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Copyright Institute for Ethics and Emerging Technologies 2008
Introduction to Bioethics
James J. Hughes Ph.D.Executive Director, Institute for Ethics
and Emerging Technologies
Public Policy Studies, Trinity College, Hartford CT
Outline of the Course July 20-22: Introduction to Bioethics July 27: Public Health Ethics July 29: Death and Dying August 3: Clinical Ethics August 5: Neuroethics August 10: Research Ethics August 12: Reproductive Ethics August 17: Gene Patenting August 19: (TBA)
Policy Briefs and ResponsesPolicy Issue Briefs 8-10 pages long. presented in class as a 10 minute Powerpoint presentation, with an
accompanying one-page handout.
Policy Issue Responses 1000 words long, copies distributed to the rest of the class presented in class as if they are Congressional testimony.
Topics Mandatory advance directives Human gene patenting 2 topics TBD
Copyright Institute for Ethics and Emerging Technologies 2008
What are Ethics?
Ideas of right and wrong, and “the good life”
Moral intuitions inherited from simian life
Shaped and filtered by modern religious and political ideas
Copyright Institute for Ethics and Emerging Technologies 2008
Copyright Institute for Ethics and Emerging Technologies 2008
Five Moral Intuitions
Harm/careFairness/reciprocityIngroup loyaltyRespect for authorityPurity/sanctity
JonathanHaidt
Dangerous Trolleys
Trolley 1: Five kids, one man, one switch to push
Trolley 2: Five kids, one (fat) man, one hard push
Copyright Institute for Ethics and Emerging Technologies 2008
Cleanliness and MoralityMoral censure and
disgust are the same area of the brain
Washing one’s hands or even thinking about “clean” words reduces the severity of moral judgments
Baptism
Copyright Institute for Ethics and Emerging Technologies 2008
Ape and Human Ethics
Copyright Institute for Ethics and Emerging Technologies 2008
Apes Humans
Harm/care Care for other apes compassion, benevolence
Fairness Punish ape cheaters and freeloaders
honesty, egalitarianism, universalism
Ingroup loyalty Our apes come before other apes
racism, nationalism, nepotism, speciesism
Respect for authority
Obey the troop's dominance hierarchy
have faith, respect authority
Purity/sanctity Poo is bad yuck factor, incest, cannibalism, sex/gender codes
Ethics vs. Self/Group Interest
Ethics are functional for groups, not individuals
Ethics subordinate self-interest to collective interest
“Enlightened self-interest” & egoismsShame vs. guilt
Copyright Institute for Ethics and Emerging Technologies 2008
Naturalistic Fallacy
The IS doesn’t tell us what SHOULD be
We each need to decide what ethics make the most sense for us
But science can illuminate why we feel that way
Copyright Institute for Ethics and Emerging Technologies 2008
You cannot go against natureBecause when you do Go against natureIt's part of nature too
Copyright Institute for Ethics and Emerging Technologies 2008
The Enlightenment
Copyright Institute for Ethics and Emerging Technologies 2008
Principles of the Enlightenment
1. Autonomy of reason from faith and authority
2. Human perfectibility and social progress
3. Empirical optimism: sapere aude! (Dare to know)
4. Legitimacy of government based on free association
5. Tolerance of diversity, freedom of thought
6. Ethical universalism – beyond nationalism, racism, sexism
Enlightened vs. Pre-Enlightened
Copyright Institute for Ethics and Emerging Technologies 2008
EnlightenedHarm/careFairness/reciprocity
Pre-EnlightenmentIngroup loyaltyRespect for
authorityPurity/sanctity
Pre-Enlightenment Medical Ethics
Professions develop codes of ethics to rationalize their unequal power and special privileges
The code of the healer
Hippocratic oath
Copyright Institute for Ethics and Emerging Technologies 2008
Summary of the Hippocratic Oath
I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
Fealty to one’s teachers and their family. Do good for, and avoid harming, patients. Don’t assist with suicide or abortion. Leave surgery to surgeons. Don’t have sex with patients, male or female. Keep all medical knowledge secret from the
public.
