Bioethical Film Festival

GBS AP Biology

Matters rarely are as simple as they sometimes seem. Concepts of right and wrong, morality, values, social mores, scientific beliefs, and religious beliefs can be surprisingly different among cultures, ethnic groups, and populations. Before we can make good decisions about controversial subjects, we should be well-informed about the important aspects of issues in question. We should entertain opposing viewpoints; they stimulate critical thinking skills and produce a free exchange of thoughts and opinions. Tolerance of views that are in conflict with your own position during a time of inquiry is a necessary step toward understanding and eventual enlightenment. Unit Objectives:

1. Engage in moral reasoning, debate, and critically reflect on contemporary bioethical issues.

2. Understand a working knowledge of fundamental concepts and forms of philosophical ethics as they are applied to dilemmas in bioethics.

3. Analyze the ethical implications of decisions in bioethics and society as a whole.

4. Consider questions of resource allocation in accordance with ethical and professional standards.

5. Articulate ethical positions with clarity and evidence of critical thinking.

6. Write about bioethical dilemmas in terms of philosophical ethics.

ETHICAL DECISION-MAKING "A Self-Study" for the AP Bio Bioethical Film Festival. Please read this material before we begin our viewing~

Moral dilemmas result when values conflict. A choice must be made between options, all of which seem desirable or all of which may seem undesirable. Or doing a good thing threatens to produce serious harm as well as benefits. For instance, an actual case:

Dr. Strong says to Geraldine, the nurse, "You must get the patient to take this medicine. Don't take no for an answer!" The nurse, however, felt there was a problem. If the patient did not want to take the medicine he should have the right to refuse it. But in that case the patient would probably experience serious medical complications.

The case illustrates how a moral dilemma is multi-faceted--you can only see all sides of it by looking at it from different perspectives. Various ethical theories give us those perspectives. Some theories relevant to bioethics follow.

I. CONSEQUENTIALISM What are the consequences of the contemplated action--for the patient, hospital, physician, family, etc. Which is the most desirable consequence(s)? In essence, the bottom line: which action produces the most advantages and fewest disadvantages for the most parties?

This is consequentialism--concern for the good results without regard for how they are obtained. There are no inviolable principles except that one must produce the best effects possible. The effects determine whether the action was right or wrong. Dr. Strong was right to make the patient take the medicine, according to this very helpful theory, because the medicine would prevent a serious medical problem; not taking the medicine would produce harm. Even a "little white lie" would be ethical if needed to get him to take the treatment.

Sounds good, right? But wait! That means one does not need to be truthful to the patient and one does not need to honor his informed decision, simply because forcing him to take it will produce greater good than the good of honoring his decision while allowing him to get seriously ill.

By the same reasoning one has the right to prescribe a placebo, for example, without informing the patient (informing will likely destroy the placebo effect) if it will relieve pain (good) without endangering respiratory functions (bad, and a danger with the non-placebo pain killer)--good consequences for the patient. The goodness of the effects make it an ethical course of action, no matter how one achieved it.

We do this, don't we? Have you ever said, "I don't care how you do it, just get it done!" But let's look at the case from another perspective.

II. DEONTOLOGICAL ETHICS This big word comes from the Greek word deon, which means duties. The big idea is that some actions are a duty, required, obligatory, regardless of the consequences (see how this conflicts with the theory above where the end justifies the means?). For example, don't we have a right to be truthful with patients, or each other? Would you like people to be truthful with you, particularly if you are in the hospital for a possibly serious condition? Don't we have a duty to respect the rights of patients to be fully informed and self-determining? To be true to our own professional ethical code? To keep the Ten Commandments? And not to break these obligations when we think it would be convenient for its effects?

Well, there are other considerations, of course. We can do the right thing by our standards and be quite moral--but with disastrous consequences for the other person (patient, family, hospital, physician, etc.) What of compassion, common decency, human welfare--do we sacrifice those for our "higher" duty? An example: to fully inform, to tell the truth to a patient when such information likely would produce a psychotic break or cardiac arrest--would that be ethical? If a patient is dying of cancer and probably will not live more than a day or so more but is waiting to see his daughter, whom you know has just been killed in an automobile accident getting to the hospital, and he asks you where is she and when will she get there, what would you do--lead him to believe you don't know her situation (a lie) or tell him the truth (a duty)?

