Biomedical ethics

• KANTIAN ETHICS (MORAL AUTONOMY)

consent cannot morally justify actions which disrespect self *and* others.

What is the meaning of the term "euthanasia"?

"? translates to "a Good Death"can be characterized as directly or indirectly bringing about the death of another person for that person's sake

What is the Rule Utilitarian 'Harm Principle' for respecting autonomy

** A person's autonomy may be curtailed to prevent harm to others (Vaughn, 2017:10) believes that the principle of utility implies a strong respect for individual self-determination and asserts that no one may interfere with a person's liberty except to prevent harm to others. would say no to PAS bc Consent cannot morally justify actions which harm others.** Limit individual choice only when there is sufficient threat of harm to others.The Harm Principle: A person's autonomy may [only] be curtailed to prevent harm to others That the only purpose for which power can rightfully be exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, it not sufficient warrant." We cannot advance the interests of the individual by compulsion, or the attempt to do so involves evil which outweighs the good done. ***Violating autonomy and failures of informed consent might lead to worse overall social consequences. ***Patients might not be given treatment they prefer/treatment which would make them happy. People would lose trust in medical professionals and researchers if they believed they could be treated or used against their will.

Which arguments support the claim that there is no moral difference between active and passive euthanasia?-

. If one's ethical responsibility is to bring about the best consequences (while avoiding worse consequences) then there can be no distinction between those consequences a physician knowingly and willingly produces through withholding or withdrawing treatment, and those he may bring about through prescribing a drug or giving a lethal injection. This argument suggests that widespread agreement that it is permissible to intentionally bring about a 'good death' for a patient means that we should also accept forms of active euthanasia. There is no reason to see these as morally distinct. self-determination and individual well-being both support the morality of voluntary active euthanasia. Brock argues against the act/omission distinction, claiming that doctors already kill when they forego treatment.

What limits might we place on parents or family members serving as decision-making surrogates for their children?

? Family member / parent (if competent)Assume know or motivated to act in best interests "The most commonly accepted ethical standard that underlies surrogate decision making for children is based on a standard of best interest. When using the best interest standard, surrogate decision makers base their decision on what they believe will provide the most benefits and the least burdens for the child.

What is the difference between an 'absolute' and 'prima facie' duty?

ABSOLUTE: Applies without exception PRIMA FACIE: Applies unless an exception is warranted---- utilitarian approach to nonmaleficence

If it is a case study question about end of life care and active euthanasia.. lil johnny has cerebral palsy and has feeding tubes and pain, locked in a mental capacity of a toddler .....

Act utilitarian argument--- allowing the current situation to continue would cause enormous unhappiness to johny physically, his parents, anxiety of family members of friends and nurses and doctor who stand by as he withers away. Administering lethal injection would immediately end johns pain and prevent future suffering. the parents would greave but then would find peace that he is not suffering. same with the doctors who couldn't help relieve him.Although negative consequences would be that people might mistrust doctors with their children however the greater new happiness would result from mercy killing, therefore morally permissible Rule utilitarian - the key question would be which rule if consistently followed would produce the greatest net happiness. They might reason that by not following the rules there would be terrible consequences. It would cause widespread suspicion about actions and motives of physicians, people would come to distrust them which in turn would damage the entire health care system. This would also be A HUGE violation of the rules of medical practice which is do not harm. If you went through with the active euthanasia, then you would permit the suffering of some impaired children but this consequence isn't as catastrophic as those produced by not following the rules. .

Are there any limits to what patients (or their surrogates) ought to be able to choose?

Patient (and surrogate) choice is not unlimited (many argue).---Some argue: It is morally permissible to restrict patient (or surrogate) choice if a treatment is judged to be futile.

In your own words, explain the thinking behind the 'Principle of Humanity' (aka, treat others as ends).

