Copyright Institute for Ethics and Emerging Technologies 2008 Introduction to Bioethics James J....

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

[email protected]

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


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



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


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


Ape and Human Ethics


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


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


You cannot go against natureBecause when you do Go against natureIt's part of nature too


The Enlightenment


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


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


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.


Pre-Modern Physician Ethics


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)


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


Stages of Moral Development

Lawrence KohlbergDevelopmental Correlated with

higher education and exposure to Enlightenment thought

Conquering animal nature with reason


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