Here would be a good place to say a word about ethics of care, which is not really a decision-making theory but is vital, owing its formulation to women who insist that decisions are not simply cognitive matters devoid of the real values of emotion, relationships, compassion, and care.

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III. ETHICS OF CARE This is a reminder that many situations involve human relationships, human tragedies, and the like, which are not to be settled simply by some ivory tower, detached, abstract principles by someone who doe not feel the pain or consequences, does not care how the parties are affected, or who acts morally but in a way that harms or depersonalizes. Logic and cognitive processes are not the only or necessarily the highest authorities; feelings are as legitimate and thoughts, and feelings often will lead us to the best decision when our rational deliberation is either unbalanced or totally inappropriate to the situation. Care, compassion, feeling, and such considerations balance cognition, principles, and objectivity.

For example, a patient has certain "patient rights." These are listed in hospital literature. However, this particular patient is part of broad family relationships (as well as other relationships: with her own life, property, values, faith, dreams, etc.!) The family is vulnerable, scared, grieving, and immersed in the situation. They too have rights. They are within the hospital's care. Should not their well-being be a balance to the patient's rights and our sometimes narrow devotion to the listed rights of the patient? The ethics of care broadens our vision to include relationships which are so very vital and valuable and to include values such as compassion, having a good death, or the like.

With that said about care, we look at another system for decision-making.

IV. PRINCIPLISM This is probably the most widely used ethical framework in American healthcare for dealing with ethical conflicts. Its authors present it in Tom L Beauchamp and James F. Childress, Principles of Biomedical Ethics, 4th ed., 1994.

This theory says there are four principles central to resolving conflicts in medical practice. They are:

1. Nonmaleficence2. Beneficence--do good 3. Autonomy--respect the individual's rights to be self-determining 4. Justice--the right to fairness

According to this theory:

1. no one of the principles is automatically more important than any other.2. but in a particular situation, one principle may "trump" or be more valuable than the others3. each principle must be protected where possible, so that all principle are balanced as much as possible.4. each principle must be considered, weighed, and evaluated against the others.5. the decision will reflect efforts to honor all four principles.6. two people may come to different conclusions using this system when considering the same set of data because each may place a different value or weight on the various principles.7. it must be repeated that going into the consideration of an ethical dilemma none of these principles is intrinsically primary, more valuable, or of greater importance than the others. After weighing all in the situation one will be weighted heavier and will lead to the solution but this is not a foregone conclusion.

A fuller explanation of each principle is helpful:

1. Nonmaleficence Nonmaleficence is a big word meaning we are obligated not to harm another person . It can mean harm physically, emotionally, or in other ways such as putting a person at risk.We want to do good without harming and while respecting rights and fairness. But sometimes two or more of these conflict. Sometimes the duty to avoid harming a patient is more pressing than the duty to do positive good. For example, CPR, perhaps extending the life a few days or weeks, for a frail, elderly, dying woman risks painful broken ribs; avoiding CPR, allowing the woman to die, may be better than attempting a procedure that likely will produce serious injury, has low rates of success, and gains only a few days or weeks of life.At other times the duty to do good overrides the duty to avoid harm, as in the provision of dangerous chemotherapy drugs, with all their poisonous impact on the body, to combat cancer in a child.Thus, at times the doing good (beneficence) produces great harm; this is seen in the case of providing great doses of pain medication (beneficence) to kill great pain, but simultaneously depressing respiration (nonmaleficence) to dangerous levels. Which is the higher call, beneficence or nonmaleficence, when they conflict? -2-

Here, fortunately, we sometimes are rescued by an established principle called the rule of double effect. When a treatment has a good effect, such as relieving severe pain, but also a serious harmful effect, such as dangerously suppressing respiration, it is permissible to provide the treatment (with its harmful effect) when the goal truly is to provide the good effect and the means of doing it are good. The harm then is unintended and unavoidable. (Another example, if needed for clarity, would be providing desperately needed surgery (good), which will repair a perforated colon, but which may overtax a weak heart and cause death in the operating room or during recovery.)