Kantian is likely going to argue that the following actions (among others) are always wrong since they are against the categorical imperative to treat persons as ends: Slavery, Sexual Assault, Telling Lies, "Strong" PaternalismKant says persons are 'ends in themselves'. We have inherent, and not instrumental, value. (So even RU which grants respect for autonomy does so because it views persons as tools for the overall greater utility; not because it places some inherent value on respecting persons). A Rule Utilitarian supports consent (limited only by the Harm Principle) and argues that persons can do whatever they want, provided they are not harming others. A person may choose an action which brings harm to herself, as an individual, but - according to the Harm Principe - no one ought to interfere with such choices. Such choices are morally acceptable choices, if they are indeed chosen by the individual. Other perspectives - such as Kant's - do not agree and hold that individual may 'choose' some course of action but this choice can be wrong if it failed to show respect for persons. In other words, Kant believes that individuals have duties not only to respect others but also to respect themselves and their own worth and value. An action can still be wrong even if a person consents to it.

If a physician was following the Hippocratic tradition in medical ethics, what would be her motivating goal when interacting with patients

Medical paternalism is rampant in the old Hippocratic tradition. The health care professional was instructed to do what is beneficial according to his ability and judgment. It did not factor in benefit based on the patients' judgment of what was good. It did not consider the possibility that the patient might have a right to choose even if that choice did not produce the most good for the patient.. medical professionals need to benefit there patients with there own decisions. They have a role who have medical expertise and are morally required to use that knowledge on people

Utility

One ought to produce the most favourable balance of good over bad (benefit over harm) to all concerned."Morally right to make trade offs if the benefit is high enough. Absolute duty in Utilitarianism. maximize utility

What are the conditions of informed consent? Can adolescents give informed consent? Do adolescents have decision-making capacity

The law recognizes four instances in which minors will be treated as having the authority to consent on their own behalf: Emancipated minor rule: minors who are married or living substantially on their own may be deemed to have the authority to consent to medical treatment without parental involvement Mature Minor Rule: some minors may be found competent to make substantially autonomous choices. This option is normally reserved for older adolescents who can demonstrate that they have a substantial understanding of the nature of the choices to be made and sufficient autonomy to make a choice consistent with a developed life plan. In many jurisdictions, state laws authorize minors to obtain certain treatments without parental consent. These often include treatments for venereal disease, birth control, and, in some jurisdictions, abortion. The fourth basis on which a minor might make medical choices that warrant respect involves choices that are too trivial to make much difference." (Veatch, Haddad, and English, 2015"398-399 A patient possesses decision-making capacity if: -The patient makes and communicates a choice regarding medical treatment/course of action. -The patient appreciates the following information regarding medical care: ¬ medical diagnosis and prognosis ¬ nature of the recommended care ¬ alternative courses of care ¬ risks, benefits, and consequences of each alternative. -The patient makes decisions that are consistent with his/her values and goals. -The decision is not the result of delusion. -The patient uses logical reasoning to make a decision.

What is the "Principle of Limited Familial Autonomy"?

The parent or parents are not given the right of parental autonomy if they are deemed to be incapacitate or incompetent because of factors such as substance abuse, certain psychiatric disorders, minimal ability to comprehend the best interests of the child, or habitual physical abuse. OR The child should be treated even against the wishes of the parents to prevent or cure serious disease or disability. OR Blood transfusions should be given to a child of a Jehovah's Witness when transfusions are needed to protect the child from serious complications of disease or injury/ Court authority need not be sought in an emergency situation, as legal precedent protects the safety of the child."

Which arguments support the claim that patients (or their surrogates) have the right to refuse treatment?

They are competent autonomous beings and what ever brings about the most happiness is their decision

Double of doctrine effect

This doctrine says that if doing something morally good has a morally bad side-effect, it's ethically OK to do it providing the bad side-effect wasn't intended. ( LOOKS AT INTENTIONS) The principle is used to justify the case where a doctor gives drugs to a patient to relieve distressing symptoms even though he knows doing this may shorten the patient's life. This is because the doctor is not aiming directly at killing the patient - the bad result of the patient's death is a side-effect of the good result of reducing the patient's pain.

Is it okay for a doctor to lie or withhold the truth?

