Biomedical ethics week 3 reading and module PDF

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Biomedical ethics week 3 Read: BE 2 (Buchanan & Brock, Sherwin), WP Chapter 3 - "Rules of Style and Content" BE 2 Different standards of competence A. - A minimal standard of competence Ex: patient merely be able to express a preference This standard...

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Biomedical ethics week 3 Read: BE 2.2 (Buchanan & Brock, Sherwin), WP Chapter 3 - "Rules of Style and Content" BE 2.2 Different standards of competence A. -

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A minimal standard of competence Ex: patient merely be able to express a preference This standard respects every expressed choice of a patient, is not a criterion of competent choice at all Disregards whether defects of mistakes are present in the reasoning process, whether the choice is in accord with the patient’s own conception of his or her good and whether the choice would be harmful to the patient Fails to provide any protection for patient well-being and is insensitive to the way the value of selfdetermination caries with the nature of the decision to be made, and differences in people’s capacities to choose in accordance with their conceptions of their own good

B. An outcome standard of competence - Standards that look only to the outcome of the decision - On this view, failure of patient’s choice to match some outcome standard of choice entails that it is an incompetent choice - Such standard protects patient well-being- fails to respect self-determination - With ideal theories for the good for persons, there are serious risks- standard may ignore patients own conception of the good and may constitute enforcement of unjustified ideals, or substitute another’s conception of what is best for patient - any standard of ind well-being that doesn’t rest on an individual’s own aims and values is problematic in theory and subject to abuse in practice - Thus, a standard that judges competence by comparing the content of a patient’s decision to some objective standard for the correct decision may fail to protect a patients well being C. A process standard of decision making competence - An adequate standard of competence will focus primarily not on the content of patient’s decision, but on the process of the reasoning that leads to that decision A process standard must set a level of reasoning required for the patient to be competent o how well must a patient understand and reason to be competent? - How certain must those people evaluating competence be about how well the patient has understood and reasoned in coming to a decision? Relation of the process standard of competence to expected harms and benefits - No standard of competence can be adequate for all decisions o Because te degree of expected harm from choices can vary o And because the importance to the patient can vary depending on choice being made - Just because a patient is competent to consent to a treatment, doesn’t mean they are competent to refuse o Ex: consent to a low risk procedure should require min competence, refusal should require high - The level of competence required for decision making varies along a full range - The balance of expected risks and benefits in comparison to other alternatives will be determined by the physician

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When patient’s values aren’t known, risks/benefits assessment will balance the expected effects of a particular treatment option in achieving the general goals of health care in prolonging life, preventing injury, and relieving suffering For each level of competence, different grounds for believing that a patient’s choice is best for them is important When expected effects of patient’s choice for his well-being appear to be worse than available alternatives, they require high level of competence o To ensure that no sig mistakes in patients reasoning are present If treatment options are similar- moderate level of competence is sufficient So, a person’s decision-making capacity may be sufficient for making a decision to refuse a diagnostic procedure without risk, but it wouldn’t be sufficient for refusing lifesaving treatment Two kinds of defect are possible: o Factural: misunderstanding about the nature and likelihood of an outcome (ex dementia) o Failure of patient’s choice to be based on his or her underlying values (ex cause depression has temporarily distorted thinking)

A relational approach to autonomy in healthcare- sherwin - Feminist analysis of autonomy Problems with the autonomy ideal - We need to question how much control patients really have over their treatment - In practice, effectiveness of the procedures used to obtain informed consent usually falls short of fully protecting patient autonomy o Attention to patient autonomy can be time consuming o Most hcp not well trained in communication o Differences in language and culture - Informed consent is built on model of intelligent patients who are accustomed to making decision bout lives and who have resources to allow them a range of options o Not all patients meet these ideals - Feminist analysis reveals several problems inherent in the construction of the concept of autonomy at the heart of most bioethics discussions o Problem: autonomy provisions are interpreted as functioning independently of all other moral values o Often understood to exist in conflict with demands of justice - Feminism encourages us to see the connections bt these two central moral ideas - Autonomy language masks barriers of oppression o Ex us in north America often think of ourselves as independent, success is deserved  This thinking encourages us to be oblivious to barriers that oppression creates- see failures in other as unwillingness to exercise autonomy - Feminism helps us recognize that autonomy is best achieved where the social conditions that support it are in place - The conception of autonomy tents to place focus of concern narrowly on individual’s decisions – this discourages attention to the context in which decisions are made - Patient decisions are autonomous if… o Patient is deemed sufficiently competent o Makes a reasonable choice from a set of options o Has adequate info and understanding about available choices o Free from persuasion - Problems with this: o Rationality od women and other oppressed groups is frequently denied o The set of available options already limits patient’s autonomy

