1. Medical ethics: introduction
Janet Radcliffe Richards
Professor of Practical Philosophy
University of Oxford
Oxford Uehiro Centre for Practical Ethics
Background.
jrr/HT10

2. Apprenticeship Clinical practice
This is about practical reasoning - the reasoning involved in reaching or assessing practical conclusions.
Medicine intensely practical. And like a lot of practical subjects, taught traditionally as an apprenticeship.
jrr/HT10

3. Apprenticeship Explanation Clinical practice
You need explanation for making inferences to other contexts, knowing where to find short cuts and so on. The irritatingness of instructions that say ‘on no account do x’ and you haven’t any idea why.
jrr/HT10

4. Current scientific beliefs
Apprenticeship
Explanation
Current scientific beliefs
Clinical practice
First go through a familiar understanding of the development of medical practice. Again, you can see examples in many other areas…
jrr/HT10

5. Current scientific beliefs
Apprenticeship
Explanation
Descriptions of cases
Current scientific beliefs
Clinical practice
jrr/HT10

6. jrr/HT10

7. jrr/HT10

8. Carlos.... All they could do was hunt for witches
Over the years Carlos grew steadily worse. He was lame, epileptic and bald at the age of 35. His hair had fallen out, his teeth were nearly gone and his eyesight was failing. In 1698 he had three fits and became deaf. The doctors put freshly-killed pigeons on his head to prevent dizziness and applied the steaming entrails of mammals to his stomach to keep him warm, but he died nevertheless.
jrr/HT10

9. jrr/HT10

10. Current scientific beliefs
Apprenticeship
Explanation
Descriptions of cases
Current scientific beliefs
Clinical practice
This shows different elements of medical education.
Because it is such an intensely practical subject, you learn a lot of it by going around doing what established practitioners do. But they explain what they are doing in terms of current science, which you have to spend a lot of time learning because there is so much of it. And you also know that research is going on in the background which you have to keep up with when you practise.
We are concerned with the values part of medicine. The values people use at the moment, questions about whether these values ought to change, and how they feed into clinical practice.
jrr/HT10

11. Current scientific beliefs
Apprenticeship
Explanation
Enquiry
Descriptions of cases
Current scientific beliefs
Clinical practice
Kuhn - crafts and sciences. Science where you have enough theory - paradigm - to know how to structure research. Gives you particular questions to ask. Germ theory of disease etc.
jrr/HT10

12. Current scientific beliefs
Apprenticeship
Explanation
Enquiry
Descriptions of cases
Current scientific beliefs
Clinical practice
How these feed into each other and interact….
And you find that when people are arguing about practical matters they tend to depend heavily on the facts.
Medical case conferences - typically lists of state of patient and interventions. Sometimes social and economic matters. Then you try to reach a conclusion.
Experts giving the government advice about what to do. Whether british beef is safe.
jrr/HT10

13. Apprenticeship Explanation Enquiry Descriptions of cases
Current scientific beliefs
Scientific reasoning and research
Clinical practice
How these feed into each other and interact….
And you find that when people are arguing about practical matters they tend to depend heavily on the facts.
Medical case conferences - typically lists of state of patient and interventions. Sometimes social and economic matters. Then you try to reach a conclusion.
Experts giving the government advice about what to do. Whether british beef is safe.
jrr/HT10

14. Apprenticeship Explanation Enquiry Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
How these feed into each other and interact….
And you find that when people are arguing about practical matters they tend to depend heavily on the facts.
Medical case conferences - typically lists of state of patient and interventions. Sometimes social and economic matters. Then you try to reach a conclusion.
Experts giving the government advice about what to do. Whether british beef is safe.
jrr/HT10

15. Apprenticeship Explanation Enquiry Descriptions of cases
Current scientific beliefs
Scientific reasoning and research
Clinical practice
How these feed into each other and interact….
And you find that when people are arguing about practical matters they tend to depend heavily on the facts.
Medical case conferences - typically lists of state of patient and interventions. Sometimes social and economic matters. Then you try to reach a conclusion.
Experts giving the government advice about what to do. Whether british beef is safe.
jrr/HT10

16. Apprenticeship Explanation Enquiry Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
How these feed into each other and interact….
And you find that when people are arguing about practical matters they tend to depend heavily on the facts.
Medical case conferences - typically lists of state of patient and interventions. Sometimes social and economic matters. Then you try to reach a conclusion.
Experts giving the government advice about what to do. Whether british beef is safe.
jrr/HT10

17. jrr/HT10

18. Here are two people with standard medical training.
jrr/HT10

19. jrr/HT10

20. jrr/HT10

21. jrr/HT10

22. The elements of medical education
Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
Current legal and professional standards
VALUE ISSUES
jrr/HT10

23. The elements of medical education
Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
Current legal and professional standards
VALUE ISSUES
jrr/HT10

24. The elements of medical education
Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
Current legal and professional standards
Moral enquiry
VALUE ISSUES
jrr/HT10

25. What is medical ethics? ‘Ethics’ has two quite different meanings:
A particular set of standards. In this sense ‘medical ethics’ is the set of standards accepted as appropriate for doctors.
Moral philosophy: an enquiry into questions about moral standards, including what standards we ought to have.
Ethics as a set of standards - as in ‘Christian ethics’, the ethical standards of particular professions etc.
These change: medical ethics now is quite different from twenty years ago.
Second meaning: ethics as an enquiry. In our diagram equivalent to scientific research in the facts part.
jrr/HT10