2. Beneficence Beneficence refers to our moral as well as contractual calling (a hospital or health personnel's implied contract) to benefit a person who seeks it and when it benefits. For example, are we obligated to provide a heart transplant for a patient who comes to the hospital, clearly needing a heart transplant to survive, but who has a long history of non-compliance with medical and self-care (the principle of justice will apply here)?

We must also ask, "Is this a benefit in the patient's view?" Providing intravenous hydration is almost automatic when dehydration is present, and it is a benefit for many people, but for someone who is dying it might be harmful rather than beneficial because it prolongs the dying (which patients often welcome--a benefit), thus adding suffering to patient and family.

3. Autonomy Autonomy means self-determination, the right to choose, to control one's own life and destiny, and the acceptance of responsibility for one's life, choices, course of treatment, and consequences. Autonomy derives from our respect for personhood; it limits the use of power (which we often have, in great abundance) over others.

For autonomy to be real, a patient must be capable of understanding the situation with its risks, benefits, and alternatives, and of reasoning through to a decision. This places on caregivers the obligation to inform the person adequately and to determine decisional capacity.

Autonomy is highly valued in the United States. Though personal autonomy seems almost an inalienable right it is, however, often limited by other values. A single parent of three small children generally is not allowed by the courts to refuse medical procedures which will save the parent's life--foregoing the treatment violates the best interests of the dependent children. Or a confused patient is not competent to make decisions for herself and does not have autonomy. A Jehovah's Witness parent is generally refused the autonomous right to decline a blood transfusion needed to save his or her minor child's life. At other times a patient's autonomous choice of treatment may conflict with the physician's ethics, professional judgment, duties, and/or rights, such that the choice will be refused.

4. Justice Justice is harder to define and pin down, but we know that justice is a basic right of U.S. citizens and a basic provision of our government and society. We have a right to justice. Justice is often divided into comparative justice and distributive justice.

Comparative justice means that what one person needs/deserves/gets is compared to the similar needs of others in society. Should this one person get the heart transplant, at a cost of $500,000, which will provide him five years of life probably, but which means that the $500,000 is not available for 5 adolescents who could benefit from it probably for a full lifetime? Or: Person A (perhaps a person on welfare) has been on dialysis waiting for a kidney transplant for five years; person B (perhaps a celebrity) is newly diagnosed with renal failure; who gets the kidney? Or: is it just for one hospital department (say, radiology) to get many high cost items while another important patient care department gets almost nothing new in the coming year. This is a comparing of needs and competing claims.

Distributive justice (how medical care is distributed in society) doesn't consider competing claims of individuals. Distribution of medical services is according to principle. For example, in principle, all people who enter the Emergency Room needing care will receive it. That is common practice and law. Failure to provide it for one person calls into question the justice of the distribution of care by that Emergency Department. Baptist hospitals are committed by principle to providing care for all who need it, regardless of ability to pay, race, religion, citizenship, or other considerations. This provides distributive justice (care distributed to all who arrive needing it), but those hospitals must decide, again in principle, how they will justly use and distribute the limited resources they have.