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Info given to patients is the info that has been deemed worthy of study- doctors aren’t considering less fortunate needs when researching Hard to eval if person is persuaded when individual is oppressed

Focusing on the individual - Physicians looking at illness and not context that causes it - Ex respond to infertility by relaxing, or surgical treatment- rather than preventing pelvic inflammatory disease, or social pressures to reproduce - Autonomy focused bioethics focuses its practitioner’s attention on patients preferences o Makes sure patients have info they need to make decisions, but doesn’t ask questions about circumstances in which decisions are made - This narrow focus shows that we need to consider questions of power, dominance and privilege in our responses to illness - Feminism offers a broader perspective- raises questions about social basis for decisions o Who is harmed - Need to distinguish bt agency and autonomy o To exercise agency: one need only exercise a reasonable choice, women who choose controversial practices (ex abortion to get away from danger, cosmetic surgery to conform to social norms) are exercising agency- making choices rational under circumstances o Together, considering agency (making choice) and autonomy : when we limit our analysis to the quality of an individual’s choice under some circumstances, we ignore oppressive conditions - We need a wider notion of autonomy that will allow us to distinguish autonomous behavior from acts of agency - Impact of oppression on persons choice and ability to exersie autonomy should be seen

A relational alternative - Recognizes the importance of social forces in shaping identity, development and aspirations - Under relational theory, selfhood is seen as an ongoing process o Includes attention to political relationships of power to see how oppression interferes with individual autonomy o Under relational view: autonomy is best understood to be a skill that is developed by social circumstances - Diana Meyers theory of personal autonomy o Autonomy involves a competency that requires the development of specific skills - Relational theory allows us to appreciate how each relationship a person participates in plays a role in fostering their capacity for autonomous action by encouraging or restricting her opportunities - When messages of reduced self-worth are internalized, agents lose the ability to even know own interests - Fem theory suggests that women and oppressed can be helped to increase their autonomy skills by being offered more opp to develop stronger self-esteem and having experiences of making choices without influence - Relational theory remained us that material restrictions constitute real limitations on options available to agent o Helps us see how stereotypes reduce agents sense of their ability to ac autonomously - Relational autonomy also demands attention to ways in which the range of choices can be modified to be less oppressive WP chapter 3 Riles of style and content for philosophical writing

