Bioethics Slides

7/30/2019 Bioethics Slides

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Ethical Issuesin Health

Research inDevelopingCountries

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The Place of Clinical

Bioethics in Health Careand Philosophy

Dan W. Brock

Harvard Medical School


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Introduction

Place of clinical bioethics in health care

Why has it been a growth industry?

Will it continue to be?

New technology has brought new choices

Relation of bioethics to philosophywhy doesclinical bioethics need philosophy?

Often, there is no clear, uncontroversial answer

about what to do


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Development of Bioethics

I Professional Code of Conduct

Example: May doctors advertise?

II Public Debate over Clinical Issues

Example: Who decides when to pull the plug?

III Structure and Financing of Health Care SystemExample: What is a fair system of health insurance?

IV Population-level Bioethics

Example: when are health inequalities unjust?


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Why Arent the Ethical Views YouAlready Hold Enough?

The problem of uncertaintywhere youre

unsure about some ethical issues.

E.g. terminal sedation

The problem of disagreementthere is

sometimes deep disagreement on ethicalissues, e.g. PAS

Some disagreement is about facts

But other disagreement is about moral permissibility


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Justification

The problem of justificationeven if you know

what you think, and others agree, how do you

know your view is justified or correct?

Empirical judgmentsthe screen is rectangular

refer to descriptive properties

Moral judgmentsdestroying embryos is wrong

wrong seems to have no empirical reference

So does it only express your attitudeyoure against

destroying embryos?


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Ethical Reasoning

How is it different from matters of taste?

For example, with taste (I like chocolate, you likevanilla) we think theres nothing more to be saidwe

just disagree and there is no correct taste

How are ethical questions different?

Some imply they arentwisdom of repugnance

But they areethical judgments/beliefs require

reasons.

A Why? is always appropriate.

Reasons will be general properties of actions, persons, etc.


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Example of Abortion

Sallys abortion was wrongWhy?

Because it is killingbut not all killing iswrong, e.g. bacteria.

But abortion kills a human being? Fetus is human, but what about humans makes

killing them wrongspeciesism?

Consciousness, self-consciousness, rationality,agency, etc?

But a fetus seems to lack theseso is a fetus a

person?


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Abortion cont.

Even if a person, not all killing of persons is

wronge.g. self defense when womans life at

risk

Does a woman owe the fetus 9 months use of

her bodye.g. if she took precautions to avoidbecoming pregnant

Thomsons violinistuse of hypothetical cases

This is a process of clarifying the reasons for

your moral judgments


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Features of Moral Reasoning

Making the reason for the initial judgment more

precise

So it fits the case at hand, but does not have

unacceptable implications for other cases

This is a requirement of consistencydoes your

judgment in this case fit with your judgments in

other cases?

E.g. relation between abortion and stem cell research


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Features of Moral Reasoning--Cont

Reasoning should be interpersonalideal is to

consider all reasons for and against your view

Know from experience, best criticisms often come

from others

Goal is judgments hold in good conditions for judging

and after full consideration of all relevant reasons

Does this guarantee agreement?

No, some moral disagreement may be irresolvable

But, it does clarify precisely what the disagreement is


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Does this guarantee your view is now correct?

No, if disagreement remains, both parties cannot be correct

Know may reconsider later on basis of new reflection or

experience

Does this make your view justified?

Yes, it is what you hold after full consideration of all relevantreasons and arguments

So there is nothing left to consider

Made in relatively ideal conditions for judging

Is what youre prepared to judge yourself and others by


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This view is subjectivistimplies your moral

beliefs justified if they survive this process

But another could end up with different and

conflicting beliefs

Often resolves disagreement, but no guarantee it does

Fits idea there is often reasonable ethical disagreement

But not subjective in crude senseyou have your

views, I have mine, nothing more to be said

That would make ethics like matters of taste, and ignores

the reasoning.


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It is not relativismwhat is ethically correct is

relative to a particular culture, group, individual Relativismaction A is right in group M, wrong in

group N; standards are relative to the group.

