Copyright Institute for Ethics and Emerging Technologies 2008 Introduction to Bioethics James J. Hughes Ph.D. Executive Director, Institute for Ethics and Emerging Technologies Public Policy Studies, Trinity College, Hartford CT

Outline of the Course July 20-22: Introduction to Bioethics July 27: Public Health Ethics July 29: Death and Dying August 3: Clinical Ethics August 5: Neuroethics August 10: Research Ethics August 12: Reproductive Ethics August 17: Gene Patenting August 19: (TBA)

Policy Briefs and Responses Policy Issue Briefs 8-10 pages long. presented in class as a 10 minute Powerpoint presentation, with an accompanying one-page handout. Policy Issue Responses 1000 words long, copies distributed to the rest of the class presented in class as if they are Congressional testimony. Topics Mandatory advance directives Human gene patenting 2 topics TBD Copyright Institute for Ethics and Emerging Technologies 2008

What are Ethics? Ideas of right and wrong, and “the good life” Moral intuitions inherited from simian life Shaped and filtered by modern religious and political ideas Copyright Institute for Ethics and Emerging Technologies 2008

Five Moral Intuitions Harm/care Fairness/reciprocity Ingroup loyalty Respect for authority Purity/sanctity Jonathan Haidt

Dangerous Trolleys Trolley 1: Five kids, one man, one switch to push Trolley 2: Five kids, one (fat) man, one hard push Copyright Institute for Ethics and Emerging Technologies 2008

Cleanliness and Morality Moral censure and disgust are the same area of the brain Washing one’s hands or even thinking about “clean” words reduces the severity of moral judgments Baptism Copyright Institute for Ethics and Emerging Technologies 2008

Ape and Human Ethics Copyright Institute for Ethics and Emerging Technologies 2008

Ethics vs. Self/Group Interest Ethics are functional for groups, not individuals Ethics subordinate self-interest to collective interest “Enlightened self-interest” & egoisms Shame vs. guilt Copyright Institute for Ethics and Emerging Technologies 2008

Naturalistic Fallacy The IS doesn’t tell us what SHOULD be We each need to decide what ethics make the most sense for us But science can illuminate why we feel that way Copyright Institute for Ethics and Emerging Technologies 2008 You cannot go against nature Because when you do Go against nature It's part of nature too

Copyright Institute for Ethics and Emerging Technologies 2008 The Enlightenment

Copyright Institute for Ethics and Emerging Technologies 2008 Principles of the Enlightenment 1. Autonomy of reason from faith and authority 2. Human perfectibility and social progress 3. Empirical optimism: sapere aude! (Dare to know) 4. Legitimacy of government based on free association 5. Tolerance of diversity, freedom of thought 6. Ethical universalism – beyond nationalism, racism, sexism

Enlightened vs. Pre-Enlightened Copyright Institute for Ethics and Emerging Technologies 2008 Enlightened Harm/care Fairness/reciprocity Pre-Enlightenment Ingroup loyalty Respect for authority Purity/sanctity

Pre-Enlightenment Medical Ethics Professions develop codes of ethics to rationalize their unequal power and special privileges The code of the healer Hippocratic oath Copyright Institute for Ethics and Emerging Technologies 2008

Summary of the Hippocratic Oath I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: Fealty to one’s teachers and their family. Do good for, and avoid harming, patients. Don’t assist with suicide or abortion. Leave surgery to surgeons. Don’t have sex with patients, male or female. Keep all medical knowledge secret from the public. Copyright Institute for Ethics and Emerging Technologies 2008

Pre-Modern Physician Ethics Copyright Institute for Ethics and Emerging Technologies 2008

Bioethics Timeline – s Declaration of the Rights of Man and of the Citizen (1789) United States Bill of Rights (1791) London's Royal Society for the Prevention of Cruelty to Animals founded (1824)

Bioethics Timeline – 1920s-1970 Nuremberg Code (1947): issue of human experimentation United Nations: Universal Declaration of Human Rights (1948) Declaration of Geneva (1948) ◦ Issued as a development on the Oath of Hippocrates World Medical Association's "International Code of Medical Ethics“ (1949) FDA requires informed consent in clinical trials (1962) Life Magazine (1962) article on dialysis selection committees – “God Squads” Declaration of Helsinki (1964) (WMA): guidelines for human experimentation Hastings Center founded (1969) Copyright Institute for Ethics and Emerging Technologies 2008