1. Write to your audience 2. Avoid pretentiousness (trying to impress) a. Pretentious writing is empty b. We need to offer real arguments c. Don’t use big words and long phrases 3. Keep the authority of philosophers in perspective a. Just because they have authority doesn’t mean their proposition is worthy of acceptance b. Citing a good author can strengthen your case 4. Do not overstate premises or conclusions a. Ex: we say everyone hates her- but not everyone does b. Overstatement raises doubts in readers- think you are exaggerating c. Overstatement arises in 2 ways: exaggerated, or overstated 5. Do not rely on rhetorical question a. Rhetorical questions is a question in which reader should answer in particular way b. Ex: isn’t it obvious that computers cannot think? 6. Treat opponents and opposing views fairly a. Sometimes it seems that what people are arguing came from unreliable source b. Makes people suspicious c. Two sources of unfairness: i. Straw man fallacy: consists of distorting, weakening or oversimplifying of someone’s position so it can be more easily attacked ii. Ad hominem fallacy: rejecting a claim on the grounds that there is something not wrong with the claim but with who makes it 7. Write clearly 8. Avoid inappropriate emotional appeals a. Not a good argument but trying to arouse someone’s feelings- ex looking for pity 9. Be careful what you assume a. If you wish to say abortion is morally okay, you shouldn’t assume readers will agree that fetus isn’t a person 10. Write in first person 11. Avoid discriminatory knowledge a. Don’t talk about a group as if they aren’t part of society Guided reading: Wekn o wa l r e a d yf r o mo u rd i s c u s s i o n sofi n f o r me dc o n s e n tt h a tc o mp e t e nc ei sa ni mpo r t a n tc o mp o n e nto f i n f o r me dc o n s e n t , b u t c o mp e t e n c ei sa l s oc r u c i a lt ou n d e r s t a n d i n gan u mb e ro fc o n c e r n si nb i o me di c a le t h i c s . Fun d a me n t a l l yt h ep r i n c i p l eo fr e s p e c tf ora u t o n o myi sp r e mi s e do nt hei n d i v i d u a li nq u e s t i onb e i n gc o mp e t e n t t oma k et h e i ro wnc h o i c e s . Wh e ni tc ome st ome d i c a ld e c i s i o nma ki n gt h e r ea r ema n yt h i n g swh i c hmi g hti mpa c to u ra b i l i t yt oma k e me d i c a ld e c i s i o n s . Asr e v i e we di nt h ev i d e ol e c t ur ewemi g htwo n d e rwh e t he rp a i nc a na ffe c tap a t i e n t ' s c o mpe t e n c et oma k ec h o i c e sa b o u tt he i ro wnh e a l t hc a r e . Co n s i d e rf o ry o u r s e l fwha to t h e rc o n di t i o n sa n d c i r c u ms t a n c e smi g h ta ffe c tap a t i e n t ' sc o mp e t e n c et oma k eme d i c a lc h o i c e s . I n" St a n d a r d sofCo mp e t e n c e "Al l e nE. Buc h a n a na n dDa nW. Br o c ko u t l i n e3s t a n d a r dso fc o mp e t e nc e .  -

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Wha ta r et het hr e es t anda r dso fc o mpe t e nc eout l i ne dbyt heaut hor s ? Mi n i mu ms t a n d a r d ,o u t c omes t a n d a r d , p r oc e s ss t a n d a r d

Wha tpr i nc i pl e so fbi o me di c a le t hi c sa r es uppo r t e do runde r mi ne db ye ac ho ft he s es t a ndar ds

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Wha tpr obl e msc any o ui de nt i f ywi t he a c ho ft he s es t a nda r ds ? Buc h a n a na n dBr o c ks e e mt ob ea r g u i n gf o ramo d i fie dp r o c e s ss t a n da r d , b u to net h a ti sr e l a t i v et ot h ed e c i s i o n b e i n gma de .

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Wha tdot he yme a nbyamo di fie dpr o c e s ss t anda r d? The ya r g u et h a tt h el e v e lo fu n d e r s t a n d i n gi sr e l a t i v et or i s ka n dh a r m: " Th eg r e a t e rt h er i s kr e l a t i v et oo t he ra l t e r na t i v e s–wh e r er i s ki saf u n c t i o noft h es e v e r i t yo ft h ee x p e c t e d h a r ma n dt h ep r o b a b i l i t yo fi t soc c u r r e n c e–t h egr e a t e rt h el e v e lo fc ommu ni c a t i o n ,u n d e r s t a n d i n ga n d r e a s o ni n gs ki l l sr e q u i r e df o rt h ec o mp e t e nc et oma k et h a td e c i s i o n . "p . 3 4 Co mp l e x i t ya l s oa ffe c t st hes t a nd a r do fc o mp e t e nc er e q u i r e d .

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Whydot heaut hor sc onc l udet ha tapa t i e ntc o ul dbec ompe t e nte no ug ht oc o ns e ntt ot r e a t me nt butno tc o mpe t e nte no ug ht or e f us et r e a t me nt ?Doy o ua g r e ewi t ht he i ras s e s s me nt ? Th ea ut h o r so u t l i n es e v e r a lp o s s i b l ed e f e c t si nun d e r s t a n d i n gt h a tmi g htu n d e r mi n ec o mp e t e nc e : " Fa c t u a lmi s u n d e r s t a n di n g" Wha ta r es o mee x a mpl e so fc o ndi t i o nso rs i t ua t i onswhi c hmi g hti mpe def a c t ua l unde r s t andi ng ? " Fa i l u r eo ft hep a t i e n t ' sc h o i c et ob eba s e donh i so rhe ru nd e r l yi n ga n de n d u r i n ga i msa n dv a l u e s "

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Wha ta r es o mee x a mpl e so fc o ndi t i o nso rs i t ua t i onst ha tmi g htr e s ul ti nac ho i c ewhi c h do e sno tr e fle c tapa t i e nt ' sl o nghe l dv al ue s ?

