Bio-Ethics Unit 1 – Flashcards

the first code of medical ethics. Ancient physicians took this oath, promising to “first, do no harm” to their patients. Today, graduating medical students take a modern version of this code in which they promise to respect their patients’ personal dignity, privacy, and use their medical knowledge for good.

Used Percival’s Code as the starting point in the development of its code of ethics. First code of ethics adopted in Philadelphia in June 1847.

During a trial of Nazi doctors, a code of permissible research was enacted. While not a legal document per se, it continues to profoundly influence the direction of research ethics policy and practice as it essentially captures historical events that ought never be repeated.

a set of ethical principles regarding human experimentation developed for the medical community by the World Medical Association (WMA). It is widely regarded as the cornerstone document on human research ethics. The fundamental principle is respect for the individual (Article 8), their right to self-determination and the right to make informed decisions. The Declaration developed the ten principles first stated in the Nuremberg Code, and tied them to the Declaration of Geneva (1948), a statement of physicians’ ethical duties.

study (although not by name) in which mentally disabled children were intentionally
infected with hepatitis in New York. Later, admittance of children into the home was contingent upon parents enrolling them in the study.

Starting in the early 1930’s, four hundred syphilitic black men in Alabama were recruited into a study to determine the incidence of syphillis in rural populations. they were denied treatment for their disease (even after penicillin was introduced in 1947). Instead the men were told they had “bad blood” by US government researchers, who observed them through the duration of their life or until the 1970’s when the study was finally exposed. Over the course of the forty years of this “life history” research, dozens of subjects died of syphilis, and hundreds more suffered complications and infected their wives and partners who in turn had infected children. Over the years, government reparations and recognition of the horrible legacy of Tuskegee have done little to rebuild the eroded trust of many African Americans regarding human subjects research.

In 1974, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was formed. The commission was a multidisciplinary group of scientists, moral theologians, ethicist-philosophers, and policy experts. Its charge was to “identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines which should be followed to assure that such research is conducted in accordance with those principles.” In 1979, The Commission promulgated the THIS, which describes the three fundamental principles of biomedical research ethics: respect for persons, beneficence, and justice. A more formal doctrine of informed consent- that human volunteers with capacity must be fully informed and consenting before being used as an experimental subject- was crafted as an application of these principles. Further THIS emphasized that fact that those with diminished capacity or voluntariness- vulnerable populations such as children or prisoners- should receive special protection from research abuses. The federal regulations guiding responsible research on human subjects are codified in Title 45 Part 46 of the Code of Federal Regulations; it is also know as “The Common Rule.”

mandated the advent of mechanisms such as advance directives and ethics committees

-Prior to these, people died when body began to die. People never thought that science or organs or machines could keep you alive linger.
-first successful one happened in 1960s=pumping devices used to keep man alive for 12 days, kept outside the body, Haskell Karp was first patient
-death became less intimidating, harder to declare exact time
-Definition of death: exact moment all vital bodily
-Barney Clark had this in 1982=different pumping machine, called Jarvik-7, kept him alive for 112 dayy leading to transplant
-but suffered through strokes, glued to bed, disease-called people to question his quality of life during his waiting time–people asked whether it would be more ethical just to have him die instead of suffering so much.

process for removing waste and excess water from the blood, and is used primarily as an artificial replacement for lost kidney function in people with renal failure

Transplantations
• First successful heart transplant 1960s: Karp, survived for a few days with this machine
• People saw Dr. Cooley’s heart wasn’t tested, against transplantations for a long time
• Death less significant, harder to declare the date of death
• Definition of death: exact moment when all vital bodily functions stop
• 1982: problem with Barney Clark’s transplant: used a different machine to keep him alive (112 days), upset because Clark’s quality of life so poor, glued to his bed and suffered multiple strokes and infections

current dilemma, similar to syphilis in history
-The beginnings of the this pandemic in the 1980’s were years fraught with bioethical controversy. The many sociobiological dimensions of the disease raised ethical questions about medical confidentiality and privacy, protection of the dignity of those infected, allocation of resources, human experimentation, and public health policy. The need to address these questions rose to a new level of urgency as this took more and more lives through the 80’s and 90’s.

