2. What is Bioethics?
Now often known as medical ethics or
clinical ethics – hospital based issues
Philosophical study of ethical issues
brought about by advances in
scientific and medical technologies
Bioethical dilemmas arise when
different parties, albeit all well-
meaning, hold divergent values that
lead to opposing viewpoints on
appropriate actions
3. Common Bioethical Issues
Disagreements between family and clinicians
regarding the patient/resident’s best interest
Living at risk (eating, wandering, falling)
Deciding appropriate forms of care
Determining legitimate level of restraint
Determining patient preferences without
clear instructions (Terri Schiavo)
Providing services that take up tremendous
resource (e.g., multiple transplants)
4. History of Bioethics
Started as concerns regarding research ethics
Nuremberg Doctors’ Trial -- 23 German
physicians who either participated in the Nazi
program to euthanize persons deemed
"unworthy of life“ or who conducted
experiments on concentration camp prisoners
without their consent were tried. The trial
lasted 140 days. 85 witnesses testified and
almost 1,500 documents were introduced. 16
of the doctors charged were found guilty. 7
were executed.
6. The Nuremberg Code (1947)
Voluntary consent
Anticipate scientific benefits
Benefits outweigh risks
Animal experiments first
Avoid suffering
No intentional death or disability
Protection from harm
Subject free to stop / withdraw
Qualified investigators
Investigator will stop if harm occurs
7. History of Bioethics
The distinct academic field began in the
1960s in the United States
Philosophers and theologians were later
joined by physician-ethicists and lawyers
Scientific advances coupled with cultural
changes
New emphasis on individual autonomy and
rights – suspicion of medical paternalism
Focused on individual research participant
and patient
8. What Were Founding
Bioethicists Studying?
Normative ethics – formulation and
defense of basic principles, values,
virtues, and ideals governing moral
behaviour
Descriptive ethics – factual descriptions
of moral behaviour and belief systems
Analytic approach – discerning meanings
of life, concepts of rights/justice/fairness,
etc.
Balancing ethical principles
Shift from the greatest good to individual
rights
9. Major Principles in Bioethics
Tom Beauchamp and James Childress’s
Principles of Biomedical Ethics:
Non-maleficence and Beneficence
Utilitarian – harm-benefit analysis
do no harm
best interest standard
Autonomy
respect for one’s rights and dignity
informed and voluntary consent
Justice
fairness
caring for the most vulnerable
10. As the Story Goes...
Suppose a trolley is running out of
control down a track. In its path are
5 people who have been tied to
the track. Fortunately, you can flip
a switch, which will lead the trolley
down a different track to safety.
Unfortunately, there is a single
person tied to that track.
Should you flip the switch?
11. Another Story...
A physician has five patients, each in need of
a different organ and will die without that
organ. Unfortunately, there are no organs
available to perform any of these five
transplant operations. A young man who just
got hit by a trolley is brought into the ER. In the
course of assessing his injuries, which are not
life-threatening if treated immediately, the
doctor discovers that his organs are
compatible with all five of his dying patients.
Would it be justified for the physician to let the
patient die to harvest his organs to save the
other five patients?
12. How Bioethics Have
Evolved
Feminist critique
Social structure and power hierarchy
Concerns of medicalization
Significance of social relationships
Multiculturalism and perceived
homogeneity among bioethicists
Care ethics -- justice reconfigured
Relational autonomy
13. How Bioethics Have
Evolved (Continued)
Disability critique
Vulnerability and dependency as human
conditions
Meanings of “normal” and a “good” life
Medical vs social model
Cure vs social acceptance
Social contexts affect individual decisions
Meaning of autonomy challenged
14. Current Focus in Bioethics
Branches – biomedical/clinical ethics,
research ethics, organizational ethics
Genetics
Brain imaging technologies
Multiculturalism
End-of-life care
Aging
Health-care resource allocation
15. Systematic Approach in Resolving
Dilemmas
Finding thoughtful and rational justification for
our beliefs and decisions
More than intuitive responses – ask why we
may have certain intuitions, and how to
manage conflicting intuitions
Systematic approach can help to identify
essential elements to ethical decision-making,
ease pressure, and promote consistency in
resolving dilemmas
16. Issues to Consider in Approaching
Dilemmas
Define and identify the ethical dilemma
Clarify the facts and identify stakeholders –
what’s known and what’s not?
Medical indications
Diagnosis, prognosis, treatments or medication history, other clinical
options, etc.
Patient/Resident/Family (PRF) preferences
Advance directives, code status, goals of care, etc.
Quality of life
The PR’s subjective evaluation of his or her situation
Contextual factors
Social contexts, family situation, cultural/religious values, financial
situation, etc.
17. Issues to Consider (Continued)
Analyze and balance the values involved
Various principles may help – autonomy,
beneficence, non-maleficence, justice
What do various available options and our
prioritization of certain values/principles over others
say about who we are?
Make a recommendation
Involve relevant stakeholders – shared decision making
Follow up and evaluation
ensures accountability, consistency, and
transparency, thereby promoting trust and integrity
18. Case Discussion
As a result of an automobile explosion, 25 year-old
Dax Cowart was badly burned over 65% of his
body. Both eyes, both ears and both hands were
damaged beyond repair. Large doses of
narcotics were required for minimal pain relief. To
control the many infected areas on his body,
Cowart had to be submerged daily in a tank of
highly chlorinated water to disinfect his wounds.
The experience was excruciatingly painful, and
Cowart protested and refused the “tankings.” He
pleaded with his caregivers to be allowed to die,
and stated several times that he wanted to kill
himself. The physicians turned to his mother to
obtain consent for all his treatments.
19. What Should the Clinicians Do?
Moral Considerations Factual Considerations
Non-Maleficence Medical Indication
Beneficence PF Preference
Autonomy Quality of Life
Justice Contextual Factors
Care
Notas do Editor
Should we continue various procedures that may appear to prolong pain based on resident/patient preference?