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Some Concepts to Know 1. Rights--What we call "rights" are not always absolute, and sometimes we should use the word "obligation" rather than rights (as in "We are obligated to provide the best health care we can for those unable to pay," but that is not to say "Every citizen has a right to basic health care." Some would say neither of these statements are true, but the illustration is appropriate. ) The claim to a service, or to a right such as self-determination is often relative--it's claim must be balanced against other competing and conflicting claims or rights. One person's rights may conflict with another person's just rights. So, in examining ethical conflicts we must not assume that what we call rights are not to be challenged. Often we truly should speak of obligations or goods rather than "rights."2. Futility--Some medical treatments will not attain the goals for which the treatment is intended. The treatment may have a profound physiological effect, exactly the one sought, yet not achieve a benefit or a goal the patient would deem desirable. A physician is not required to perform or order a treatment he or she deems ineffective for the goal intended, though an effect well might be achieved. (Often, we also balance the benefit to be achieved versus the pain/harm to be inflicted, the expense of the procedure, or the danger involved--thus the balancing/weighing of principles and values.3. Grave Burden--The first question is whether a treatment is effective, but the next often is, "Does it impose an excessive burden on the person or the loved ones?" This burden, or effect, is not just physiological. Burdens, or suffering, are also psychological, and/or social/relational, and spiritual. Sometimes when a loved one dies the family experiences joy and relief, not that they are happy the person is dead but that the burden has been lifted. Medical treatment is intended to restore or maintain one's ability to enjoy the goods of life. If treatment cannot do that (as in persistent vegetative states), why is the treatment provided??? Except when called for by law, treatment is not required when its provision produces a burden (nonmaleficence) greater than the benefits (beneficence)--again the balancing of principles, goods, values.4. Suffering--It is not the same as physical pain necessarily, though pain produces suffering. One may truly suffer from the effects of incapacity, bodily mutilation, loneliness, disfigurement, loss of self-esteem, identity, etc. The emotions one experiences or the mental awareness of certain realities (such as one's own imminent death, or the loss of a loved one, or one's responsibility for another's pain) can produce great suffering, and these mental states of suffering (not physical pain) are the one's so powerful that people end their lives to end the suffering. One can say generally that suffering is present when the self or the body is seriously assaulted in its wholeness.5. Life-Prolonging Treatment--I will use Kentucky law as an example.

According to Kentucky law, life-prolonging treatment is any treatment that prolongs life when death would occur within a short time. Any treatment:

Life-prolonging treatment means any medical procedure, treatment, or intervention which:

1. uses mechanical or other artificial means to sustain, prolong, restore, or supplant a spontaneous vital function; and2. when administered to a patient would serve only to prolong the dying process. (Not to include measures to alleviate pain)

For example, antibiotics may slow the dying, which draws out suffering for patient and family (antibiotics in other cases may be a desired comfort measure). Measures to boost blood pressure or stabilize cardiac rhythms often prolong dying--actually causing harm rather than benefit, and, if the patient and family do not understand this effect of the seemingly but not actually helpful intervention (causing harm rather than benefit), it also violates the right of self-determination (autonomy) (having enough information to make an informed decision).

6. Paternalism--this means acting paternally, like a parent, in the sense of, "I know what you need better than you do. Just do as I say." It is generally inappropriate, often conflicting with autonomy (self-determination). At other times it may be appropriate, as in the case of no decision-maker being able to make an informed decision; then, often the healthcare provider has the duty to do what he or she thinks is best (beneficence) for the person.

7. Terminal Condition--Again, in Kentucky law, it is defined as "a condition caused by injury, disease, or illness which, to a reasonable degree of medical probability, as determined solely by the patient's attending physician and one other physician, is incurable and irreversible and will result in death with a relatively short time, and when the application of life-prolonging treatment would serve only to artificially prolong the dying process."

8. Values--we must distinguish between our values and the patient's values (what we would want if we were in that situation may be totally at odds with what this individual wants, or would want if he or she could speak). Providing a medical treatment may seem appropriate to a care giver because "life is precious" but the patient may believe otherwise and perhaps sees clarity of mind (no clouding due to treatment) in the last hours as a greater, more precious value, or may see death as more precious (often the case). Or, independence may be the highest value for a man who has farmed all his life, whereas we may think that "a nursing home is not so bad," or "you can still live without your legs." Values--whose are they?

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By the way! Remember the case with the patient Bob, Dr. Strong, and Geraldine??:

Dr. Strong says to Geraldine, the nurse, "You must get the patient to take this medicine. Don't take no for an answer!" The nurse, however, felt there was a problem. If the patient did not want to take the medicine he should have the right to refuse it. But in that case the patient would probably experience serious medical complications.