Yes, i agree with the therapeutic privilege with says that physicians can withhold information or lie to them for therapeutic purposes... the priveledge not to share information with them if the info would be medically harmful to the patient. Although Strong paternalism =question if its justified ---- arguments would say beneficence would say to lie????. Anyone that is ill or sick has diminished autonomy and mental workings ,,, fundamentally weakened.. so tis the physicians role to make decisions. Other arguments would say that theres no scientific proof that people do better if they have hope--- KANTIAN would say DON'T LIE... utilitarian would say depends on what brings about the most happiness

What does it mean to say that moral rules are 'categorical imperatives'? (in Kantian ethics

an unconditional moral obligation that is binding in all circumstances and is not dependent on a person's inclination or purpose.

Outline the arguments for and against the legalization of physician-assisted suicide and mercy killing

arguments in favor of voluntary active euthanasia: people are happier when their choices are respected (including the choice to die); actively ending a person's life can bring a quicker end to their suffering; passive and active euthanasia intend and bring about the same consequences and so if we accept passive euthanasia, we ought to accept active forms; the doctrine of double effect is unconvincing; physicians will be happier if they are able to fulfill their patients wishes to the end; patients have a right to self-determination which includes a right to die. Brock, for example, argues that legalizing active voluntary euthanasia would enable physicians, within a legalized and authorized framework, to respect patient's wishes to the end. It would bring comfort to those who choose euthanasia and to a majority who would be comforted in the knowledge that the option exists. Failure to legalize active euthanasia, while justifying passive euthanasia is inconsistent and unfair to those who are receiving no life-saving treatment, and risks allowing patients to endure prolonged death, rather than humanely and swiftly bringing life to an end. However, while consideration of the needs of individual patients can give support for euthanasia, some worry that the wider consequences of legalizing active euthanasia outweigh the ethical arguments which support active euthanasia. In other words, while ethical arguments from autonomy and mercy might judge a particular case of euthanasia to be morally justified, the law should not give general permission for active euthanasia. Laws will impact on a wider population and might cause more harm than good (especially to vulnerable patients). • These proposals are based on ethical and principles considerations (respect for autonomy, mercy, etc.). These arguments suggest that active euthanasia be restricted to those who have made a competent and voluntary request, are suffering from terminal illnesses (in considerable and incurable suffering), that reasonable alternatives to PAS or active euthanasia have been explored, and that there is accurate reporting of cases. It is open for us to consider whether other cases might ethically justify PAS or active euthanasia, but proposals for legalization currently require these conditions. Laws on PAS suicide within the US require that patients make a voluntary request, be terminally ill (less than six months to live) and that all actions of PAS be reported. It is not suggested that other types of active euthanasia (for non-terminal or life-threatening illnesses or without consent) should not be legal (although you can make that argument). • Arguments against legalizing appeal to the possible harmful consequences of euthanasia, including worries about a slippery slope from justified to unjustified euthanasia inlcluding: -Does legalizing euthanasia lead to a weakening of society's commitment to provide optimal care for the dying? -Would legalizing euthanasia lead to more court involvement in decisions of withdrawing treatment? Would this be bad? -Would legalization of voluntary active euthanasia for terminal illness lead to the legalization of others forms of euthanasia? (Would this be bad?) "some foresee that . . . legalizing euthanasia would weaken society's commitment to care for dying patients, We live at a time in which the control of health care costs has become, and is likely to continue to be, the dominant force of health care policy. If euthanasia is seen as a cheaper alternative to adequate care and treatment, then we might become less scrupulous about providing sometimes costly support to dying patients." (Brock, 2017:652)

Hypocratic oath

medical professionals need to benefit their patients with there own decisions. They have a role who have medical expertise and are morally required to use that knowledge on people

Non maleficence

o "One ought not to inflict evil or harm."Negative principle to avoid harm. Key principle in biomedical ethics - prima facie( meaning you follow rules unless theres an expection) requirement in Utilitarianism. One can cause harm if it is for a greater benefit. Utilitarianism supports a (prima facie) duty of nonmaleficence:

Beneficence

o - Key principle in biomedical ethics - absolute and overriding requirement in Utilitarianism. We should do good to others." Positively promote the good of others and their well being(not merely avoid causing harm). Impartially pursue the most good in the world.

