Med HUM III Introduction to Ethics Medical ethics
- Slides: 59
Med HUM III Introduction to Ethics, Medical ethics, Bioethics Main ethical approaches Prof. Marija Definis-Gojanović October 2016
ETHICS / MORAL l l The oldest scientific and philosophical discipline ? Demarcation: science / subject ethics moral (gr. ethos = custom, (lat. mos = character, practice) nature) - Ethics – discipline about moral or philosophy on moral - Moral – system of norms or rules, written or not, about human behavior
Ethics is a philosophical discipline about moral problems, deals with art of living
What is Ethics? l The formal study of: l What is right and wrong. l The study of the bases or principles for deciding right and wrong. l The analyses of the processes by which we decide what is right and wrong.
Ethics is not: l l Merely obeying the law Compliance Although in many instances laws are statements of considered ethical positions and most of the time obeying the law is an element of ethical behavior.
Relation between moral and other regulative norms Moral norm – specific individual system of personal values with validity of genesis, development and adoption l Other regulative norms (close to moral): - Of primitive society - Of customs - Of religion - Of law -
l Religious vs. Moral norms: - religious norms are characterized by concept “sanctity” (moral ones by term “good”) - religious norms are more absolute, without conditions and inevitable that moral ones - when broke religious norm, a man committed sin (when violated moral norm, a man felt he committed mistake against his dignity)
Traditional arrangements of the field of ethics: l Meta-ethics (nature of right or good, nature and justification of ethical issues) l Normative ethics ( standards, principles) l Applied ethics (actual application of ethical principles to particular situation)
Three Broad Types of Ethical Theory: l l l 1) Consequentialist theories (primarily concerned with the ethical consequences of particular actions) 2) Non-consequentialist theories (broadly concerned with the intentions of the person making ethical decisions about particular actions) 3) Agent-centered theories (more concerned with the overall ethical status of individuals)
Consequentialist Theories: l The Utilitarian Approach l The Egoistic Approach l The Common Good Approach
Consequentialist Theories: l - - - The Utilitarian Approach Epicurus (341 -270 BCE) - the best life is one that produces the least pain and distress Jeremy Bentham (1748 -1832) - actions could be described as good or bad depending upon the amount and degree of pleasure and/or pain they would produce John Stuart Mill (1806 -1873) - modified this system /subjective concept of “happiness” opposed to the more materialist idea of “pleasure”/
Consequentialist Theories: l - - The Egoistic Approach variation of the utilitarian approach - known as ethical egoism, or the ethics of self- interest: an individual often uses utilitarian calculation to produce the greatest amount of good for him or herself proponents: Thrasymacus (c. 459 -400 BCE), Thomas Hobbes (1588 -1679), Ayn Rand (19051982)
Consequentialist Theories: l - - The Common Good Approach Plato (427 -347 BCE) and Aristotle (384 -322 BCE) promoted the perspective that our actions should contribute to ethical communal life Jean-Jacques Rousseau (1712 -1778): the best society should be guided by the “general will” of the people which would then produce what is best for the people as a whole
Non-consequentialist Theories: l The Duty-Based Approach l The Rights Approach l The Fairness or Justice Approach l The Divine Command Approach
Non-consequentialist Theories: l - - The Duty-Based Approach sometimes called deontological ethics associated with Immanuel Kant (1724 -1804): doing what is right is not about the consequences of our actions but about having the proper intention in performing the action Kant’s formula for discovering our ethical duty: “categorical imperative. ” The most basic form: “Act only according to that maxim by which you can at the same time will that it should become a universal law. ”
Non-consequentialist Theories: l - - The Rights Approach history that dates back to the Stoics of Ancient Greece and Rome, John Locke (1632 -1704) stipulates that the best ethical action is that which protects the ethical rights of those who are affected by the action it emphasizes the belief that all humans have a right to dignity many now argue that animals and other nonhumans such as robots also have rights
Non-consequentialist Theories: l - - The Fairness or Justice Approach the Law Code of Hammurabi in Ancient Mesopotamia (c. 1750 BCE) held that all free men should be treated alike, just as all slaves should be treated alike today: John Rawls (1921 -2002), who argued, along Kantian lines, that just ethical principles are those that would be chosen by free and rational people in an initial situation of equality
Non-consequentialist Theories: l - - - The Divine Command Approach sees what is right as the same as what God commands; ethical standards are the creation of God’s will following God’s will is seen as the very definition what is ethical because God is seen as omnipotent and possessed of free will, God could change what is now considered ethical
Agent-centered Theories: l The Virtue Approach l The Feminist Approach
Agent-centered Theories: l - - - The Virtue Approach argues that ethical actions should be consistent with ideal human virtues Aristotle: ethics should be concerned with the whole of a person’s life, not with the individual discrete actions a person may perform in any given situation approach prominent in non-Western contexts, especially in East Asia (Confucius (551 -479 BCE): to act virtuously (in an appropriate manner)
Agent-centered Theories: l - - The Feminist Approach virtue approach to ethics supplemented and sometimes revised by thinkers in the feminist tradition, who often emphasize the importance of the experiences of women and other marginalized groups to ethical deliberation the most important contributions of this approach: the principle of care as a legitimately primary ethical concern, often in opposition to the cold and impersonal justice approach