It should seem simpler now to pick out the ethical issues. You may see other issues, but the following at least seem true:

1. The physician is acting paternally--which just might be appropriate in this case (is the patient competent to make the decision?). And the physician is using consequential ethics, that the good end result justifies overpowering Bob. 2. The physician is trying to do good (beneficence) for the patient 3. Patient autonomy (if patient is able to make informed decision) may be overridden 4. Nonmaleficence is involved if treatment is NOT provided, if failure to provide it would harm Bob by making bed sores likely. Thus honoring autonomy by not providing treatment would mean the principle of autonomy in this case wins out over beneficence (providing the good) and nonmaleficence (doing no harm). 5. I would say that if this patient is fully informed of the risks, benefits, and alternatives of treatment, and if he is able to reason competently through to a decision (not seriously clouded or distorted by depression, misconceptions, pain, senility, etc.), then refusing the treatment should be honored by the medical personnel. If the patient cannot make the informed decision, it should go to a substitute decision-maker (next-of-kin or surrogate), and if that is not possible the physician and hospital have a duty to provide treatment to avoid the harm.

What would YOU say???

(Thanks to Dr. Stuart G. Collier for his help with this material.)

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After viewing (lab procedure grade component) each one of the selected films, critique, in word-processed and numbered paragraph form the bioethical dilemma/s presented using the criteria below. 

1. Identify the dilemma. Some dilemmas are obvious and others are more covert. 2. Describe the involvement of individuals, discussing their histories when appropriate.

3. Define the action or actions surrounding the dilemma, noting contexts and intentions.  4. Discuss the implications or consequences of the action. 

5. Using the information in this packet, identify the moral principles enhanced or negated by the course of action (e.g. self-determination, truthfulness, beneficence, justice, etc.)

6. Identify or propose alternative choices. For example, if the ethical dilemma has not been resolved, what do you feel would be the most ethical way to resolve it? What ethical theory fits your solution? Support your arguments.  

Your essay should be a 2-3 page analysis of the ethical issue depicted in the movie.

(Thanks to Dr. L. Newton and Dr. Fleitas at Fairfield University, Fairfield, CT for their help with this material.)

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The Assignment:Bioethical Film Festival

GBS AP Biology

Suggested films: Some bioethical issues depicted in the films below are obvious. Others are not as overt. While watching each film, it would be helpful in the construction of your essay assignment to take notes.

_____ • Altered States (1980)~ A scientist becomes involved with primal research, using himself as guinea pig with mind-bending results. (Bioethical issue: human experimentation)

_____ • Andomeda Strain, The (1971)~ A U.S. Army satellite (Scoop VII) falls to earth near Piedmont, New Mexico. The recovery team experiences difficulties as it becomes clear that the satellite has performed its intended function all too well, and has brought back something from space. A team of

scientists is assembled to identify and defeat the "enemy" before it is too late. (Bioethical issue: human influence)

_____ • And The Band Played On (1993)~ Dramatization of the Randy Shilts best-seller about the early years of the AIDS epidemic. (Bioethical issue: H.I.V.)

_____ • Awakenings (1990)~ Powerfully affecting true-life story of a painfully shy research doctor who takes a job at a Bronx hospital's chronic care ward in 1969 and discovers that his comatose patients still have life inside them. (Bioethical issue: human experimentation)

_____ • Boys From Brazil, The (1978)~ Former Nazi chieftain Dr. Josef Mengele has insidious plan to breed new race of Hitlers. (Bioethical issue: cloning)

_____ • Cocoon (1985)~ A group of senior citizens residing in a rest home find their lives turned upside down after they are offered the gift of eternal youth by benevolent aliens in Ron Howard’s tribute to the human spirit. (Bioethical issue: aging)

_____ • Critical Care (1997)~ A young resident, already cynical about the medical system and his career, is drawn into a controversy over a patient who's on a life support system, and whose two daughters disagree about his future. (Bioethical issue: life support)