• Outline the arguments in favor of strong paternalism, and also explain the arguments against strong paternalism.

o Arguments FOR paternalism: ¬ P1) Disclosure of information to the patient will sometimes increase the likelihood of depression and physical deterioration, or result in the choice of medically inoptimal treatment. ¬ P2) Disclosure of information is therefore sometimes likely to be detrimental to the patient's health, perhaps even to hasten his death. ¬ P3) Health and prolonged life can be assumed to have priority among preferences for patients who place themselves under physician's care. ¬ P4) Worsening health or hastening death can therefore be assumed to be contrary to patients own true value orderings. ¬ C) Therefore, paternalism is justified: doctors may sometimes override patient's prima facie rights to information about risks and treatments or about their own conditions in order to prevent harm to their health. ¬ Medical paternalism is justified *if we assume that everyone wants medical benefit, *assume that everyone wants health and long-life, and *Recognize that healthcare professionals are experts in medical benefit ¬ Therefore, can be justified in making decisions on behalf of patients when patient 'choice' might interfere with medical benefit: ---E.g. patient may disagree based on lack of knowledge/understanding. ----E.g. patient might make the wrong choice. ----E.g. patient might experience worsening in health if given options or is told the truth. ARGUMENTS AGAINST PATERNALISM: "Health is viewed by virtually everyone as good, as something intrinsically desirable. Yet there are many other goods that rational people desire as well. These include knowledge, aesthetic beauty, and psychological and material well-being. Often, unfortunately, these various goods that people want to pursue compete for scarce resources including time, money, and energy. Deciding what mix of goods is the proper one is a complex and highly individual decision...people constantly sacrifice their future material well-being for the pleasures of the moment, so they also make some compromise with their health for other goods they consider important." (Veatch, Haddad, and English, 2015:67) o "no rational person wants to maximize his or her medical well-being. People have goals for well-being that have nothing to do with their health. Health is an important goal, but not the only one. Sometimes marginal gains in medical well-being can come at the price of serious losses in other spheres. Sometimes those small medical gains are simply not worth it to the patient." (Veatch, 2016:51)

Autonomy

o Autonomy refers to a person's rational capacity for self-governance or self-determination - the ability to direct one's own life and choose for oneself. The principle of autonomy insists on full respect for autonomy.delivering a complete picture of their prognosis and treatment options so patients can take an active role in their own healthcare"...The right to refuse treatment.The right to give informed consent.The right to privacy.The right to competent medical care provided with 'respect for human dignity'.

What is "beneficence" and why is this principle most supported by the Utilitarian approach to ethics?

o It is the key principle in biomedical ethics - absolute and overriding requirement in Utilitarianism. We should do good to others." Positively promote the good of others (not merely avoid causing harm). Impartially pursue the most good in the world.

Explain the three main aspects of utilitarianism

o happiness- what brings about the greatest happiness to ourselves and others, capable of sacrificing our own happiness for others... this is one aspect we might think was important in living a good life. A life with overall more pleasure than pain o Consequentialism- Actions are judged as right or wrong solely based on the consequences they bring about. Nothing else matters. In principle one might be morally obligated to perform any action [kill, lie, break a promise, steal, cause harm. Such actions may be morally obligatory if they bring greater overall benefit. Note: Intention, Action, Consequence. Classical (Act) Utilitarianism is consequentialist because it states that no act - in itself - is intrinsically wrong. Instead, the rightness (or wrongness) of an act ought to depend entirely on its consequences. o Equality/Impartiality- Happiness is desirable and good. Each individual wants to be happy. The right action (overall), however, is not the action which (necessarily) maximizes my own happiness (or that of my friends/family). It is the action which has the highest overall utility in comparison with alternative. "In deciding what policies or laws to enact, a government should do whatever will maximize the happiness of the community as a whole" equal consideration to everyone and the highest utility over all.

