Introduction to Bioethics
Anita Ho, PhD
Ethicist, Ethics Services, PHC
Assistant Professor, Center for Applied Ethics, UBC
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
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)
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.
Nazi Experiments
The Nuremberg Code (1947)
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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
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
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
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
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?
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?
How Bioethics Have Evolved
• Feminist critique
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Social structure and power hierarchy
Concerns of medicalization
Significance of social relationships
Multiculturalism and perceived homogeneity
among bioethicists
– Care ethics -- justice reconfigured
– Relational autonomy
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
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
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
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.
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
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.
What Should the Clinicians Do?
Moral Considerations Factual Considerations
Non-Maleficence
Beneficence
Autonomy
Justice
Care
Medical Indication
PF Preference
Quality of Life
Contextual Factors