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LECTURES Module One What is Ethics?  Morality vs. Ethics o Morality  System of rules which when followed causes individuals to act in predictable, co-operative ways that minimize conflict between them  Moral codes can differ between and within cultures  Cultural dependent o Ethics  Systematic study of morality the study of the concepts and theoretical justifications involved in practical reasoning or reasoning meant to be applied to govern individual behaviour  Not normally understood as culturally dependent o Divisions of ethics  Metaethics  Ask questions the answers to which form the very foundation of ethical inquiry  What is good? Why be moral?  Normative ethics  Focus on the construction evaluation and justification of theories of morality  Applied ethics – our main focus in this course  Deals with morality in practice and focuses on specific areas of inquiry such as business ethics, computer ethics or biomedical ethics  What is the connection between law and morality? o There are things are immoral but are not illegal  Examples, lying, cheating o There are things that are illegal but not immoral  Examples, the use of drugs o Fisher argues, that all laws rely on moral justifications that is all laws are aimed at creating social cooperation, protecting the vulnerable, guiding action, and resolving conflicts the very things morality is aimed at Principles of biomedical ethics?  Four main issues o Respect for autonomy o Non-maleficence o Beneficence o Respect of justice

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Respect for autonomy o Respect others rights to make their own choices o Doesn’t mean that everyone gets to pick what they want o Children- are protected by society and parents  Called paternalism  Interact differently Non-maleficence o Based on fundamental right not to be harmed o Requires we do no harm  Minimize harm o We do some harm  Example taking someone else’s parking spot Beneficence o only to avoid harm but do good for others o balancing this principle of doing good against the need to respect autonomy and minimize harm is often the challenge Justice o Most challenging o Different moral theories differ regarding what is just but fundamentally it is a principle of fairness and consistency of treating like cases alike and treating different cases differently

Module Two What is informed consent?  Voluntary consent to a treatment made by a competent patient or a surrogate representative who is adequately informed of all relevant information pertaining to the treatment and its alternatives- Fisher  Faden and Beauchamp article o Sense 1- autonomous authorization  Requires  Substantial understanding  Substantial absence of control by others  Intentionality  Authorizes a professional o Sense 2- effective consent  Policy oriented  Hospital,  Legal or institutionally effective authorization  Obtained by using a particular set of accepted procedures  People are more aware of this sense o What is the relationship between these two senses?

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Important to balance the need for consent in the first sense with what is fair and reasonable to expect of HCPs Effective authorization without autonomous authorization Autonomous authorization without effective authorization

Brody’s transparency  Brody: assumptions o Informed consent is only one, important part of the practice of good medicine o Status Quo  View of physicians  Alternative treatments are downplayed o Differences between primary care and other forms of medical care  Talks about specialist that perform tasks over and over again can do a video about it. But a doctor who sees thousands of people with different problems they cant make a video of explaining everything  Brody: legal standards o Rejects two possible standards  1. Community practice standard  Based on what others in the field are doing  Too paternalistic o More about what is other doctors are doing in order to get informed consent  2. The reasonable patient standard  A reasonable patient requires all the information  This standard requires far too much disclosure for the wrong reasons o Concerns about the medical field o Thinks that the doctor is covering his ass so he doesn’t get sued o He’s looking at what is the information that patients need in order to consent  Brody: the conversation model o Metaphor suggests that informed consent consist not in a formal process carried out strictly by protocol but in a conversation designed to encourage patient participation in all medical decisions to the extent that the patient wishes to be included o What do you like about this model?  Brody: the transparency standard o Important to understand on what he is saying o Informed consent is obtained when a reasonably informed patient is allowed to participate in the medical decision to the extent that the patient wishes o To what extent must patients participate in their own medical decisions?  Their own choice

o Does Brody think it is ok to chose to trust your doctor why? o Does the transparency standard offer a workable compromise? Module Three The importance of competence  Do you think the pain can affect a patients competence to make medical decisions? Such as if you are in more pain you take more drugs  Does a person’s level if intelligence and rationality affect medical decision making such as drugs  Competence o An individual ability to perform a particular task o To make medical decisions requires the rational, mentally mature decision maker to  Be able to make a decision that reflects his long term settled values  Be free from any internal or external constraints that might impede his ability to understand the medical situation, prognosis and treatment options and the risks of treatment and non-treatment o Rational o Mentally mature o Free from constraints to understanding o Long term settled values  Buchanan and Brock o 1. Minimal standard of competence  Standard might be as simple as respecting the choice of anyone who is able to express a preference  This standard lies at one extreme  What is problematic about this standard?  Yes or no answers  Preference o 2. Outside standard of competence  Other extreme this is Kant’s standard  Example  That the choice be reasonable or what a reasonable person would do  What is problematic about this standard o 3. Process standard of decision making  Central questions- how well must the patient understand and reason? How certain must those persons evaluating competence be about how well the patient has understood and reasons in coming to a decision  Modified process standard o Buchanan and Brock seem to be arguing for a process standard but one that is relative to the decision being made

o Different types of decisions will required different standards of competence  More hard decisions o What do you think of the suggestion that a patient could be competent enough to consent to treatment but not competent enough to refuse it?