-Karen Ann Quinlan and Nancy Cruzan
-Karen (22) fell into coma because of drugs-sustained on a medical ventilator, her parents wished that she could be taken off life support. 9 years lying like a vegetable before taken off. Family was Catholic-arguing for her to be taken off. Doctors holding on.
-Nancy Cruzan (33)=car crash and fell into coma-diagnosed in a persistent vegetative state. Parents found proof that she did not want to be on life support, so she was taken off and died 11 days later.
-Important cases in allowing the families the ability to choose whether their children should die or live continuously on life support in the hopes of resuscitation. Brought advance directives (self-determination)
-Patient Self-Determination Act (1991)=requires health facilities to provide info to the patients about advance heath care directives, tell doctor what you want to happen in case something bad happens during surgery, tell them in advance.
-Oregon Death with Dignity Act=allows Oregonians to end their lives through the voluntary self-administration of lethal medications prescribed by . Bush challenged it.
-Dutch legalization of euthanasia in 2002=patients with unbearable suffering can ask for euthanasia, doctors follow strict procedure, patient’s life must be grim, doctor free from prosecution if followed, patient must request, all other options considered.
-Jack Kevorkian-proponent of right to die movement.
-Dr. Death=assisted in suicides of more than 100 people=convicted in 1999 for helping in suicides, released after 8 years. Jack Kevorkian aka “Dr. Death”: assisted in suicides of more than 100 terminally ill people, controversial figure, convicted of 2nd-degree murder in 1999 in a case involving voluntary euthanasia

-Texas, 1973
-Jane Roe challenged Texas to get abortion
-legalized abortion
-ethical considerations: murder of living being, woman’s choice, still controversial/debated.
-Jane Roe (claimed rape to get abortion, because only way to get abortion in Texas, actually was lesbian, only 21 years old), real name Norma McCorvey, changed name for press. 3 year trial before it reached Supreme Court. Her initial intention was not even for womens’ rights, that became pro-life.
-Henry Wade-defense lawyer in the case from Dallas, lost because cross-appealing.
-Politics of the Case: left-poorly constructed; right=loose interpretation of constitution.
-Outcome=abortion was legalized in 1973 but only in the first three months of pregnancy (not a fetus yet).

-we can clone, but should we?
-are clones really human or not?
-scientist community progressing in cloning techniques
-religious groups and other dissidents are against cloning.
-how do we define humans?
-if every single scientists cloned, livestock would require a lot of resources, overpopulation, etc.

-reproductive medicine
-gave infertile women hope that they could become mothers
-very common, regular practice now for struggling mothers.
-in vitro fertilization-joining of woman’s egg and a man’s sperm in a special dish/test tube to achieve fertilization. Mother’s egg.
-Brown’s parents couldn’t conceive, wanted to try new experiment.
-1977: experiment began. Born in 1978 in Great Britain=major mark in medical birth science.
-scientific break-through
-led other scientists ti pursue in vitro fertilization
-Ethical Controversy:
-birth defects (blamed on scientists, would kill experiment)
-discarded fertilized eggs (issues of moment of life, killing children?)
-playing god: scientists choose who lives/dies, choose eggs.
-People couldn’t fathom a different way of having/creating a baby=outside of a body.

introduced the field of reproductive medicine, in vitro fertilization
• In vitro: joining of a woman’s egg and man’s sperm in a test tube, so common that more than 5 million have conceived babies this way
• Background: parents unable to conceive for 9 years, mother had blocked fallopian tubes, doctors wanted to try a new experiment, major mark in medical birth science
• Significance: led other scientists to pursue in vitro, made people more positive toward biotechnology
• Ethical controversy: birth defects, discarded fertilized eggs, “playing God”
• Zygote, Blastocyst, Embryo, Fetus

fell unconscious after coming back from a party, fell into a coma, parents wished her to be allowed to die after months
• First Right to die case
• Respiratory arrest, after resuscitation went into a coma and then a vegetative state
• Parents requested ventilator removed, doctors refused because was “murder”
• 1976: New Jersey Supreme Court ruled in favor of her parents, based on the right to privacy
• Quality of life considered a legitimate factor when choosing to die; right to refuse life-sustaining machinery
• Formation of a prognosis committee (clinical ethics committee)
• Because in a vegetative state and feeding tube was not removed, she survived on her own for 10 years until dying of pneumonia