Applied Ethics Terms Used in Ethical Judgments - Obligatory: it is not only right to do it, but that it is wrong not to do it (ethical obligation to perform the action) - Impermissible: it is wrong to do it and right not to do it - Permissible: or ethically “neutral, ” because it is neither right nor wrong to do l Supererogatory: types of actions are seen as going “above and beyond the call of duty (they are right to do, but it is not wrong not to do them) l
Types of Ethics Professional Ethics: Obligations of the profession - Self-regulation - Education of self and others l Medical Ethics: - human: medical (in narrow sense) and dental - veterinarian Knowledge, deliberation, understanding of medical practice that should be in perspective of right, honorable, accurate behavior l
Medical Ethics l a field of applied ethics, the study of moral values and judgments as they apply to medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, sociology, and anthropology. Based on definition of “Medical Ethics” http: //en. wikipedia. org/wiki/Medical_ethics
Medical Ethics l Long history l l l l l Third Dynasty (Egypt) 2700 BCE Code of Hammurabi (Babylon) 1750 BCE Oath of the Hindu Physician (Vaidya’s Oath) 15 th cy. BCE Hippocratic oath (Hippocrates, ca 460 -370 BCE) The Oath of Asaph and Yohanan (ca 6 th cy. CE) Advice to a Physician (Persia) 10 th cy. CE Oath of Maimonides 12 th cy. CE Ming Dynasty (China) 14 th cy. CE Seventeen Rules of Enjun (Japanese Buddhist Physicians) 16 th cy. CE) Drawn from Codes of Medical and Human Experimentation Ethics by Victoria Berdon and Jennifer Flavin viewable at http: //wisdomtools. com/poynter/codes. html
History cont. Percival's Code (England), 1803: basis for first AMA Code of Medical Ethics. l Beaumont's Code (United States), 1833: experimental treatments, voluntary, informed consent. l American Medical Association (AMA) - Code of Medical Ethics, 1847. l Claude Bernard (France), 1865. l Walter Reed (United States), 1898: introduces written consent “contracts”. Allows healthy human subjects in medical experiments. l Berlin Code or Prussian Code (Germany), 1900: no medical experiments when subject not competent to give informed consent, in the absence of unambiguous consent, or when information not properly explained to subject. l Reich Circular (Germany), 1932: concerned with consent and wellbeing of the subjects. l Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http: //wisdomtools. com/poynter/codes. html
Modern issues and statements l Nuremberg Code (1947) l l l Medical research Declaration of Geneva, W. M. A. (1948, 1968, 1984, 1994, 2005, 2006) World Medical Association International Code of Medical Ethics AMA revision (1957) Declaration of Helsinki, application to medical research (1964, rev. 1975, 1983, 1989, 1996, 2000) l l Belmont Report (1979) AMA revision (2001) Drawn from “Codes of Medical and Human Experimentation Ethics” by Victoria Berdon and Jennifer Flavin viewable at http: //wisdomtools. com/poynter/codes. html
Why study medical ethics? l “As long as the physician is a knowledgeable and skilful clinician, ethics doesn’t matter. ” l “Ethics is learned in the family, not in medical school. ” l “Medical ethics is learned by observing how senior physicians act, not from books or lectures. ” l “Ethics is important, but our curriculum is already too crowded and there is no room for ethics teaching. ”
Why study medical ethics? l l l ethics is and always has been an essential component of medical practice some ethical principles are basic to the physicianpatient relationship, but application in specific situations is often problematic due to disagreement about what is the right way to act) study of ethics prepares medical students to recognize difficult situations and to deal with them in a rational and principled manner
Why study medical ethics? l integral part of medicine at least since the time of Hippocrates concept of medicine as a profession l in recent times - influence by developments in human rights (e. g. , violations of human rights, such as forced migration and torture; whether healthcare is a human right) l closely related to law (e. g. , medical licensing and regulatory officials), but ethics prescribes higher standards; occasionally requires that physicians disobey laws that demand unethical behaviour; laws differ significantly from one country to another while ethics is applicable across national boundaries
Bioethics Medical ethics closely related to bioethics (biomedical ethics), but not identical - medical ethics focuses primarily on issues arising out of the practice of medicine - bioethics: very broad subject, concerned with the moral issues raised by developments in the biological sciences - bioethics does not require the acceptance of certain traditional values that are fundamental to medical ethics l
Bioethics l l branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences it is chiefly concerned with human life and wellbeing, though it sometimes also treats ethical questions relating to the nonhuman biological environment
Bioethics l l era of replacing human organs and their functions began with chronic dialysis and renal transplantation in the 1960 s. unprecedented problems (selection of patients; "God Committee“) origin: Potter’s “Bioethics, the Science of Survival” (1970), which suggests viewing bioethics as a global movement; Callahan’s “Bioethics as a Discipline” (1973), in which he argues for the establishment of a new academic discipline; creation of institute in which researchers should examine and analyze medical dilemmas
Bioethics l l l repeated story about the origin of the term bioethics is incorrect German theologian Fritz Jahr published articles (1927, 1928, 1934) using the German term “Bio. Ethik” (which translates as “Bio-Ethics”) and forcefully argued more civilized, ethical approach to issues concerning human beings and the environment his bioethical imperative: “Respect every living being, in principle, as an end in itself and treat it accordingly wherever it is possible. ”
As Practical Ethics, Medical Ethics focuses on: The process of deciding what is the most appropriate (right) course of action in a particular situation: l given these facts l given my skills and abilities l operating with finite knowledge l in real time l and then effecting that course of action.