On relativism Ms say A is right, Ns say A is wrong,

and each are correct because their views arejudged by their different standards

So they are not disagreeing

Relativism is mistaken


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NOTE--giving reasons is the beginning of

theory construction Reasons can apply to other cases

For example, right of persons not to be killedApplies to wide range of cases

Has other featuresrights can be waived, exercised,forfeited, etc

Rights make person small scale sovereign in area of theright

Focus on victim of rights violation


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Cf. different duty based account of wrongness of

killingalways wrong to deliberately take innocenthuman life

Focuses on duty of agentnot waivable by victim

Cf. different goal based accountloss of the good of a

life is bad, minimize this loss of value So, could kill one to save more.

Application to euthanasia

Rights, duty, and goal-based views are different very

general moral theories.


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How Should Your Hospital Distribute

Antiviralsin an Avian Flu Pandemic?

For the past several months, there has been sustained human-to-

human transmission of a novel strain of avian influenza A withgenetic components of human influenza in several countriesaround the world. Your community was first affected three weeksago, and since then there have been over 500 cases and 50deaths. Oseltamivir phosphate is the only drug that may effectivelyreduce mortality of ill patients and limit infection of exposed

persons. However, supplies of oseltamivir are limited, andhospitals across the country are independently making decisionsto govern allocation of antivirals within their institutions. In yourcommunity, the four major academic medical centers haverecently established four different protocols regarding prioritizationof access to care:


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Hospital A

Recognizing the importance of protecting its

workforce in order to minimize absenteeismand ensure continuous response capacity,

Hospital A has decided to use its remaining

cache of oseltamivir forprophylaxis of staff

who are exposed while caring for influenza

patients.


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Justifications

Special responsibility to those who ask to take

extra risksthey deserve extra concern

Ensuring staff health will maximize their ability

to care for pts and so maximize health

outcomes But will prophylaxis of staff actually maximize

benefits?


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Hospital B

In an effort to save its very ill patients, Hospital B has

decided to reserve its remaining cache of oseltamivirfortreatment of the sickest influenza patients. Thisapproach isconsistent with the usual practices ofproviders at Hospital B, who are accustomed tofocusing primarily on treatment. Hospital B is relying on

airborne infection isolation and personal protectiveequipment, namely N-95 respirators, gloves, andgowns to protect its staff, and is not using oseltamivirfor prophylaxis.


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Justification

Most theories of justice give special priority to

the worse off.

E.g. Prioritarianismbenefiting people matters

more morally the worse off those people are

But how much health benefits should we beprepared to sacrifice to treat the worst off?


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Hospital C

In order to maximize survival rates, Hospital C has

decided to reserve its remaining cache of oseltamivirfortreatment of the patients most likely to benefit,namely those who present within 48 hours of diseaseonset. As this prioritization plan will result in fasterdepletion of the antivirals, Hospital C is relying on

airborne infection isolation and personal protectiveequipment, namely N-95 respirators, gloves, andgowns to protect its staff, and is not using oseltamivirfor prophylaxis.


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Justification

This may save the most lives possible

But does this maximize benefits?

Should it matter how long survivors are likely to

live?

Should it matter what their QL is likely to be? Should their social value count? For example, if they

are scarce health care workers?


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Hospital D

Assuming that its cache of oseltamivir will soon

be depleted regardless of distribution strategy,Hospital D is using the antiviral for

prophylaxis of exposed staff and treatment

of all probable and confirmed cases,

regardless of severity. This is the most

comprehensive approach, but Hospital D will

reach limitations most quickly.


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Justification

First come/first served among all in need of

care

To give all in need of care a fair chance to get what

they need

To avoid making other distinctions


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Hospital E

Hospital E has decided to give preference to

younger patients who have been exposed andnot to treat patients over 70


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Justification

Patients who die at a younger age will have

had less of the good of life years than olderpatients.

Each person deserves a fair chance to live a full

human life span

Different conception of fairness than hospital Ds

Notethis is different than maximizing life

years gained


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What does this case show?

In thinking through how to distribute antivirals

in a pandemic, one quickly finds oneselfaddressing broader question of justice

Should we simply seek to maximize benefits? Only

health benefits, or other benefits such as economic

benefits as well?

Do those who put themselves at risk to help others

deserve special concern to?

What does fairness require in prioritizing the use of

antivirals?


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Conclusion

My aim has been:

To briefly illustrate the nature of ethical reasoning

To show how ethical beliefs can be justified

To show how you inevitably find yourself dealing

with issues in ethical theory

Next lecture will be about different ethical

theories

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Bioethics Slides