fell into a coma after she lost control of her car, diagnosed to be in a persistent vegetative state, taken off life support when parents found proof that she would have wanted to die (8 years later)
•First right to die case to reach the US Supreme Court
•(last name) v. Missouri, brought forth the right-to-die movement, ability of the family to decide whether their children should live on life support or die
• In a car wreck and in a vegetative state
• Parents wanted the feeding tube removed, brought to the Supreme Court
• Ruled that the tube was to be removed, ruled that states could regulate circumstances under which a life-sustaining machine could be removed

1990=cardiac arrest, may have been associated with bulimia, Michael Schiavo as legal guardian; petitioned for removal of gastronomy tube in 1998; parents (Schindlers) object; experts in courts continue to verify that Schiavo is in persistent vegetative state and will probably not recover; multiple court challenges; ANH discontinued twice and then restarted in 2001 and 2003; Terri’s Law allowed Governor Bush to reinsert feeding tube; found unconstitutional; March 2005=ANH removed, federal courts try to have case reviewed, Terri dies peacefully on March 31, 2005.

• Cardiac arrest, possibly due to bulimia
• Michael Schiavo assigned guardian
• Underwent physical, occupational, and speech therapy
• Malpractice claim against obstetrician-gynecologist possibly related to Terri’s eating disorder
• $1 million settlement, $300,000 to Michael, $700,000 in trust for Schiavo’s case
• Michael makes claim to petition for the removal of Terry’s gastrostomy tube (1998), Terri would not want to be kept alive in a vegetative state (now decided permanent)
• Ruled that there was clear and convincing evidence that Terri was in a permanent vegetative state and that she would choose to discontinue life-prolonging medical care
• 3 chosen board-certified academic neurologists concluded that Terri’s vegetative state was permanent and that she could not be recovered
• Parents appealed
• Next 5 years, multiple court challenges, all with the same result: vegetative state
• ANH discontinued twice and then restarted (2001, 2003)
2003 Florida House and Senate passed
• Terri’s Law: Permitted Governor Bush to have Terri’s tube reinserted, first time a governor directed that a specific medical act be carried out on a patient
• 2004: Florida Supreme Court struck down on the bases of separation of powers
• Gastronomy tube removed in 2005 due to further legal maneuvers that agreed with Michael
• US Congress passed/ Bush signed a federal law directing a review of the Schiavo case in federal courts
• Federal District Judge James Whittemore declined to direct that ANH be restarted
• Terri died peacefully of dehydration on March 31

Actions are right in proportion as they tend to promote happiness, wrong as
they tend to produce the reverse of happiness

maximize “utility” (happiness, welfare, well-being)

a type of consequentialism
more benefit for the most people

the view that normative properties depend only on consequences. This general approach can be applied at different levels to different normative properties of different kinds of things, but the most prominent example is consequentialism about the moral rightness of acts, which holds that whether an act is morally right depends only on the consequences of that act or of something related to that act, such as the motive behind the act or a general rule requiring acts of the same kind.

the end justifies the means

refers to an ethical theory in which the right and the good are defined by acts, duties, and obligations rather than outcomes. An extremist will argue that only acts matter, and not outcomes. Opponents of this theory argue that consequences are morally relevant and should not be discarded.

refers to the idea that two diametrically opposed ideas remain simultaneously true. It is difficult to construct a consistent system of ethics based on this because the same decision or the same answer can be right and wrong at the same time. Several theories of this ethic have been used to argue that there is no absolute right and wrong. These theories have not garnered support in academics, but many students and patients purport to hold this type of system in an unreflective manner. It is true that many personal beliefs that do not affect rights and obligations of others are not open to be questioned. However, since medicine involves many people who have competing rights and obligations interacting, we need to have some way to justify which idea ought to be put into practice. This must be a weighing of what is lost and gained by following one ideal over another.