Justice

o justice refers to people getting what is fair or what is their due.' ***BOTH AUTONOMY AND JUSTICE ARE are not given ultimate priority within Utilitarianism are the principle of 'autonomy' and justice'

Thereapuetic priveldge

physicians can withhold information or lie to them for therapeutic purposes... the priveledge not to share information with them if the info would be medically harmful to the patient. Strong paternalism =question if its justified ---- arguments would say beneficenece would say to lie???? Confused. Anyone that is ill or sick has diminished autonomy and mental workings ,,, fundamentally weakened.. so tis the physicians role to make decisions. Other arguments would say that theres no scientific proof that people do better if they have hope--- KANTIAN would say DON'T LIE... utilitarian would say depends on what brings about the most happiness

If she asks a case study about Refusing treatment and if it is morally ok? pg 82

refusing treatment makes patient autonomy and physician beneficience collide. Prompts the question is it ever morally permissible for a physician to treat a patient against her will? --- they can refuse treatment now legally even life saving ones... also it is legal to follow a competents person wishes if they do an advance directives.

vaco v quill

¥ supported the legality of passive euthanasia. Physicians have a duty to respect patients wishes and to give treatments which are not judged to be medically futile. Patients have a right to refuse treatments. If patient or surrogate refusal results in death of patient, the patient has not been killed.

Define active vs. passive and voluntary vs. non-voluntary euthanasia

¬ Voluntary passive- Withholding or withdrawing life-sustaining measures with the consent of the patient. ¬ Involuntary passive - Withholding or withdrawing life-sustaining measures without the consent of the patient. ¬ Voluntary active- Directly causing death with the consent of the patient. ( mercy killing or physician assisted suicide) ¬ Involuntary active- Directly causing the death of a patient without the consent of the patient.

What are 'rationality' and 'autonomy'? Why does Kant think these are important in ethics? Why does the Kantian approach give good support to the principle of autonomy in bioethics

• "Persons" are those beings who are rational and autonomous. Rational: Persons can use reason to tell them how to pursue their goals. Autonomous: Persons are capable of directing their own lives; determining their own ends; with ultimate responsibility for the choices they make. we are rational and autonomous which makes us special... peersons can make our own decisions and choices kant says that's what gives us dignity and makes us respectable--- you show respect to someone by treating them as an "ends "not a means" ---

Which arguments support the claim that there is a moral distinction between passive and active euthanasia?

• ---- "There is considerable agreement about the moral rightness of allowing a patient to die but intense controversy about the permissibility of deliberately causing a patient's death" One reason for supporting passive, but not active, would be if we could draw a relevant moral distinction between the morality of acts vs. omissions. Many argue that there is a moral difference between bringing about death as a result of an omission (e.g. failure to begin treatment or the withdrawing of treatment - withdrawing treatment is an act but its treated as an act of omission; no longer providing the means to support continued life), and using lethal measures to bring about the death of a patient. One could be seen as allowing the patient's condition to kill them; the other involves a patient or the physician initiating the death by introducing 'external' means. Other reasons to support a distinction between active and passive euthanasia argue that the intention of physicians in passive euthanasia is not to kill their patients but merely to respect their wishes to refuse treatment. Respecting a voluntary request to forego treatment (with the consequence that a person dies) is very different from taking active measures which hasten death.

What does it mean to treat people as 'end in themselves'? To what extent do you agree with this principle?

• ? Treating someone as an end is treating them with the 'respect they deserve'. Recognizing that they can reason and make their own choices; recognizing that they are capable of directing their own lives and showing respect for them because these capacities give them inherent worth.

What theory best supports the 'Hippocratic Tradition' in medicine?

• Act utilarianism bc Hippocratic traditions in medical ethics emphasize the idea that physicians ought to treat patients according to their [the physicians] own "ability and judgment" (as opposed to consulting with the patient over their wishes and values). . Hence, the Hippocratic ethic is often considered paternalistic; that is, it approves of actions intended to benefit another person even if that person does not want the benefit.