Module Four  Drug test on children o Risks in enrolling children in clinical trials o The dosage can be wrong- if it gets to high we have to deny the med – too toxic o The dosage can be low and it wont work o New drugs should be tested on children o Some children has died and some children has been sick  Ethical riddle in HIV research o Story about Celine  Housewife in south Africa  Needed to participation in healthcare= were able to get free meds and transportation  Very ill  Stopped going to healthcare clinic because she was poor and couldn’t cost  Did not know what meds she used= not know the results 

Module Five Right to health care  No o Health is important but the cost of health care and the way in which we fund health care detracts from more basic negative freedom based rights o We cannot sacrifice justice for beneficence o Very few argue that we have no right but for many this right is very limited  Yes o Justice and beneficence are inseparable o Basic health is a precondition human flourishing o The right to health care is justified because without health we are unable to exercise more negative freedom based rights  What is Buchanan arguing? o The right to a decent minimum of health care must be justified but this is rarely done o Many arguments for publicly funded health care rely on this right

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o Buchanan argues that we can justify publicly funded healthcare without appealing to this o He appeals to three kinds of arguments which work together  1. special rights  2. Prevention of harm  3. Prudential Special Rights o Past injustices o Compensating those who have suffered unjust harm or who have been unjustly exposed to health risks o Providing some benefit for those who make sacrifices for the public good o These arguments do not justify a universal right to publicly funded health care but they do justify a special right Preventions of harm o We have an obligation to prevent others from coming to any harm o Publicly funded healthcare can significantly reduce the likelihood of experiencing harm o Measures such as sanitation, vaccination and preventative health care can significantly reduce suffering and death Prudential o Simple idea that some of our interests are group interest and rely on others to reduce illness and increase health o How everyone connects with health  Being around someone sick, looking out for them to feel better and may get sick  Someone surveying food= don’t want them sick Enforced beneficence o In order for people to do good we have to force them to do it o All we benefit for using but no one wants to take responsibility= don’t want to be in charge  Example, bathroom in the household no one wants to clean where it gets so bad no one wants to use it anymore  Where someone in the household is cleaning the bathroom and the rest of the people in the house rely on them to clean it or no one wants to clean It so nothing gets it done. o Tragedy to the commons  Everyone needs to take part o How does Buchanan justify enforced  1. Public goods argument  2. Mutual assurance argument Conclusion o If we combine special rights, harm and prudential concerns and arguments for enforced beneficence, publicly funded health care system

o Mandating contributions to that system because of public goods problems Module Six Allocating Scarce Resources  Rationing o Practice forced by a scarcity of resources of withholding potentially beneficial medical treatment from individuals or groups  Soft rationing  Implicit criteria  Example o Calling into the doctors office, the individual on the phone has to see what your concern is and has to determine if you can take one of the emergency spots or not  Hard rationing  Explicit criteria established through public debate  Commodification vs. exploitation o Commodification  Attaching a value to something  Water  Individual people  Resources o Exploitation  Taking advantage of our own hands, kind of linked to commodification  Taking advantage to a friend that they wont benefit it  Organ transplants o 4 approaches to rationing  1. Selection committee process  2. Lottery approach  3. Customary approach  4. Market approach o Selection committee process  Look at who should get an organ if one is available  Pattern of decisions will arise in which case we can use that as a standard reducing the need  No pattern arises and decisions appear arbitrary and unacceptable  Can be biased from non medical reasons o Lottery approach  Ultimate equalizer  First come first serve approach is not as unbiased as it might appear  Equality  Everyone can be able to get the organ all depends on the draw of who gets it

 Money can play an impact, more money can easily get in first o Customary  Depends on culture  List of criteria which makes the choices for us  Some criteria can be family support, those relating to age seem reasonable but can hide beliefs about social worth  Too old o Market approach  Those who can afford to pay would get what they need those who cant afford it could ask for charity  Some concerns with this Kishore- article  Donations can be made and to help others  Those who sell their organs can still have as a goal helping others  Selfish? o Benefit out of it money or helping a loved one staying alive  Donations are always voluntary but sales are forced Module Seven Terminal Sedation  The use of high doses of pain medication to treat patients suffering at the end of his natural life with the awareness that such high dosages will hasten the patients death by reducing respiration heart rate  Drugs provided will die sooner rather than later  Controlling the pain, the increase of drugs/increase problems  Moral dilemma o Pain management in palliative care requires this sedation but it will at some point lead to the patients death and this might be seen as indistinguishable from euthanasia o If you are in favour this may not be a problem o If its morally acceptable health care providers find themselves in a situation where they either fail to respond to the pain of their patients or harm them by contributing to their death  Doctrine of double effect o Principle stating that a proposed action that will have benefits but will cause some harm is permissible if the action itself is morally appropriate and the foreseen harm is not intended  Key conditions for double effect o 1. The action itself must be good or at least indifferent o 2. The good effect and not the evil effect must be intended o 3. The good effect must not be the product of the evil effect

o 4. There must be a proportionately grave reason for permitting the evil effect

Module Eight Legalizing Euthanasia  Brock argues in favor of the legalization and Callahan argues against it  Brock o Two principles  Individual well being  Individual self determination or autonomy  Callahan o Moral claim of self determination and if there are limits o You cant consent your death Module Nine On the moral and legal status of abortion by Mary Warren  “fetus is not a person hence not the sort of entity to which it is proper to ascribe full moral rights”  Argument against abortion o 1. Wrong to kill innocent human beings o 2. Fetuses are innocent human beings o Conclusion  Wrong to kill fetuses  Genetic human being vs moral person o Genetic  Fetuses are genetically human beings o Moral person  Five traits central to personhood o Consciousness o Reasoning o Communication o Self awareness o Self motivated activity  If there is none of these traits it is not a person Why is abortion is immoral by Don Marquis  Argues that fetus is a person and it is equally wrong to kill a fetus  What makes killing wrong? o Effects on the victim in a negative way o Loss of ones life of all experiences and future o Worst crimes and those who are dying is a bad thing

Module Ten  videos Module Eleven  Videos...