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PHIL 244: Bioethics Dr. Katharine Schweitzer Spring 2017 LECTURE NOTES UP TO TEST 1 ON FEBRUARY 10 After each class, I will post lecture notes for that class period in this file on WebCampus. These notes are meant to supplement your reading of the assigned pages and paying attention in class lecture and discussion. Class 3: Wednesday, January 25 Introduction: Four Questions of Ethics (pages 1-15) Biomedical ethics is a branch of applied ethics (1). In this introductory chapter, we are constructing a systematic ethical perspective, that is, a comprehensive scheme. Over the course of this semester, we will use this framework to answer practical questions about what a person should do when he or she faces a moral dilemma. The authors of our textbook claim that there are four fundamental questions that we must answer in order to create a systematic ethical perspective (2). 1. What are the source, meaning, and justification of ethical claims? 2. What kinds of acts are right? 3. How do rules apply to specific situations? 4. What ought to be done in specific situations? Let’s examine each of these fundamental questions. First, what are the source, meaning, and justification of ethical claims? There are three branches of ethics: metaethics, normative ethics, and applied ethics. Metaethics is the branch of ethics that studies the answer to these very abstract questions. Metaethics is not the branch of ethics that helps us to determine what actions are right and wrong (2). Ethics involves making evaluations (4). Ethical evaluations are judgments of what is good or bad. I will treat the words “ethical” and “moral” as synonymous. “Prefer” and “responsible” are words that signal that the speaker is making a normative evaluation. Familiarize yourself with the terms signaling normative evaluations on page 3. Note that not all evaluations are ethical (that is, normative) evaluations. For example, I could say that a decision is illegal. I am making an evaluation about its status with respect to legality. Yet legality is distinct from ethics. Non-ethical evaluations include evaluations made from the standpoint of a religion or a culture (4). Ethical evaluations possess three characteristics (5). 1. Ethical evaluations are ultimate. They cannot be overridden. 2. Ethical evaluations must possess universality. They reflect a standpoint that applies to everyone. 3. Ethical evaluations must treat the good of everyone alike. Ethical evaluations cannot privilege the interests of some people over other people.

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What is it that makes right acts right? (6). There are three kinds of answers to this question. 1. Versions of relativism. a. Social relativism is the view that the rightness or wrongness of an action depends on whether the action fits within the customs of the social group. Social relativists believe that moral judgments can be true or false. It is a group’s believing that it is true that makes it true. b. Personal relativism is the view that the rightness of wrongness of an action depends on whether the speaker approves of the action. Personal relativists believe that moral judgments can be true or false. It is a person’s believing that it is true that makes it true. 2. Versions of universalism (which is sometimes called absolutism). a. Universalism is the view that the rightness and wrongness of an action are independent of social or personal views (6). b. Theological universalism is the view that the rightness or wrongness of an action is based on a single divine standard. c. Natural law is an example of empirical absolutism. Empirical absolutism is the view that the rightness or wrongness of an action can be found in nature. d. Intuitionism is the view that what is right and wrong is known by intuition. Intuitionism is a form of universalism. 3. Versions of emotivism. a. Emotivism is the view that ethical utterances are simply the expression of the speaker’s feelings. Emotivists believe that it does not make sense to ask whether a moral statement is true or false. Instead, moral judgments are just feelings (7). The authors are clear that they believe that relativism and emotivism are not the correct approaches to understanding what makes right acts right. “If the dispute is a moral one, the same act cannot be both right and wrong at the same time. One must ask what it is that makes right acts right, how conflicts can be resolved, what the final authority is for morality, and whose judgment about what is right should prevail” (7). Second, what kinds of acts are right? Remember that there are three branches of ethics. We have already talked about metaethics. Normative ethics is the branch of ethics that studies general principles or norms that explain the characteristics that make actions right or wrong. Principles are general criteria that make human actions morally right or morally wrong. There are two major views about what kind of acts are right: consequentialism and deontological ethics (8). Consequentialist ethical theories claim that acts are right to the extent that they produce good consequences and wrong to the extent that they produce bad consequences (8). Beneficence and nonmaleficence are the two principles of consequentialist ethics. Beneficence is a principle that says that the patient should be benefited. Nonmaleficence is the principle that says that the patient should be protected from harm.