refers to a special theory of ethics in medicine propounded most eloquently by Joseph Fletcher, an Episcopalian theologian. In the beginning of the medical ethics movement in the United States, it was quite influential.
Fletcher constructed a moral system based on the maximization of selfless, self- sacrificing Christian love, or Agape (αγάπη). Agape is also sometimes construed as referring to Christian charity. It is the love alluded to in the rule ―Love thy neighbor. Because love in this form is the greatest good, other laws may be set for its benefit.
Fletcher distinguished this system from two other approaches to ethics that he deemed flawed: a legalistic approach based on moral rules, whichever they might be, and an antinomian approach empty of rules that disputes validity of ethical principles and holds each situation to be unique. This method was meant to offer a middle ground between legalism or formalism, which is sometimes considered an over- emphasis on codes of conduct, and antinomianism, where there are no rules at all. It is used more commonly to refer to the idea that moral rules are neither absolute nor always binding but are instead open to subjective modification according to circumstance. The theory is criticized for its subjectivism, relativism, and consequentialism; however, it highlights the importance of appreciating the unique circumstances of each clinical case and of avoiding stereotyping a case too quickly.

refer to a set of principles and obligations (e.g., truth telling) that are construed to hold true ―by default. They possess a very high moral priority that remains valid except when overridden or displaced by more pressing considerations. W.D. Ross’s seven ______ obligations include fidelity (promise keeping), reparation (gratitude and returning favors or kindnesses), gratitude, non-maleficence, justice, beneficence, and self-improvement, and any number of these may apply to any given situation. Ross acknowledges that these obligations may be contradictory in some circumstances.
In any event, the idea of these principles and obligations softens the view of absolute deontology and allows for a conversation about which of a list of compelling obligations ought to prevail. It is a very useful construct for discussing problems in clinical ethics. Simply, in clinical ethics cases, it helps to identify fundamental values that individuals believe are foundational to their lives.

refers to the idea that ethics should focus on the development of character because good character is what reliably results in ethically good judgment and in motivation to act morally. It also argues that character can be formed by appropriate instruction. It is not rule- or principle-directed at first pass but rather character directed.
This was the preoccupation of much of classical ethics. It fell into decline but then rose to prominence once again in the latter half of the twentieth century.13 It has been criticized for dwelling on the agent rather than the action. The fact that an individual is virtuous does not necessarily and certainly not automatically explain why an action he takes is right. As an ethical theory, it suffers from the lack of a mechanism to reconcile possible conflicts. The most important aspect of this theory may be the idea that a person may better him- or herself by acting in an appropriate manner, i.e., internal motive to sacrifice for others may be a reward in itself in making one a better person.

refers to an ethical system centered upon relationships, caring, and prevention of harm. It proposes that moral decisions be guided by feelings of attachment rather than detachment and informed by personal needs as well as by impersonal principles. This perspective on ethics has been very influential in the nursing literature and is sometimes used to explain, in part, the different ethical perceptions of nurses and physicians in any given instance. Rather than being used to attack the traditional establishment, it serves as a reminder to take into account the impact on all those who are important to and have relationships with patients. The illness and the related decisions have ripple effects for individuals, particularly caregivers, who might have a legitimate role in decision making that affects them.

…

To each person an equal share
To each person according to need
To each person according to effort
To each person according to contribution
To each person according to merit
To each person according to free-market exchange
benefits and risks should be fairly distributed

WHEN IS AN INEQUALITY A RELEVANT INEQUALITY?

Tell the truth
Respect the privacy of others
Protect confidential information
Obtain consent for interventions with patients
When asked, help others make important decisions
one should respect the right of individuals to make their own decisions

DO NOT DEPRIVE OF FREEDOM

One ought to prevent evil of harm
One ought to remove evil or harm
One ought to do or promote good
Protect and defend the rights of others
Prevent harm from occurring to others
Remove conditions that will cause harm to others
Help persons with disabilities
Rescue persons in danger
one should take positive steps to help others

BRING BENEFIT

Do not kill
Do not cause pain or suffering
Do not incapacitate
Do not cause offense
Do not deprive others of the goods of life
one should avoid causing harm

DO NO HARM

BENEFICENCE
-Making efforts to secure a person’s well-being;
-maximizing possible benefits
NON-MALEFICENCE
-Do No Harm
AUTONOMY
-Self-rule that is free from both controlling interference by others from limitations such as inadequate understanding that prevent meaningful choice
JUSTICE
-Who receives the benefits? Who bears the burdens?
-Fairness of distribution

Since Vatican II, the church developed ______ centered around these 7 principles:
Life and Dignity of the Human Person
Call to Family, Community and Participation
Rights and Responsibilities
Option for the Poor and Vulnerable
The Dignity of Work and the Rights of Workers
Solidarity
Care for God’s Creation

From womb to the tomb- no interruption in life

Any means that involves burdens greater than the benefits to me.
NOT morally obligated, but person free to use it.