Bioethics Timeline – Kennedy Institute of Ethics founded at Georgetown University Tuskegee Syphilis Experiment (1930s-1972) National Commission for the Protection of Human Subjects established in the U.S. (1974) Belmont Report outlines ethical principles for the protection of human subjects in research (1978) Carter Bioethics Commission established (1979) CIOMS Guidelines (1993) ‘International Ethical Guidelines for Biomedical Research Involving Human Subjects’ (CIOMS: the Council for International Organizations of Medical Sciences) U.S. National Bioethics Advisory Commission established (1995)

Bioethics Timeline – Appointment of Bush President’s Council on Bioethics (2001) Universal Declaration on Bioethics and Human Rights (UNESCO; United Nations Educational, Scientific, and Cultural Organisation) (2005) Dismissal of Bush PBC (2009) Bioethics skirmishes in healthcare reform debate (2009) Appointment of Obama Bioethics commission (2010)

Contemporary Ethical Theories Deontology – There are clear rights and wrongs Virtue theory – Intention of the actor is most important Consequentialism – Greatest good for greatest number Principlism – There are general ethical principles

Deontology From the Greek word for ‘duty’ rules, which express our duties E.g. killing someone to give their organs to someone else may ignore our duty to respect that person’s right to life. Generally associated with religious ethics, such as 10 commandments & Sharia

Kantian Deontology Immanuel Kant ( ) is the most influential deontologist. Rejecting Consequentialism: "A good will is good not because of what it effects or accomplishes." Even if by bad luck a good person never accomplishes anything much, the good will would "like a jewel, still shine by its own light as something which has its full value in itself."

The Categorical Imperative Kant claims that all our actions should be judged according to a rule he calls the Categorical Imperative. First Version: "Act only according to that maxim [i.e., rule] whereby you can at the same time will that it become a universal law." Second Version: "Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means." Important to treat people as autonomous agents

Problems of Deontology Problems: Always following rules of conduct can lead to negative consequences e.g. allowing a massive bomb to explode by refusing to torture someone e.g. not fabricating a research result might mean admitting that your study found nothing that is interesting. Sometimes the rules are vague Sometimes the rules conflict

Virtue Theory Focus on the intent of the agent of action, rather than on rules or consequences Problems: People with good intents can do things that have terrible consequences

Consequentialism Good: what is likely to produce more good than bad consequences. Bad: what is likely to produce more bad than good consequences. E.g.: utilitarianism: good is what produces the greatest utility (usually understood in terms of ‘happiness’) for the greatest number. Often used for resource allocation issues: how can we promote the largest amount of happiness with limited resources?

Utilitarianism What Utilitarians Think Is Intrinsically Valuable: happiness (or pleasure or satisfaction…) "actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness." (John Stuart Mill's Greatest Happiness Principle) In other words, judge an action by the total amount of happiness and unhappiness it creates John Stuart Mill

Problems of Consequentialism Problems: Can we know the likely consequences of our actions? What if there is great uncertainty? Impartial moral theory  Some would say that we have a duty to be partial. Certain rules may be ignored (yet some forms of consequentialism take some deontological principles into consideration)

Principlism ‘The four principles’ approach The most widely used approach in Western bioethics Incorporates elements from both consequentialist and deontological theories

What are these 4 principles? ◦ Autonomy  Right of self-determination  Related to ‘informed consent’  In order to give consent: autonomy/competency/capacit y must be possessed. ◦ Beneficence – to do well, to promote well-being ◦ Non-maleficence – to do no harm, to avoid doing harm ◦ Justice – treat like alike (T. Beauchamp and J. Childress, Principles of Biomedical Ethics, 5 th edition, New York/Oxford: Oxford University Press, 2001.)

Principlism & French Revolution New Virtues Respect for diversity & self-determination of others is a new, Enlightenment virtue Liberte, fraternite, egalite Georgetown mantra: autonomy, beneficence, justice Copyright Institute for Ethics and Emerging Technologies 2008

Stages of Moral Development Lawrence Kohlberg Developmental Correlated with higher education and exposure to Enlightenment thought Conquering animal nature with reason Copyright Institute for Ethics and Emerging Technologies 2008