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Utilitarianism is the ethical theory that says that the right action is the action that produces the total net good for all people who are affected by the decision. There are many kinds of consequentialism besides utilitarianism. Some versions of consequentialism give priority to avoiding harm (9). Hippocratic health care ethics is a consequentialist ethical theory. Deontological theories of ethics focus on what actions are inherently right or wrong because of the kind of action they are. Deontological theories of ethics also focus on duties (9). Justice, fairness, veracity, autonomy, and fidelity are examples of duty-based principles. We will study these principles in the course material that will be assessed in Test 2. Here is an example of how consequentialist and deontological perspectives diverge in how they interpret the ethical principle of truth-telling. A consequentialist would value the principle of truth-telling only in situations in which telling the truth produces the greatest amount of good for the largest number of people who are affected by the action. Deontological ethicists value the principle of truth-telling no matter what the consequences of the action happen to be (10). In normative ethics, it is important to know the differences between three terms (11). 1. Principles. Principles are “general criteria that make human actions morally right or wrong” (11). 2. Virtues. Virtues concern the character of an agent. Virtues are “praiseworthy traits of character” (12). A vice is a blameworthy character trait. 3. Values. A value refers to “a good outcome” (12). Value refers to “those things that are considered good or beneficial” (12). Things that have intrinsic value are good in themselves. Things that have instrumental value are good because they are useful in accomplishing something else. Many people believe that happiness, truth, and health are valuable in themselves. Third, how do rules apply to specific situations? Ethical principles can be very broad. Rules are the middle steps between principles and specific situations. Rules are more specific than principles, but sometimes rules can be rather general and it can be difficult to determine how the rule applies to an individual case (12). Situationists are willing to be guided by moral rules, but they do not think that a rule should be applied to every situation. Situationists are willing to reassess the rules on a case-by-case basis. People who hold the “rules of practice” view believe that rules should be applied to every situation. These people nevertheless believe that sometimes a society might revise its rules (13). Fourth, what ought to be done in a specific case? Now we turn to the third and final branch of ethics: applied ethics. Applied ethics involves taking what we have learnt in normative ethics and using it to determine what to do if we face a moral dilemma. The first task is to identify the moral rules and rights that might apply to the case (15). Sometimes the relevant moral rules and rights will conflict with each other. It won’t be clear what the practitioner should do. In this case, the practitioner should consult more abstract principles, virtues, and values. Empirical data and clinical facts are also important to have when determining what should be done in a specific case.

4 Class 4: Monday, January 30, 2017 Chapter 1: A Model for Ethical Problem-Solving (pages 19-28) In the context of a class on bioethics, it is important to be able to determine a solution to an ethical dilemma that you can defend with good reasons. When you and your partner lead discussion of a case study, you should follow this model in your presentation (20). 1. Respond to the intuitive sense or feeling that something is wrong. 2. Gather clinical and situational information. 3. Identify the ethical problem. 4. Propose at least two courses of action and determine their ethical justifications. 5. Work with others to determine a course of action. Step 1: There are usually no objective signs that an ethical problem is present. One has to identify it using “subjective” assessments like feelings, interpretations, and judgments. One might get the sense that something is wrong if people disagree with each other, that is, if there are interpersonal conflicts. If there are negative emotions, it is also possible that they are because there is an ethical disagreement or something wrong going on (22). Step 2: Clinical information is the relevant clinical data about the case. You should look up online any words that you do not understand. I needed to look up “gastric cancer,” “metastases,” “acute renal failure,” “hydronephrosis,” “ureter,” “creatinine” and “CT scan.” Situational information includes facts like what the people who are involved in the case believe and feel, what the setting is, whether there are time constraints, and cultural and religious factors (23). Step 3: What is the ethical dilemma? For whom is it a dilemma? In other words, who is the person who is placed in the position of doing an action whose morality we are evaluating? Identify whether any of the seven ethical principles that we will study in this course are relevant (24). Step 4: Propose at least two possible courses of action and see whether the proposals can be ethically justified. Ask yourself, what are the consequences of the proposed decision? What are the intentions of the people who are making that decision? Are there any moral duties that the agents in question ought to fulfill? (26) You must decide which principle is most important. You must decide whether consequentialist ethics or deontological ethics helps us determine what the right thing to do is. Step 5: Once you have determined for yourself what the correct ethical course of action is, seek the insight of others. Once you have reached an answer and supported it with good reasons, you should ask others what they think of your reasoning. Do they agree with your judgment? (27) Step 5 should take about 3 to 5 minutes of your allotted 15 minutes for class presentation. Ask questions of your classmates and answer any questions they may have for you.

5 Let’s return to the discussion of principles in the introductory chapter. Remember, a principle identifies the general criteria that make a human action morally right or morally wrong (11). Principles are part of normative ethics. For Test 1, be sure that you can define the following seven ethical principles and the rules that they justify. We will study these principles in greater depth for Test 2, but it is important that you know the basic definition of these principles now. Beneficence: right actions involve doing good. Rule: one should do the action that produces good. Nonmaleficence: right actions involve avoiding harm. Rule: one should not do harm or bring about evil. Respect for autonomy: right actions involve allowing others to make choices freely. Rule: one should let a competent person make his or her own decisions about what to believe and what to do. Justice: right actions are fair. Rule: one should distribute goods and harms fairly. Veracity: right actions promote the truth. Rule: one should tell the truth. Fidelity: right actions involve fulfilling obligations that respect a relationship. Rule: one should be faithful, keep promises, and be loyal. Avoidance of killing: right actions involve preserving life. Rule: one should avoid taking a human life. Class 5: Wednesday, February 1, 2017 Chapter 2: Values in Health and Illness (pages 29-44) Not all evaluations and judgments are moral. Many evaluations and judgments are non-moral. “I think people with red hair are cuter than people with other kinds of hair” is a non-moral judgment. The main goal of this chapter is to teach the skill of distinguishing nonmoral values from moral values and nonmoral judgments from moral judgments. Remember back in the introduction that we learnt that a value is “a good outcome” or a “positively evaluated consequence” (12). Value is something that is considered good or beneficial. But not all values are moral values! There are aesthetic values and legal values, which are nonmoral in nature.