26. ‘Ethical’ is ambiguous
Sometimes it means ‘in line with accepted professional standards’
Sometimes it means ‘morally right’
These two are quite different.
Notice that one of them is a claim of fact, the other a claim of value.
Moral - in your coursebook - don’t use the term ‘ethical’ at all. Say what you mean in full, to make it clear. And when other people use it, get them to clarify what they mean.
If you do that, you will have taken an excellent first step towards good reflective practice.
jrr/HT10

27. The elements of medical education
Descriptions of cases
FACTUAL ISSUES
Current scientific beliefs
Scientific reasoning and research
Clinical practice
Current legal and professional standards
Moral enquiry
VALUE ISSUES
jrr/HT10

28. Disagreements and difficulties can come from either source
jrr/HT10

29. The case of Dr Cox
jrr/HT10

30. How Dr Cox might have defended his action
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
So - remember the case of Dr Cox
We imagined the kind of justification he might have given for his action to someone who disapproved of it…..
And we noticed that anyone who could mount a successful challenge any of the premises would have undermined the case for the conclusion.
Any of the fact premises…..
Or the value premise…..
jrr/HT10

31. Different ways of challenging Dr Cox
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
So, taking the first one…..
jrr/HT10

32. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
Someone might say…..
jrr/HT10

33. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was not right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

34. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

35. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She was being put under pressure by the family
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

36. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She was being put under pressure by the family
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was not right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

37. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

38. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
He could easily have controlled the pain by consulting an expert colleague
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

39. Different ways of challenging Dr Cox
She wasn’t in pain - just getting attention
She wanted to die
He could easily have controlled the pain by consulting an expert colleague
People who are in uncontrollable pain and want to die should be helped to do so
So it was not right to kill her
Which would undermine the conclusion….
So he would have to be prepared to discuss that point and justify his belief in it.
Same with reflective practice on his own, when he was wondering whether he should have done it.
Now imagine a slightly different challenge.
jrr/HT10

40. Different ways of challenging Dr Cox
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
If you disagree with the conclusion, you must disagree with something about the argument.
All those claims are facts….. And implied value…….
jrr/HT10

41. Different ways of challenging Dr Cox
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
Killing people or helping them to die is always wrong
So it was right to kill her
If you disagree with the conclusion, you must disagree with something about the argument.
All those claims are facts….. And implied value…….
jrr/HT10

42. Different ways of challenging Dr Cox
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
Killing people or helping them to die is always wrong
So it was not right to kill her
Can’t just concentrateon the conclusion. You need to identify the different elements of the argument.
Even more - the facts you invoke are going to depend on the implied values.
jrr/HT10

43. The values determine which facts are even relevant
That makes the two sound equal.
For instance, if you think people have the right to ask to die, you don’t need to establish that there is no way of dealing with the pain.
If you think it’s absolutely wrong to kill, all the factual questions are irrelevant
If you think euthanasia is justified only in extreme cases...
jrr/HT10

44. How Dr Cox might have defended his action
Mrs B was in terrible pain
She wanted to die
No available medication could have controlled the pain
People who are in uncontrollable pain and want to die should be helped to do so
So it was right to kill her
So - remember the case of Dr Cox
We imagined the kind of justification he might have given for his action to someone who disapproved of it…..
And we noticed that anyone who could mount a successful challenge any of the premises would have undermined the case for the conclusion.
Any of the fact premises…..
Or the value premise…..
jrr/HT10

45. The advance of science and technology increases the significance of value issues in practical reasoning.
The more you can do, the more choices you have, the more there is for values to do.
jrr/HT10

46. Recent and current controversies
Conjoined twins
Time limit for abortion
Sustaining patients in PVS
Fertility matters
Organ donors and the dying process
jrr/HT10

47. jrr/HT10

48. The ‘best interests’ principle
When a patient is not competent to consent to treatment, the doctor must act in the patient’s best interests
It looks as though this will still be accepted after the Act…. but details may change…
Anyway, this is the situation now.
Y2 Non-competent patient/ jrr/ Dec 2005

49. Treatment in the non-competent patient’s best interests
Which elements matter at all? e.g:
Length of life?
Absence of pain?
Mental abilities/ level of awareness?
Physical abilities?
Appearance to relatives and friends?
Patient’s former character and wishes?
Again, the question of which elements appear on your list of relevant elements is a value issue.
Once you have decided which things matter you can start finding out about them…..
Y2 Non-competent patient/ jrr/ Dec 2005

50. Treatment in the non-competent patient’s best interests
Perhaps you might decide that the important elements are length of life, absence of pain, awareness…..
But once again, you still have the question of how to measure different things against each other. Which of these possible treatments is in the patient’s best interests? Is it more in someone’s interests to live a long time with no awareness and no suffering than to live a less long time with some pain but more awareness, or what?
These value questions are not matters of medical expertise - doctors have no more of a basis on which to judge them than anyone else - but they are integral to the question of best interests. Once again, the fact questions in which doctors have expertise, and the value questions in which they have no special expertise; but doctors have to make the judgment.
How do current legal and professional standards answer this question?
Y2 Non-competent patient/ jrr/ Dec 2005

51. Y2 Non-competent patient/ jrr/ Dec 2005

52. Mill’s ‘Harm Principle’
…the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.
John Stuart Mill, On Liberty, 1859
Start with the best interests of the competent person.
The principle of autonomy states that competent persons are the judges of their own best interest……
[Explain the Mill statement again.]
It’s called the harm principle because it says that you shouldn’t stop people doing things for their own good, only for the good of others. The principle of autonomy……
Doctors sometimes wonder whether they should respect patients’ autonomy or act in their best interests. According to the harm principle, and general liberal attitudes, the two are the same. The value to aim for is respecting what the patient thinks is good for the patient.
With that in mind, consider three types of non-competent patient.
Y2 Non-competent patient/ jrr/ Dec 2005