Ethical Reasoning & Contemporary Medical Ethics Lecture 3 21st October 2009 Dr. Ruth Pilkington Ethics Lectures to date 1. Historical Overview of Medical Ethics 2. Traditional Moral Theory Find at : www.medicine.tcd.ie/ethics/ethicsyrone/index.php Traditional Moral Theory Kantian (Deontological) Ethics Utilitarianism Virtue Ethics Contemporary Medical Ethics ‘...the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools...’ Sir William Osler, Canadian Physician(1906) As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics (2008) Ethical Reasoning Clinical Ethics is learnt in the same way as clinical medicine is learnt, ‘at the coalface’, through meeting patients and their families, being involved in their cases. It is a practical discipline. The doctor must learn to recognise the ethical aspects of his/her clinical (and scientific research work), and to make reasoned decisions about this work within the framework of the law and Medical Council guidelines. Ethical Reasoning Learning to Reason Many (most?) clinical situations, and decisions involve a combination of factual concerns and ethical issues. Ethical Reasoning Learning to Reason Scientific Reasoning The skill of evaluating the scientific evidence available and applying it, using clinical judgement to the clinical scenario at hand. This is a fundamental part of your medical education and later practice. Ethical Reasoning In the same way, ethical reasoning is a skill required to allow you to identify and negotiate ethical problems, using an organized framework of ethical methods or tools in the clinical setting. Ethical reasoning must stand up to scrutiny, (in court if necessary) in the same way as the scientific aspects of decision-making. Ethical Reasoning Learning to Reason Judgement Judgement is needed in making final decisions – there is no ethical algorithm that can be applied without judgement. Tools of Ethical Reasoning How should I act morally in this situation? Methods or Tools in Bioethics – to help determine how best to guide human action Bioethical Methodologies How should I act morally in this situation? 1. Practical or Applied Ethics Applied Philosophy of Medicine (Theoretical Framework using various elements of ethical theories, etc.) 2. Principlism (Fixed set of moral principles, e.g. Beauchamp & Childress) 3. Case comparison (Case based approach – real /paradigm cases but no clear method) 4. Combined technique to seek compromise (?fails to achieve moral clarity) Tools of Ethical Reasoning 1. Distinguish Facts from Values 2. Clarify the logic of the argument 6. Reason from principles & theories Tools 5. Rational Decision Theory 3. Case comparison 4. Thought experiments Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Clarify the Logic of the Argument Syllogisms – deductive argument expressed in the form of two propositions called premises, and a conclusion that results logically. P1 P2 C P1 is P2 C If p then q p q e.g. If a foetus is a person it wrong to kill it A foetus is a person It is wrong to kill a foetus Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) P1 P2 C P1 is P2 C If p then q Not q Not p e.g. If a foetus is a person it wrong to kill it It is not wrong to kill a foetus A foetus is not a person Clarify the Logic of the Argument II An Invalid argument P1 P2 C If p then q Not p Not q e.g. P1 If a foetus is a person it is wrong to kill it P2 A foetus is not a person [C] [It is not wrong to kill a foetus] Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Clarify the Logic of the Argument III An Invalid argument P1 P2 C If p then q Not p Not q e.g. P1 If it is raining I will wear a coat P2 It is not raining [C] [Therefore I will not wear a coat] Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Tools of Ethical Reasoning 1. Distinguish Facts from Values 2. Clarify the logic of the argument 6. Reason from principles & theories Tools 5. Rational Decision Theory 3. Case comparison 4. Thought experiments Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Thought Experiments I Absolute Argument : ‘It is never right to kill someone’ The Case Of The Trapped Lorry Driver The Case Of The Trapped Lorry Driver1 A driver is trapped in a blazing lorry. There is no way in which he can be saved. He will soon burn to death. A friend of the driver is standing by the lorry. This friend has a gun and is a good shot. The driver asks his friend to shoot him dead. It will be less painful for him to be shot than to burn to death. Should the friend shoot the driver dead? 1 As quoted in Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Thought Experiments II Absolute Argument: ‘There is an absolute right to life’ The Case Of The Connected Violinist The Case Of The Connected Violinist (JJ Thompson, A Defense of Abortion , 1971) You wake up one morning with your circulatory system connected to another person. It turns out that you are connected to a famous violinist, with a fatal kidney ailment. If he remains connected to your circulatory system, he will eventually be cured. The Society of Music Lovers have kidnapped you and connected you up, as you are the only person with a suitable blood type. ‘But, never mind’, his doctors say, ‘It is only for 9 months and then he will be fully recovered and then you can be disconnected.’ Thought Experiments III Acts and Omissions: ‘Is there a moral difference between killing and letting die’ The Cases of Smith and Jones (Rachels J, ‘Active and Passive Euthanasia’, NEJM (1975) The Cases of Smith and Jones Rachels J, ‘Active and Passive Euthanasia’, NEJM (1975) Smith stands to gain a huge inheritance should anything happen to his 6 yr old cousin. One evening, he sneaks in while the child is having a bath and drowns the boy. Jones also stands to inherit if anything happens to his 6 yr old cousin. He sneaks into the bathroom, to drown his cousin, but finds that the child has slipped and is drowning in the bath. Jones does nothing and allows him to drown. Is there any moral difference between what Smith and Jones did? Tools of Ethical Reasoning 1. Distinguish Facts from Values 2. Clarify the logic of the argument 6. Reason from principles & theories Tools 5. Rational Decision Theory 3. Case comparison 4. Thought experiments Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Rational Decision Theory Consequentialist approach To determine / maximise the best outcome, e.g. in the allocation of scarce health resources, etc. Assign probabilities and values to outcomes to calculate the best ‘expected utility’ and thus make decision on this basis. Rational Decision Theory Clinical Scenario A decision must be made on whether or not to resuscitate Mr. O’Connor, in the event of cardiac arrest. Possibilities Resuscitation Outcome 10% (p=0.1) success Future QoL (value) Reasonable (+5) 40% (p=0.4) success Poor (-10) 50% (p=0.5) death 0 No resuscitation (DNR) = Death = value of 0 Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Rational Decision Theory Clinical Scenario II Whether or not to resuscitate Mr. O’Connor? DNR : ‘Expected Utility’ 1 x 0 = 0 Resuscitation: ‘Expected Utility’ (0.1 x 5) + (0.4 x -10) +(0.5 x 0) = -3.5 Hence on basis of ‘expected utilities’, it is better not to attempt resuscitation. Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) Tools of Ethical Reasoning 1. Distinguish Facts from Values 2. Clarify the logic of the argument 6. Reason from principles & theories Tools 5. Rational Decision Theory 3. Case comparison 4. Thought experiments Adapted from Hope, Savulescu, Hendrik, Medical Ethics and Law (2008) ‘The Four Principles’ in Medical Ethics Beauchamp & Childress (2001) The Four Principles in Medical Ethics Respect for (Patient) Autonomy Non-Maleficence Beneficence Justice Respect for Patient Autonomy Autonomy literally means ‘self-rule’ or ‘selfgovernance’. An individual’s capacity to make decisions about their health care needs and to consent to or refuse treatment depends on their ability to think, decide and act, freely, on the basis of such thought and decision. Two essential conditions for autonomy: Liberty Agency Respect for Patient Autonomy ‘The autonomous individual acts freely in accordance with a self chosen plan,...A person with diminished autonomy, by contrast, is in some respect controlled by others or incapable of deliberating or acting on the basis of his or her desires and plans’, (Beauchamp & Childress (2001)) c.f. Those with diminished autonomy e.g. prisoners, learning disabled persons, patient with Respect for Patient Autonomy Look at Autonomous Choice rather than Generally Autonomous Capacity, i.e. a generally autonomous person may not be able to act autonomously in certain situations. Respect for patient autonomy requires doctors (+ family) to help patients make their own decisions and to respect those decisions (irrespective of whether one believes those decisions to be wrong). ‘The Four Principles’ in Medical Ethics Beauchamp & Childress (2001) The Four Principles in Medical Ethics Respect for (Patient) Autonomy Non-Maleficence Beneficence Justice Non-Maleficence We should avoid doing harming to others. ‘Primum non nocere’ – [trans. first (or above all) do no harm] – this would make medicine a very difficult pursuit! It is an extremely important principle to avoid harming others, but cannot take priority and be expressed as an absolute principle. Must be considered in the context of the obligation in medicine of the principle to do good for our patients (beneficence), e.g cancer surgery. Also balance required with the principles of autonomy and justice, e.g. involuntary isolation. ‘The Four Principles’ in Medical Ethics Beauchamp & Childress (2001) The Four Principles in Medical Ethics Respect for (Patient) Autonomy Non-Maleficence Beneficence Justice Beneficence The obligation to do good / promote what is best for the patient. Sometimes conflict may arise between doctor's judgement of what is in the patient’s best interests and his desire to respect the patient’s different but autonomous decision. Must be balanced with the principles of respect for autonomy, non-maleficence and justice (e.g.. rights and needs of others). ‘The Four Principles’ in Medical Ethics Beauchamp & Childress (2001) The Four Principles in Medical Ethics Respect for (Patient) Autonomy Non-Maleficence Beneficence Justice Justice Distributive Justice: Decisions re the allocation of scarce health resources (e.g. outpatient time, drugs, money, ICU beds,...) Patients in similar situations (e.g same diseases) should normally have access to the same health care (e.g. same diagnostic technologies/pharmaceutical interventions). But attempt to distribute our limited resources fairly, so that in providing for some, others are not left wanting. Justice also applies to Forensic Medicine (psychiatrists assessment of sanity for court), Employment Justice (fair promotion in the workplace), Prohibition of involvement in Torture (Declaration of Tokyo), etc.