Ethical Problems l l l Problems caused by fact of having to choose between goods or things to which we owe an obligation Bad rankings of goods Failure to grasp facts l l Ignorance Incompetence Willful blindness Bad factual analysis l Often caused by personal or institutional distortion
Organizational Problems l l l l General organizational culture Ego and narcissism Overly punitive responses Lack of a culture of responsibility Failure to acknowledge information distortion Bad communication flows High transaction costs for doing the “right” thing
Process of making ethical decisions l l l l l Awareness—Is there a moral issue here? l What is its nature? How important? What are the facts? What are the issues? What rules or values apply here? To whom or what do I owe a duty? How should they be applied? Who needs to decide and act? Who ought to? To what am I obligated because of role/position? What are the consequences? What are the options? !
Duties to whom or what? l Individuals l l l Groups l l Patients’ families/guardians Colleagues Co-workers Self Profession Society The weak Ideas/Principles l l The Law Truth Justice Individual value
Duties—Sources l Legal Obligations l l Institutional Obligations l l Health insurance Emergency treatment Reporting duties Practices of hospital Professional norms and obligations l Inhere with being a physician
How do individuals decide what is ethical? - Two different ways of approaching ethical issues: 1. Non-rational (not irrational) 2. Rational
How do individuals decide what is ethical? 1. - - Non-rational (not irrational) approaches: Obedience - following the rules or instructions of those in authority, whether or not you agree with them (common way: children and those who work with authorities) Imitation - following the example of the role model Feeling or desire (subjective approach) Intuition - location in the mind (rather than the will) Habit – there is no need to repeat a systematic process each time a moral issue arises similar to one that has been dealt with previously
How do individuals decide what is ethical? 1. - - Rational approaches: Deontology (search for well-founded rules) Consequentialism (the right action is the one that produces the best outcomes; the best known is utilitarianism uses “utility” as a measure: “the greatest good for the greatest number”) Principalism (often clash of principles) Virtue ethics (a type of moral excellence; important virtues: compassion, honesty, prudence, dedication)
Framework for ethical decision-making IN PRACTICE 1. 2. Four steps problem-solving process: Problem identification (identify: technical facts, moral parameters, legal constraints, relevant human values) Develop alternative curses action (identify: relevant ethical principles for each alternative, recognize ethical assumptions for each alternative, determine additional emerging ethical problems)
Framework for ethical decision-making IN PRACTICE Four steps problem-solving process: 3. Select one alternative course of action (justify the selection of your alternative, defend your selection upon ethical grounds) 4. Consider objections to alternative selected (objections arising from: factual errors, faulty reasoning, conflicting values) -
Framework for ethical decision-making IN PRACTICE 1. 2. 3. 4. 5. 6. Determine whether the issue at hand is an ethical one. Consult authoritative sources to see how physicians generally deal with such issues. Consider alternative solutions. Discuss your proposed solution with those whom it will affect. Make your decision and act on it. Evaluate your decision and be prepared to act differently in future.
Factors in ethical decision-making in health-care 1. 2. 3. Ethical theories Ethical principles Ethical rules
ETHICAL MAXIM (principles) General guidelines that site what is forbidden, desirable or permissible (often base for rules) 1. 2. 3. 4. Respecting autonomy Doing no harm (nonmaleficence) Benefiting others (beneficence) Being just (justice) - Being faithful (fidelity)
ETHICAL RULES (codes) manners developed by professional organizations Structure of codes: 1. regulative 2. protective (for public opinion) 3. specific (regarding membership) 4. obligated
Professional codes as a framework for decision making - - - Over centuries medical profession has developed its own standards of behavior for its members – expressed in codes of ethics and related policy documents Global level: WMA, UN Principles of medical ethics Ethical directives of medical associations are general in nature but “in making decisions, it is helpful to know what other physicians would do in similar situations”
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