Look: Use your current wisdom to look at, and assess the situation, try to view the situation and issue as clearly as possible, expository phase.
Pray: pray that your heart is open to doing what is right
Seek Wisdom: Use your head to widen and test your understanding of what is good and right by seeking the wisdom of others (God, key people, the Church)
Decide: use your head and heart to make a personal decision
Act: Use your hands, feet, and heart to act on your decision (e.g what are the first steps I must take to put this decision into practice? After action, has anything changed to re-evaluate the decision? If so, go back to Step 1 and restart).

“is our human awareness of value and of our human responsibility to choose it.”

“God places within us the capacity (our conscience) to grow in our ability to understand what is good and what is evil.”

-Body: 8,9,1
-Head: 5,6,7
-Heart: 2,3,4

Jean Valjean, Javert, the Bishop

involves examining every situation on its own merits, independently of any particular theoretical construct. The analysis is driven by the details of the case at hand. This is the analysis typically conducted to resolve an ethical problem that arises in the course of patient management. This type of analysis is the tool more commonly used in clinical ethics, at least at first. Physicians typically examine ethical cases the way they examine patients: one at a time. Nevertheless, an appeal of some kind to ethical grounding almost always appears at some point in the discussion to provide a clearly articulated set of reasons why a position is permissible and preferable over other options.

involves the identification of a moral theory to which one attributes credibility and that one believes to be generally correct. The case is then examined from the perspective of that moral theory.15 This approach is particularly useful in retrospective analysis of cases that prompts a change in practice or policy for future patients.

Coma
Brain Death
Vegetative State
Locked-in State
Minimally Conscious State

eyes-closed unconsciousness

Irreversible loss of the clinical function of the whole brain
Clinical judgment by the physician based upon the total absence of all brain functions
Legal death in all 50 states (with cultural sensitivity exceptions in New Jersey and New York)
No legal or moral obligation to maintain treatment for brain-dead patients

Eyes-opened unconsciousness
Condition that Karen Ann Quinlan, Nancy Cruzan and Terri Schiavo were in following their serious brain injuries up until the moment of their deaths
Patients will not have reproducible responses to stimuli
Prognosis for recovery is a key concept and an essential feature of the moral analysis

Consciousness is preserved
Patient is paralyzed except for eye movement and blinking

No consensus within neurology community but…
-Sleep-wake cycle exists
-Arousal levels range
-Visual tracking is in tact but inconsistent
-Communication ranges

When the benefit to me is greater than (or at least equal to) the burden.

Consider this scenario: A woman goes to her doctor to receive the results of a genetic test. The results show she does have the condition for which she was tested and this allows her doctor to prescribe a treatment strategy that will reduce her symptoms and delay (and perhaps prevent) the progression of the condition. Her doctor knows from their discussions that the woman has an identical twin sister and he asks if she is going to tell her sister of the test results. The sister could then undergo genetic testing herself and perhaps enter treatment. The woman says she does not want her family to know about her condition; as well she will not talk to her sister as they are not on speaking terms. The doctor knows the woman’s twin should be notified so that she can be helped also, but he has a duty of care to his patient. Which principles should be considered when trying to decide how to proceed?

“The Loyalist”
The committed, security-oriented type: Engaging, Responsible, Anxious, and Suspicious
Basic fear: of being without support and guidance
Basic desire: to have security and support
Five wing: “The Defender”
Seven wing: “The Buddy”
Growth: 9
Stress: 3

Reality-Revealing Questions
What
Who
Why
How
Where
When
Consequences

We need to prioritize our values
Are there alternatives?