_____ • Doctor (1991)~ Successful surgeon is diagnosed with throat cancer--and for the first time in his career, learns what it's like to be a patient at the mercy of cold-blooded doctors and a bureaucratic hospital. Perkins stands out in a showy role as fellow cancer patient. Engrossing, well acted, and utterly believable; based on Dr. Ed Rosenbaum's own experiences, described in his book A Taste of My Own Medicine. (Bioethical issue: patient rights)

_____ • Elephant Man, The (1980)~ Based on the true story of John Merrick, a 19th-century Englishman afflicted with a disfiguring congenital disease. With the help of kindly Dr. Frederick Treves, Merrick attempts to regain the dignity he lost after years spent as a side-show freak. (Bioethical issue:

human treatment of deformities)

_____ • Erin Brockovich (2000)~ An unconventional drama based on true events, starring Julia Roberts as the twice-divorced mother of three young children who sees an injustice, takes on the bad guy and wins. (Bioethical issue: environment)

_____ • First Do No Harm (1997)~ When Lori Reimuller (Meryl Streep) learns that her young son Robbie (Seth Adkins) has epilepsy, she first trusts the judgment of the hospital staff in how best to bring it under control. As Robbie's health slides radically downhill, however, she becomes frustrated and

desperate, and so does her own research into the existing literature on treatments. (Bioethical issue: alternative medicine)

_____ • Fly, The (1986)~ Goldblum is just right as slightly crazed scientist who tests himself in a genetic transporter machine--and starts to evolve into a human fly. (Bioethical issue: human experimentation)

_____ • GATTACA (1997)~ In the near future, parents can choose to have all genetic imperfections eliminated from their children prior to birth. (Bioethical issue: genetic engineering)

_____ • Handmaid’s Tale, The (1990)~ Set in a time when a buildup of toxic chemicals has made most people sterile, Volker Schlondorff's film offers a disturbing view of a society under martial law in which fertile women are captured and made into handmaids to bear children for rich and infertile

matrons. (Bioethical issue: human experimentation)

_____ • If These Walls Could Talk (2000)~ Strong abortion-themed trilogy about three women and the ways they deal with unplanned pregnancies in different social and political climates. (Bioethical issue: abortion)

_____ • Island of Dr. Moreau (1996)~ A ship-wrecked man floats ashore on an island in the Pacific Ocean. The island is inhabited by a scientist, Dr. Moreau, who in an experiment has turned beasts into human beings. (Bioethical issue: human experimentation)

_____ • Jurassic Park (1993)~ Based on Michael Crichton's novel about an island amusement park populated by cloned dinosaurs, the film works best as a thrill ride with none of the interesting human dynamics. (Bioethical issue: cloning)

_____ • Lorenzo’s Oil (1992)~ True-life story of Michaela and Augusto Odone, who learned their son had adrenoleukodystrophy, an incurable degenerative disease, and proceeded to turn the medical community upside down to keep him alive. (Bioethical issue: alternative

medicine)

_____ • Philadelphia (1993)~ Up-and-coming lawyer is battling AIDS; when he's fired from his prosperous Main Line Philadelphia law firm, he decides to bring suit. (Bioethical issue: H.I.V./A.I.D.S.)

_____ • Rain Man (1988)~ What begins with a cold-hearted attempt by one man to steal his autistic brother's inheritance evolves into a cross-country odyssey of love, family and self-discovery. (Bioethical issue: autism)

_____ • Soylent Green (1973)~ In the year 2022, Manhattan has become an overcrowded hellhole; cop Heston, investigating murder of a bigwig, stumbles onto explosive government secret. (Bioethical issue: overpopulation)

_____ • Wit (2001)~ Based on the Margaret Edson play, Vivian Bearing is a literal, hardnosed English professor who has been diagnosed with terminal ovarian cancer. During the story, she reflects on her reactions to the cycle the cancer takes, the treatments, and significant events in her life.

(Bioethical issue: medical treatment) -7-_____ • Write in Candidate ______________________________________________ ( Bioethical issue: ________________________ )