6 On many matters, people are permitted to have a wide variety of preferences. There is no problem that some preferences might conflict with each other. On moral matters, however, there is a right and a wrong answer. The same action cannot be both morally right and morally wrong at the same time. Why? Remember the discussion of universalism: the rightness and wrongness of an action are independent of social or personal views (6). “[I]f two people disagree about what they take to be matters of ethics, logically, at least one of them must be wrong” (38). The book does not want us to be relativists. Relativists are people who believe that you could think that some action is immoral and that I could think that the same action is moral, and that we’d both be correct. The book wants us to assume that universalism is true and that there is truth and falsity in matters of morality. What features must be present if the evaluation is moral in nature? 1. An ethical evaluation is made according to the most ultimate standard (38). 2. The evaluation is such that we think everyone ought to reach the same conclusion. 3. The evaluation must not privilege some people’s interests over the interests of other people; it must treat the good of everyone alike. There are four case studies in this chapter. The authors of our textbook claim that the first two case studies do not involve an ethical dilemma. There is no right and wrong answer about whether Jake should pursue diet or exercise or whether he should take the stations. There is no right or wrong answer about whether May should choose the breast conservation therapy treatment or the mastectomy. The authors of our textbook say that it is harder to determine whether Case Studies 2-3 and 2-4 present the decision-maker with an ethical dilemma or whether their decision is just one of preference. Case 2-3 asks, is it morally wrong for Bette not to reduce the number of embryos in her pregnancy? Case 2-4 asks, is it morally wrong for the parents of Baby Doe to refuse to treatment to fix his anatomical issues (the atresia, fistula, and cardiac septal defect)? Some people might say that Bette and the parents of Baby Doe are not making choices that are in the realm of ethics. Other would say, ethics is clearly involved. After this class period, you should be better prepared to determine when an issue is ethical and to give evidence for your view. Ask yourself: Is this a decision that is within the realm of ethics? NO: it’s a matter of preference YES: okay, it’s a decision to which there is a right action and a wrong action. Then you have to ask yourself: did the person actually make the right action? Or did the person do the wrong action? Note: someone might think that they understand which action is right and which action is wrong, but they might be mistaken about which is which. Someone could correctly view a decision as ethical but still fail to determine correctly which action is in fact ethical.

7 Class 6: Friday, February 3, 2017 Chapter 3: What Is the Source of Moral Judgments? (pages 45-62) In this chapter, we return to the branch of ethics called metaethics. Metaethics is one of the three branches of ethics. (Normative ethics and applied ethics are the other two branches.) Metaethics involves asking questions like what is the source of moral judgments, who has the authority to determine what morality requires, and how can one know what is morally right and wrong. The textbook authors tell us that morality is universally binding on everyone, whether they like it or not or accept it or not. The textbook authors reject relativism, which is the idea that a person or a society creates what is moral by believing that it is moral. The authors believe: “[M]orality is not merely a matter of personal judgment; it rests in some definitive, objective external standard” (57). Morality cannot be reduced to personal preference. So there is truth about what is moral to do and not moral to do. But who do we authorize to make the final decision about morality requires? Here are seven potential sources of moral authority in the context of bioethics: 1. The code of the ethics set by a professional organization. 2. The code of ethics set by the hospital. 3. The ethical commitments of a religious group who sponsors the hospital. 4. The health professional’s own moral and religious conscience. 5. The patient’s own moral and religious conscience. 6. The judgment of the Institutional Review Board (IRB) about whether a research study on human subjects is moral or not. 7. The government, exercising decisions through judges, laws, or executive orders. In the case studies in this chapter, we are not trying to figure out what should be done. We are trying to figure out who should be allowed to decide what should be done. Consider case study 3-1: should the AMA has the authority to determine whether physicians may participate in capital punishment? Or should the government have the authority to decide this question? See page 50: “Should the people of the state or the professional association have control over decisions about what is ethical physician behavior?”

8 Consider case study 3-3: should the occupational therapist feel bound by his hospital’s code of ethics that they must always work for the good of the patient (which his supervisor interprets as authorizing him to provide care to the patient, even though he is not a certified hand specialist), or should the occupational therapist believe that he is the person who should decide what morality requires?...