L1. Introduction to Medical Ethics

Alfarabi College of Medicine, (Sep.2017)

What we will try to learn today?

• Section I: Definitions & Concepts

Morality

Ethics

Bioethics

Medical ethics

• Section II: Western approaches to medical ethics

• Section III: Islamic approaches to medical ethics

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SECTION I: OVERVIEW OF ETHICS & BIOETHICS

Why do we do what we do? htt

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Levels of Behavioural ‘Control’

Why can’t/don’t we do what we want to?

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Factor Originates from Developed by Written as Binding/ voluntary

Committing to

Morality General unchallenged community values

Inherited values; not argued; changes slowly with time

Not written Voluntarily Community members

Ethics Argued through logically established literature (moral philosophy)

Philosophers Inspires codes, policies, & laws

Voluntarily Not universal

Professional standards

Professional values Professional bodies

(Professional) Codes of Ethics

Binding those in profession

Laws & Regulations

Legal and moral values

Legislators Laws Binding ALL

Institutional Policies

Professional and institutional values

Healthcare institutions

Codes, policies, guidelines

Binding Those in institution

Personal beliefs &preferences

Personal belief system

Individuals (persons)

Not written ? The person only

SECTION II: DEFINITIONS & CONCEPTS

What is ethics?

What is bioethics?

What is medical/clinical ethics?

What is an ethical question/dillema?

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What is ethics? A system of moral principles or standards governing

conduct.

a system of principles by which human actions and proposals may be judged good or bad, right or wrong;

A set of rules or a standard governing the conduct of a particular class of human action or profession;

Any set of moral principles or values recognized by a particular religion, belief or philosophy;

The principles of right conduct of an individual. (UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)

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Ethical reasoning

• Ethical reasoning is necessary to resolve the potential conflicts between personal values and professional values.

• Ethical decision making requires everyone to consider the perspectives of others, even when they have different values.

Ethical reasoningValues and ethical principles

The Fact-Value Distinction

• Fact: description of the way the world is; an actual state of affairs (“is”). • Example: our health-related decisions involve many people, not only

ourselves

• Value: judgment about the way things should be (“ought”).• Example: Doctors ought to take consents from the individual patient

• Value = something a person/community has identified as important (e.g., autonomy/self-determination)

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Values, Morals, Ethics

• Values signify what is important and worthwhile. They serve as a basis for moral codes and ethical reflection.

• Morals are codes of conduct governing behavior. They are values put into practice as actions.

• Ethics provide a systematic, rational way to work through dilemmas and to determine the best course of action in the face of conflicting choices.

What is bioethics?

• It is derived from Greek bio- life and ethicos moral.

•Applied bioethics aim at the identification, analysis, and resolution of the ethical issues in almost any field that is related to human life and health.

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Why bioethics?

• the new scientific/technological developments in biomedical and life sciences, and debates about:

• Abortion

• Contraception

• Kidney dialysis machine (Who had the priority?)

• Organ transplant, artificial ventilator, and brain death

• In virtro fertilization (IVF)

• Cloning and stem cell research

• Genetic engineering

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Ethics

Bioethics

Clinical Ethics

Research ethics

Resource Allocation ethics

Public Health ethics

Nursing ethics

other

Business ethics

Environmental ethics

Social ethics

Organizational ethics

IT ethics

Other

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What is clinical/medical ethics?

• Clinical ethics is a practical discipline that provides a structured approach to assist physicians in identifying, analyzing and resolving ethical issues in clinical medicine.

• The practice of good clinical medicine requires some working knowledge about ethical issues such as informed consent, truth-telling, confidentiality, end-of-life care, pain relief, and patient rights h

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• Give example of an ethical issue/problem you faced or witnessed, mentioning the following:

What was the situation?

What was your feeling towards it?

What did you do?

Do you think you did the best thing? why?

What you think you need to know more to be able to handle similar situations in the future?

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Questions answered by Bioethics

• deciding what we should do (what decisions are morally right or acceptable);

• explaining why we should do it (how do we justify our decision in moral terms);

and

• describing how we should do it (the method or manner of our response when we act on our decision).

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What is an “ethical issue” or a “moral dilemma”?

• There is an ethical issue when:

• …we encounter conflicting values, beliefs, goals, or responsibilities

• …we are concerned that persons or their rights are not being respected

• …we are concerned about fairness and justice

• …we are unsure what we should do or why we should do it, morally speaking h

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What is an Ethical Question?

And what is not?Ethical questions have the following components:

• often involve the words ought or should.

• There are several alternate solutions, none of that is

without some challenging or problematic aspect.

• They contain conflicting moral choices and dilemmas, and conflicting underlying values of the people involved

• They have no right or wrong answer which satisfies all parties, but better or worse answers based on well- reasoned justifications.