Copyright Institute for Ethics and Emerging Technologies 2008
Pre-Modern Physician Ethics
Copyright Institute for Ethics and Emerging Technologies 2008
Harm/care Do no harm
Doctor-patient relationship
Fairness Universalist commitment to treat
Ingroup loyalty
Code of silence
Keeping medical secrets (HO)
Respect for authority
Veneration of teacher & tradition (HO)
Purity/sanctity Proscription on euthanasia and abortion (HO)
Bioethics Timeline – 1789-1920s Declaration of the Rights of Man and of the Citizen (1789) United States Bill of Rights (1791)London's Royal Society for the Prevention of Cruelty to
Animals founded (1824)
Bioethics Timeline – 1920s-1970
Nuremberg Code (1947): issue of human experimentation
United Nations: Universal Declaration of Human Rights (1948)
Declaration of Geneva (1948)◦ Issued as a development on the Oath of
Hippocrates World Medical Association's "International Code of
Medical Ethics“ (1949) FDA requires informed consent in clinical trials
(1962) Life Magazine (1962) article on dialysis selection
committees – “God Squads” Declaration of Helsinki (1964) (WMA): guidelines
for human experimentation Hastings Center founded (1969)
Copyright Institute for Ethics and Emerging Technologies 2008
Bioethics Timeline – 1970-2000 Kennedy Institute of Ethics founded at Georgetown University Tuskegee Syphilis Experiment (1930s-1972) National Commission for the Protection of Human Subjects
established in the U.S. (1974) Belmont Report outlines ethical principles for the protection of
human subjects in research (1978) Carter Bioethics Commission established (1979) CIOMS Guidelines (1993)
‘International Ethical Guidelines for Biomedical Research Involving Human Subjects’
(CIOMS: the Council for International Organizations of Medical Sciences)
U.S. National Bioethics Advisory Commission established (1995)
Bioethics Timeline – 2000-2010
Appointment of Bush President’s Council on Bioethics (2001)
Universal Declaration on Bioethics and Human Rights (UNESCO; United Nations Educational, Scientific, and Cultural Organisation) (2005)
Dismissal of Bush PBC (2009) Bioethics skirmishes in healthcare
reform debate (2009) Appointment of Obama Bioethics
commission (2010)
Contemporary Ethical Theories
Deontology – There are clear rights and wrongs Virtue theory – Intention of the actor is most
important Consequentialism – Greatest good for greatest
number Principlism – There are general ethical principles
Deontology
From the Greek word for ‘duty’rules, which express our duties
E.g. killing someone to give their organs to someone else may ignore our duty to respect that person’s right to life.
Generally associated with religious ethics, such as 10 commandments & Sharia
Kantian Deontology
Immanuel Kant (1724-1804) is the most influential deontologist.
Rejecting Consequentialism: "A good will is good not because of what it effects or accomplishes." Even if by bad luck a good person never accomplishes anything much, the good will would "like a jewel, still shine by its own light as something which has its full value in itself."
The Categorical Imperative
Kant claims that all our actions should be judged according to a rule he calls the Categorical Imperative.
First Version: "Act only according to that maxim [i.e., rule] whereby you can at the same time will that it become a universal law."
Second Version: "Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means."
Important to treat people as autonomous agents
Problems of Deontology
Problems:Always following rules of conduct can lead to
negative consequencese.g. allowing a massive bomb to explode by
refusing to torture someonee.g. not fabricating a research result might mean
admitting that your study found nothing that is interesting.
Sometimes the rules are vagueSometimes the rules conflict
Virtue Theory
Focus on the intent of the agent of action, rather than on rules or consequences
Problems:People with good intents
can do things that have terrible consequences
Consequentialism
Good: what is likely to produce more good than bad consequences.
Bad: what is likely to produce more bad than good consequences. E.g.: utilitarianism: good is what produces the greatest
utility (usually understood in terms of ‘happiness’) for the greatest number.
Often used for resource allocation issues: how can we promote the largest amount of happiness with limited resources?
Utilitarianism
What Utilitarians Think Is Intrinsically Valuable: happiness (or pleasure or satisfaction…)
"actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness." (John Stuart Mill's Greatest Happiness Principle)
In other words, judge an action by the total amount of happiness and unhappiness it creates
John Stuart Mill
Problems of Consequentialism
Problems: Can we know the likely
consequences of our actions? What if there is great uncertainty?
Impartial moral theory Some would say that we have a duty to be partial.
Certain rules may be ignored (yet some forms of consequentialism take some deontological principles into consideration)
Principlism
‘The four principles’ approachThe most widely used
approach in Western bioethics
Incorporates elements from both consequentialist and deontological theories
What are these 4 principles?
◦ Autonomy Right of self-determination
Related to ‘informed consent’ In order to give consent:
autonomy/competency/capacity must be possessed.
◦ Beneficence – to do well, to promote well-being
◦ Non-maleficence – to do no harm, to avoid doing harm
◦ Justice – treat like alike(T. Beauchamp and J. Childress,
Principles of Biomedical Ethics, 5th edition, New York/Oxford: Oxford University Press, 2001.)
Principlism & French Revolution
New VirtuesRespect for diversity
& self-determination of others is a new, Enlightenment virtue
Liberte, fraternite, egalite
Georgetown mantra: autonomy, beneficence, justice
Copyright Institute for Ethics and Emerging Technologies 2008
Stages of Moral Development
Lawrence KohlbergDevelopmental Correlated with
higher education and exposure to Enlightenment thought
Conquering animal nature with reason
Copyright Institute for Ethics and Emerging Technologies 2008