedures for donation after cardiac death?

Situation: Patient is on a ventilator, family chooses to withdraw life support No less than 8 hours after removal and consent, patient moved to operating room Hospital physician determines death of patient Wait at least 2 minutes before making an incision Usually only liver and kidneys can be used--lungs in exceptional cases

How do we weigh and balance the principles when they conflict? (If two principles are being considered, how do we decide which one is the priority?)

Some guidelines for choosing which to prioritize include: Good reasons can be offered to act on the overriding norm rather than on the infringed norm The moral objective justifying infringement has a realistic prospect of achievement No morally preferable actions are available The lowest level of infringement that achieves the primary goal of the action is selected (we only tolerate larger infringements if the benefits are larger as well) All negative effects of the infringement have been minimized All effective parties have been treated impartially

How do we specify principles into rules?

Specification is about the scope of the norms--determining the where, when, why, how, by what means, to whom, by whom, the action is to be done or avoided Specification can help dissolve conflicts of norms and dilemmas

Philosophical Ethics

Studies what people should think is ethical "What is ethical?" A prescriptive, normative field

Bioethics

Study of the ethical issues that arise in medical research and practice, especially those raised by new technologies and medical advancements Interdisciplinary

Kantianism

Tells us to look at our reasons for acting, to see if they are morally right or wrong Focuses on autonomy, rationality, human dignity Must follow FUL and answer 2 questions: is the world possible and is it rational for you to desire it

Suicide

The act of intentionally taking one's own life

Aggregationism

The assumption that: Everyone counts (universality) and Everyone counts the same amount (impartiality) Just add up all the welfare across all people. The morally best scenario has the highest total Doesn't matter how the welfare is distributed, just the total amount there is

Advantages of Kantianism

The claim that people matter in and of themselves We only need to check our intended action and make sure it follows FUL

Voluntariness

The decision is free from: Coercion Undue influence Manipulation

Absolute Deontology

The idea that one may never harm one person to help many, at all, ever Not as intuitive as moderate deontology, but much simpler

Competence

The patient has the mental capabilities to make decisions on their own OR having legal status to make one's own decisions in a particular area (in this case, about medical treatment or research Decision-making capacity is the basis on which competence determinations are made Choosing to go against what is medically best is not a sign of incompetence Ex: Many Jehovah's Witnesses reject life-saving blood transfusions, and this wish is respected by clincians

Theory of Good (What is "good?")

The relevant good is welfare

Utilitarianism

The theory that says morally right action is that which maximizes utility (welfare, well-being, happiness) for all people taken together It is often summarized as: the greatest good for the greatest number principle It is: consequentialist, welfarist, aggregationist