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Dot he s eki ndso fe r r or spr o vi deg o o dr e a s o nt os ug g e s tt ha tapa t i e nti sno tc ompe t e ntt oma ke me di c alde c i s i ons ?Wha two ul dt heaut hor ss a y ?

Th ei mp or t a n c eo fc o mp e t e n c emo d u l ev i de o - Do e sp a i na ffe c tp a t i e n t sc o mp e t e nc et oma k eme d i c a ld e c i s i o n s ?d o e si nt e l l i g e nc ea ffe c tme dd e c i s i o n ma ki n g ? - Co mp e t e n c et oma k eme dd e c i s i o n sr e q u i r e st her a t i o n a lme n t a l l yma t ur ed e c i s i o nma k e rt o … o Bef r e ef r o mi nt e r n a lo re x t e r n a lc o ns t r a i n t st h a tmi g h ti mp e d eh i sa b i l i t yt oun d e r s t a n dt h e me d i c a ls i t u a t i o n, p r o g n o s i s , a n dt r e a t me n to p t i o nsa n dt her i s k soft r e a t me n ta n dno n t r e a t me n t o Bea b l et oma k ead e c i s i o nt ha tr e fle c t sh i sl o n gt e r mv a l u e s -

Wh a ti sr a t i o n a l ? Wh a ti sme n t a l l yma t u r e ? Wh a tki n dso fc o n s t r a i n t sma yi mp e d eu n d e r s t a n d i n g ?–p a i n , i n t e l l i g e n c e Co n s i s t e n twi t hl o n gt e r mv a l u e s -b utwh a ti fy o u rp r i o r i t i e sc h a n g ewi t hme d i c a l di a g n os i s( e xc a n c e r g i v e sn e wpe r s p e c t i v e )

Br oc ka n dBu c h a na n - Ami n i ma ls t a n da r do fc o mp e t e n c e : o Su c hs t a n d a r dma yb ea ss i mp l ea sr e s p e c t i n gt h ec h oi c eofa n y o n ewhoi sa b l et oe x p r e s sa p r e f e r e n c e -e xmi n i ma l l yc o mp e t e n ti fy o uc a ns h a k eh e a dn oo rs i g no nd o t t e dl i n e o Wh a tpr i n c i pl e so fbi o me dma yb es u p po r t e dc h a l l e n g e db yt hi s ? o Thi ss t a n da r dl i e sa ton ee x t r e me - Ou t c o mes t a n d a r do fc o mp e t e nc e o Th eo t h e re x t r e me -t hi si sk a nt ’ ss t a n da r d-wh a tp r o v e sust ob ec o mpe t e n ti so u ra b i l i t yt o r e a s o n o Ex : c h o i c eb er e a s on a b l eo rwha tar e a s o n a b l epe r s o nwo u l dd o o Yo ua r ec o mp e t e n ti fy o uma k eac h oi c et h a tar e a s on a b l ep e r s o nwou l db e  Pr ob l e ma t i cb cwedo n ’ tkn o wwh a tar e a s o n a b l ep e r s oni s o Su p p o r t sa u t o n omyo ft h o s ewh oa r er a t i o n a l o Wh e r ema yt h i sg owr on g ? - Pr oc e s ss t a n d a r do fde c i s i o nma ki n gc o mp e t e n c e o Ac o mp r o mi s e , ord i ffwa yo fu n de r s t a n di n gc o mpe t e n c e o Ce n t r a lq u e s t i o ns -ho wc e r t a i nd oweha v et obea b ou th o wc ompe t e n tt h a tp a t i e n ti s ? o Re q u i r e sap a t i e n tt obea bl et oe x p l a i nr e a s o n sf o rt h e i rc ho i c e -ma yb emo r eo rl e s s c o mpl i c a t e dp r o c e s s -

