Nancy Cruzan Baby Fae UNOS Terri Schiavo Jack Kevorkian Karen Quinlan Dolly Dialysis committees Tuskegee Willowbrook Nuremburg Hippocrates Roe v. Wade

An Introduction to Bioethics Michelle Kaplan, MD

Ethics: The branch of philosophy concerned with principles which allow us to make decisions about what is right and wrong.

Bioethics The study of moral principles and decisions in the context of medical practice, policy and research.

When you lack the ability to do something, you never have to consider whether or not you should.

Three levels of abstraction: Metaethics Normative ethics Applied ethics

Metaethics AKA analytical ethics The most abstract branch of moral philosophy. Concerned with how moral judgments are made and the meaning of ethical terms such as good, just, fair, duty, etc.

Normative ethics AKA substantive ethics The theory of ethics Attempts to determine what it is that makes actions right or wrong, just or unjust, etc.

Applied ethics AKA practical ethics The theories of normative ethics applied to specific situations This is the realm of professional ethics, business ethics, medical ethics, etc.

A little background on ethics… Utilitarianism Deontology ActRule MonisticPluralistic

Utilitarianism Based on the work of John Stuart Mill and Jeremy Bentham The principle of utility states that “actions are right in proportion as they tend to produce happiness, wrong as they tend to produce the reverse of happiness.” Consequentialist

Utilitarianism Comes in two flavors: act and rule Act: each action is judged individually by the principle of utility. The right action produces the greatest good for the greatest number of people. Rule: A set of rules is chosen according to the principle of utility.

Deontology Based on the work of Immanuel Kant and W.D. Ross Duty-based system of ethics Non-consequentialist Also comes in two flavors: monistic and pluralistic

Monistic Deontology Kant’s categorical imperative: –The rule or “maxim” must be universalizable. –Always treat a person as an end unto themselves, never as a means to an end. –Every rational being is capable of determining moral truth, and must have the autonomy to do so.

Pluralistic Deontology Based on the work of W.D.Ross Duties are not absolute, but rather prima facie. Lists 7 key duties which “reflective, mature adults” will find reasonable. These include nonmaleficence, beneficence, fidelity, reparation, gratitude, self- improvement and justice.

Moral contractualism Based on the work of John Rawls A deontologist position with roots in the social contract theories of Locke and Hobbes. Focuses on the principle of social justice

Western Bioethics Has roots in all of the previous theories. Attempts to bring into balance four primary prima facie duties: –Autonomy –Nonmaleficence –Beneficence –Social justice

Autonomy The right to self-determination. In the US, it tends to trump the other duties. Some cultures have no sense of individual autonomy, and the family (or sometimes, the village/tribal leader) makes decisions for patients.

Nonmaleficence From the Hippocratic oath Above all, do no harm. Mentioned in nearly every ethical theory.

Beneficence The duty to help others. Also mentioned in the Hippocratic oath. Central in Judeo-Christian ethics.

Social Justice Concept of fairness Involved especially in the allocation of scarce medical resources. Particularly important in policy decisions for socialized medicine.

The Case of Terri Schiavo… An ongoing dilemma

The facts: December 1963… Terri is born November 1984… Terri and Michael marry February 1990… Terri, at the age of 26, suffers anoxic brain injury. August 1990… Terri leaves the hospital in what has been called a persistent vegetative state.

The facts… May 1992… Michael disagrees with Terri’s parents over her care and he moves away from them. January 1993… Michael gets $1 million settlement in medical malpractice case for Terri.

The facts… March 1994… Terri is transferred to a nursing home. May 1998… Michael petitions the court to determine whether Terri’s feeding tube should be removed. He states that in casual conversation, she said she would not want to continue living this way. Her parents disagree.

The facts… February 2000… Following trial, Judge Greer rules that clear and convincing evidence shows Terri would choose not to receive life-prolonging medical care under her current circumstances. April 2000… Terri is transferred to a hospice facility.

The facts… January 2001… Second District Court of Appeal affirms the trial court’s decision. April 23, 2001… Florida Supreme Court denies review of the Second District’s decision. April 24, 2001… Trial court orders her feeding tube removed.

The facts… April 26, 2001… Terri’s parents file a motion stating they have new evidence RE Terri’s wishes. The motion is denied as untimely. Her parents then file new legal action against Michael, and request that her feeding tube be replaced pending the outcome. Judge Quesada grants the request.

The facts… July 2001… Second District rules that Judge Greer erred in not allowing the new evidence and that the trial court should reconsider whether the new information would change their ruling. Terri’s parents also move to disqualify Judge Greer. Both motions are denied as insufficient.

The facts… October 2001… Second District affirms denial of the parents’ motions, however a trial is ordered on whether there are new medical treatments which could improve her functioning enough that she would choose to live. March 2002… Florida Supreme Court denies review of the Second District decision

The facts… October 2002… Trial court holds hearing on new medical treatment issue. Terri’s parents assert that she is not in a persistent vegetative state. November 2002… Trial court rules that there is no new medical treatment and that Terri is in a persistent vegetative state.

The facts… February 2003… Terri has been in a persistent vegetative state for 13 years. June 2003… Second District affirms the trial court’s decision. August 2003… Florida Supreme Court denies review of the Second District’s decision.

The facts… September 2003… Terri’s parents file federal action challenging Florida’s laws on life-prolonging procedures as unconstitutional. October 10, 2003… Federal court dismisses case. October 15, 2003… Terri’s feeding tube is disconnected.

The facts… October 20, 2003… Florida House passes a bill to permit the Governor to issue a stay in cases like Terri’s and restore her feeding tube. October 20, 2003… Advocacy Center for Persons with Disabilities files a federal court action claiming that removal of Terri’s feeding tube constitutes abuse and neglect.

The facts… October 21, 2003… Federal court rejects injunction request. October 21, 2003… Florida House and Senate pass bill to permit the Governor to issue a stay in cases like Terri’s and restore her feeding tube; Governor Bush signs the bill and issues a stay. Terri is taken to a hospital to have her feeding tube replaced.

The facts… October 21, 2003… Michael requests the trial court to enjoin the Governor’s stay based on its alleged unconstitutionality; the trial court rejects the request for immediate injunction, allowing the tube to be restored, and requests briefs on the constitutional arguments against the new law The saga continues…

A precedent… June 25, 1990… The US Supreme Court rules on the case of Nancy Cruzan, a woman in her early thirties who had, at that time, been in a persistent vegetative state for more than 7 years and whose life was being prolonged by a feeding tube. In a 5-4 decision, they decided that the Constitution provides for a “right to die,” and that the feeding tube could be removed.

A precedent… Justice Rehnquist wrote the majority opinion. No distinction was made between providing artificial feeding and hydration and providing other forms of medical care. The court rules that patients have a right to forego life-prolonging medical care. Nancy Cruzan’s feeding tube was removed on December 14, 1990; she died 12 days later.

The issues of this case… Issues of autonomy: –What would Terri want, and how do we know? Issues of beneficence: –Is what has happened to Terri really helping her? Issues of nonmaleficence: –Is she being harmed by the feeding tube, by the controversy, etc.? Issues of social justice: –This case is setting a precedent. Even the Catholic church has issued a ruling on it. How does this affect our society in general?

Bigger questions… What makes life worth living? What is the value of a person’s life, and how should it be measured? Is artificial feeding & hydration fundamentally the same as other medical care? Who should make decisions for us when we cannot?

The most important question… How many of us have an advanced directive?