Is the principle of Hippocratic Utility primarily important in modern medicine? Compare the principles of 'doctor knows best' with 'patient knows best'

• In many situations, what is best for the patient will be determined by . . . the patient. Utilitarians will argue that the patient usually knows what he or she wants, and if we adopt a preference-maximizing stance, then this approach would say that the best thing to do in any situation is whatever will bring about the highest benefit to the patient (with benefit here being understood as what the patient wants). Even on a pleasure/pain viewpoint, we can discover which action would cause pleasure vs. pain often by consulting those involved (and in many cases primarily the patient). Note that this is a slightly different approach than was used in the past where the idea that physicians had a duty to benefit the patient but 'according to their [the physicians' own judgment]. Treatment was given according to what a doctor judged to be best, rather than by consulting the patient and knowing her preferences or values. What follows from all of this is that for those individuals who have preferences and can say what those preferences are, the Utilitarian would often be in favor of allowing whatever treatments or withdrawals of treatment that the patient judges would be in their best interests. This will often be a choice which reflects a desire to avoid pain and increase pleasure (or at least avoid pain) but it won't always be such a choice. Since it is a consequentialist approach, the Utilitarian is going to say that (in principle) no action, treatment, or withdrawal of treatment could be inherently wrong. Instead they are going are going to say that any number of steps may be taken if it is judged that they will bring about the best results for the patient.

What are some of the ethical issues that arise around the idea of "medical futility"?

• Medical futility" refers to interventions that are unlikely to produce any significant benefit for the patient. "the burden on the patient of starting or continuing treatment is far greater than any possible gain in quality or continuation of life" (Campbell, 2017:83) Treatments often considered medically futile include cardiopulmonary resuscitation (CPR), medications, mechanical ventilation, artificial feeding and fluids, hemodialysis, chemotherapy, and other life-sustaining technologies. (Butts and Rich, 2013:262)

Kantian view

• RESPECT FOR PERSONS bc they are rational and autonomous.means end----- kant says that when we are thinking about what to do--- he says when we think about thats importatnt to people and what determines permissible ways to interact with people we are rational and autonomous which makes us special... peersons can make our own decisions and choices kant says that's what gives us dignity and makes us respectable--- you show respect to someone by treating them as an "ends "not a means" --- a means means that you are using them to help your goal... he says if you tell someone a lie you are doing something that the person might not want, you are using them as a means bc you are choosing to lie Ex) we use our teacher as a means bc we are using her to help us for the exam... but we also treat her as an end bc she is consenting and its consitient with her goals and happiness. Consent matters...bc people hold value in their decisions being respected --- when you interact w someone and view them as how can I use you for a tool for your purposes you are treating someone as a meer "means"—only looking at you as a tool for a goal ---kant said suicide was wrong,... people have dignity in person and you aren't allowed to use yourself as a means to end your suffering.. theres an ultimate requirement of a person to respect life. Kantian would say everyone has negative duties to not lie or kill but also positive duties to help people who needs assistant..

Why might Act Utilitarianism have a problem in accounting for 'respect for autonomy'?-

• because at the end of the day if they need to disrespect autonomy they will If they think it will result in the greatest utility ( an act is permissible if it brings about the greatest utility). Such as the example of a doctor doing treatment without a patients consent because it would help them however it might go against the utilitarian rule of "respecting autonomy"

Give an example of how you might treat someone as a 'mere means' and an examples of treating someone as an 'end'

• means means that you are using them to help your goal... he says if you tell someone a lie you are doing something that the person might not want, you are using them as a means bc you are choosing to lie Ex) we use our teacher as a means bc we are using her to help us for the exam... but we also treat her as an end bc she is consenting and its consitient with her goals and happiness. Consent matters...bc people hold value in their decisions being respected --- when you interact w someone and view them as how can I use you for a tool for your purposes you are treating someone as a meer "means"—only looking at you as a tool for a goal ---kant said suicide was wrong,... people have dignity in person and you aren't allowed to use yourself as a means to end your suffering.. theres an ultimate requirement of a person to respect life. Kantian would say everyone has negative duties to not lie or kill but also positive duties to help people who needs assistant..

What is "paternalism"? (Strong vs. Weak)

• paternalism is the intentional overriding of one person's preferences or actions by another person, where the person who overrides justifies this action by appeal to the goal of benefiting or of preventing or mitigating harm to the person whose preferences or actions are overridden WEAk paternalism would be such as if a doctor infringes on someones autonomy and detains a person in a mental hospital because they are pulling their hair out STRONG --the overriding of a person's actions or choices even though he is substantially autonomous." )Decisions made on behalf of another person where that person "does not accept the values used to define his or her own best interests."