amo d i fie dp r oc e s ss t a nd a r d :*wha tt hea ut ho r sado pt * o l e v e lo fc o mp e t e nc ei sr e l a t i v et od e c i s i o nb e i n gma d e o d i ffs i t u a t i o nswi l lr e q u i r ed i ffe r e nt s t a nd a r d so fc o mp e t e nc e o wh a td oy o ut hi n ko ft h es u g gt h a tap a t i e n tc o u l db ec o mp e t e n te n o u g ht oc o n s e n tt o t r e a t me n tb utn o te n o u g ht or e f u s e ?  Ex : i nLTC, d oy o uh a v eah e a d a c h e ?Ye s , b utma yh a vPOAt oma k ed e c i s i o n sof DNR  The yc a nma k es omed e c i s i o n s( e xy e sIh a v ep a i n ) , bu tn o tl o n g e rt e r md e c i s i o n s  I fat r e a t me nti ss t r a i g ht f or wa r d -l i t t l ec on s e q u e n c e sa n ds i d ee ffe c t s -c o mp e t e n c et o a c c e p ti sl e s st h a nc o mp e t e n c er e q u i r e dt or e j e c t

Le v e lo fu n d e r s t a n d i n gi sr e l a t i v et or i s ka n dh a r m - “t h egr e a t e rt h er i s kr e l a t i v et oo t h e ra l t e r n a t i v e s -wh e r er i s ki saf un c t i o noft h es e v e r i t yo ft h e e x pe c t e dh a r ma n dt h ep r o b a bi l i t yofi t soc c ur a nc e -t h egr e a t e rt h el e v e lo fc o mm, u n d e r s t a n di n ga n d r e a s o ni n gs ki l l sr e q ui r e df ort h ec o mp e t e n c et oma k et h a td e c i s i o n

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c o mpl e xi t ya l s oa ffe c t st h es t a n d a r do fc o mp e t e n c er e q ui r e d

p r of sa n s we rt oq u e s t i o na b o uts h e r wi n sa r t i c l e : Iwi l ls a yab i ta b o u tt h eSh e r wi nr e a d i n g .He rd i s t i nc t i onb e t we e na g e n c ya n da ut o no myi si mp or t a ntt oh e r a r g u me n t , a n di t ' sma i n l yd i s c u s s e di nt h es e c o n dha l fo fhe rs e c t i o ne nt i t l e d" Fo c uso nt heI n d i v i du a l " .Th e t e r ms" a g e n c y "a n d" a ut on omy "a r eo f t e nu s e di n t e r c ha n g e a b l yi np h i l os op h y ,b utSh e r wi nt h i nk st h a tt he s e c o nc e p t sa r eabi td i ffe r e n tf r o mo n ea n o t h e r .I np a r t i c u l a r , s h et h i n k st h a ta g e nc yi sme r e l yap a r to fa ut o n omy , a n dt h a ta d di t i o n a lc o n d i t i o n smu s tbeme tf o rs o me on ewh op os s e s s e sa g e nc yt oa l s op os s e s sa u t on o my .I n s u p p o r to fh e rc l a i m,s hep r o v i de sv a r i o u se x a mpl e st h r o u g h o u th e ra r t i c l eo fc h oi c e st h a te xp r e s sa g e n c ybu t wh i c ha r eno n e t h e l e s s( a l l e g e dl y)n o na u t o n o mo us . Sh e r wi n ' sr e l a t i o n a lc o n c e p t i o no fa ut o n omya t t e mp t st os pe l lo u tt h ec on d i t i o nst h a tmus tb eme tf o rs o me o n e wh op o s s e s s e sa g e n c yt oa l s opo s s e s sa u t o no my .I np a r t i c u l a r , s h et hi n k st ha tt wos o r to fc o n di t i o n smus tb e me tf ors o me o n et obef u l l ya u t o n o mo us . Wh e ne x pl a i n i n gShe r wi n ' sa r g u me n t ,b ec a r e f u la b o u tho wy o uus eh e rt e r mi n ol o g y .Us i n gat e r ml i k e" s oc i a l s e l f "i ny o u re s s a yi sfin e , bu to n l yi fy o ua l s oe x pl a i nwh a ti tme a ns .Wh e r ep os s i b l e , i t ' sag o o di de at o e x pl a i nShe r wi n ' sa r g u me n twi t h o ut us i n gh e rj a r g o n ....