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Ethical Dilemma

• A situation in which a person must decide whether or not to do something that, although beneficial to the patient, may be considered unethical and perhaps illegal.

• Examples of Ethical Dilemmas

• Should I remove the life-saving equipment from a terminally-ill patient to save another patient?

• Which patient should receive a donated organ?

• Is it O.K. to befriend my patients?

• If there is shortage of ICU beds, who should get the service?

L3. SECTION III: WESTERN APPROACH TO ETHICS AND ETHICAL REASONING

How right and wrong are distinguished?

How to approach the ethical dilemmas?

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Main Western Philosophies

Other philosophies Devine (dogmatic) philosophies

Oriental philosophies

Utilitarianism African, Asian, etc. Islamic Buddhist

Deontology Human Rights Jewish Confucius

Feminist ethics Catholic Indian

Virtue ethics Protestant Persian

Casuistry Jehovah Witnesses

Justice theory

Principlism

Why do we need to know about western philosophies?

• A Doctor is an international currency (you may be practicing anywhere)

• Bridging the knowledge & cultural gaps

• Western literature & experience are steps ahead of ours

• Ethical concepts & tools are quite universal

• No self-development without knowing others

• To reflect Islamic concepts to non-Muslims in an appropriate manner

General characteristics of western philosophies

• Secularism: people are free to practice their religion but no particular religious guidance to right & wrong

• Individualism: It’s all about I, me and myself!

• The individual and nuclear family structure are the societal building block.

• The individual's interest is what should come first (vs. more collective extended family ethics in our region)

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the value of an

action is determined by its utility; all actions should be directed toward achieving the greatest happiness for the greatest number of people.

Examples: quarantine, isolation, vaccination, etc.

actions are judged based

upon inherent right-making characteristics or principles rather than on their consequences. Emphasis on duty, rules and regulations, principles and moral obligations which govern ones right

action

Examples: Doctor’s duties to care for their patients

It emphasizes the

virtues, or moral character (who is your

virtuous model?)• Examples: Doctors as role models.

• Should not a patient comply with a “don’t smoke” advice from a smoking doctor?!

(cont.)

(Ethics of Care) commitment

to correcting male biases (e.g. women’s subordination is morally wrong) and that the moral experience of women is as worthy of respect as that of men.

The greatest confidence in our moral

judgments resides not at the level of theory, where we endlessly disagree, but rather at the level of the case, where our intuitions often converge without the benefit of theory.

Respect for Autonomy: respect humans' ability to choose,

Beneficence: Do Good for others,

Nonmaleficence (Do No Harm), &

Justice (Be fair to your patients) Where do these principles meet with Islam?

Section IV:

Islamic approach to ethical analysis and decision making

Ethics in Islam… not a separate entity!

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How should Muslims decide their acts?

1)The Koran and 2) the Sunna,

• Ijmaa االجماع means a unanimous agreement among Muslim Scolars on any Shariah ruling

• Qiyas القياس likening a new case in question without textual evidence to an original ruling which is supported by explicit legal text which shares the same cause.

• Maslahah المصلحة deciding a ruling based on the principle of general public interest in issues which do not have clear and specific textual ruling

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• Istihsan االستحسان setting aside an established ruling backed by dalil (evidence) on a matter in favor of an alternative ruling which is stronger and more convincing than the first ruling, based on the support by dalil.

• Istishabاالستصحاب the presumption of continuity of the original ruling as long as there is no other dalil to establish the contrary

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• Sadd Zari`ah سد الذرائع signifies an approach used to prevent any means to evil in order to avoid from forbidden acts. It is regarded as an early preventive measure to keep away a Muslim from committing actions prohibited by Allah SWT.

• `urf العرف is defined as established norms and common to the majority of people in a community either in the form of sayings or doings as long as it does not contradict the Shariah ruling.

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The are to preserve person’s:

1. Religion حفظ الدين

2. Soul حفظ النفس

3. Mind حفظ العقل

4. Wealth حفظ المال

5. Progenyحفظ النسل

All Islamic legislations strive to achieve these goals and prohibit what contradicts them

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• It is the methodology of

• defining, analysing and resolving the ethical issues that arise in healthcare practice, or research;

• based on the Islamic moral and legislative sources (Koran, Sunna & Ijtihad); and

• aims at achieving the goals of Islamic morality (i.e. preservation of human’s religion, soul, mind, wealth & progeny )

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• Clear and fixed sources• Clear goals of morality (Maqasid Alshariya)

• Its moral style endorses values of:

▫ Bringing hope (بشروا وال تنفروا)

▫ Softness (فقوال له قوال لينا)

▫ Kindness (ما كان الرفق في شيء اال زانه)

▫ Respect for vulnerable (ليس منا من لم يوقر ( )رفقا بالقوارير

(كبيرنا ويرحم صغيرنا

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THANK YOU

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