2. Module 13: Biomedical Ethics Philosophy 240: Introductory Ethics Online CCBC Author: Daniel G. Jenkins, MA Updated May 2008

3. This is a stand-alone module with no accompanying reading. Module Goals: After completing readings, presentations, discussions, and coursework for this module, you will be able to: ◦ Identify and explain core aspects of Biomedical ethics ◦ Apply Biomedical ethics in moral decision-making ◦ Analyze the usefulness and critique features of Biomedical ethics ◦ Synthesize Biomedical ethics with other theories in the academic study of ethics

4. Specialized action, special attention Biomedical ethics involves moral deliberation in the context of healthcare and research It is important for practitioners as well as for recipients of healthcare and participants in research It does not involve a special kind of ethics, but special attention to apply the same ethical standards that apply to other areas of life

5. Why do we need biomedical ethics? There is an imbalance of power between practitioners and patients Special circumstances arise in healthcare and research that do not arise in other walks of life In the past, physicians and researchers have behaved immorally in significant ways

6. Abuses of Power Tuskegee Syphilis Study  African-American men in Alabama deliberately infected with syphilis against their will and without their knowledge Nazi Doctors  Prisoners of war used in horrific medical experiments Milgram’s Obedience Experiments  A psychologist uses his authority to push research subjects to administer shocks to others A history of paternalism  Physicians routinely withheld information from patients and did not allow them to participate in treatment decision-making

7. Tuskegee

8. Experiments by Nazi Doctors

9. Milgram’s Obedience Experiments Watch a clip from Milgram’s experiment by clicking here.here

10. Medical Ethics in History Hippocratic Oath, 500 BCE  Physicians do what is best for the patient according to the physician’s judgment, not the patient’s judgment  Physicians pledge secrecy about their craft  Endorses paternalism Percival’s Code, 1803  Helps resolve disputes among physicians, but makes no mention of rights of patients Ethics Code of the American Medical Association (AMA), 1848  Focused on licensure and establishing fees, makes no break with paternalism

11. Hippocrates

12. New Doctors Taking the Hippocratic Oath

13. Breaking with the Hippocratic Tradition Nuremberg Code, 1946  A product of the Nuremberg Trials  The first document in the 2500 years since Hippocrates to make any mention of patient’s rights.  Designed to guide how we conduct research to benefit society while still benefitting patients  A patient has the right to be informed of relevant facts and to approve or disapprove of any treatment done, either in research or traditional treatment settings  written by an international body of law and placed requirements on physicians, and was not written by physicians and bestowed upon the public.

14. The Nuremberg Trials

15. The Patient’s Bill of Rights, 1973  Details patient’s rights  Created by the American Hospital Association and places demands on physicians The Belmont Report, 1979  created by the former United States Department of Health, Education, and Welfare (which was renamed to Health and Human Services)  Provides principles and guidelines for the protection of human subjects of research  1991, 14 other Federal departments and agencies joined HHS in adopting a uniform set of rules for the protection of human subjects  This uniform set of regulations is the Federal Policy for the Protection of Human Subjects, informally known as the “Common Rule.” 

16. AMA Acknowledges patient rights American Medical Association Code of Ethics, 1981  Finally, the AMA caught up with the changes in moral philosophy happening around the profession  The first document generated by physicians that makes reference of patient’s rights  We cannot justify violating rights if good consequences occur – rights cannot be violated.  For the first time physicians have to listen to the patient

17. Principles of Biomedical Ethics Revised ethics codes are a step in the right direction But simply listing guidelines for how physicians ought to behave is not compelling. To elaborate a biomedical ethical model of decision-making, Beauchamp and Childress have written the “Principles of Biomedical Ethics.”

18. Beauchamp and Childress Tom Beauchamp is a Professor of Philosophy and a Senior Research Scholar in Georgetown University's Kennedy Institute of Ethics. In 1976, he joined the staff of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, where he wrote the bulk of The Belmont Report (1978). James F. Childress is the Hollingsworth Professor of Ethics and Professor of Medical Education at the University of Virginia, where he directs the Institute for Practical Ethics.

19. Beauchamp

20. Childress

21. Principles 1) Respect for Autonomy 2) Nonmaleficence 3) Beneficence 4) Justice.

22. Virtues 1) Respectfulness 2) Nonmalevolence 3) Benevolence 4) Fairness

23. We need both principles and virtues in biomedical ethics Without principles, virtue is not efficacious Without virtue, we merely have principles that fail to impress themselves upon us

24. Autonomy To respect autonomy is to acknowledge a person’s right to hold views, make choices, and take actions based on personal values and beliefs Requires respectful action, not just attitude An obligation to build up and maintain others’ capacity for competent choice

25. Competence Competency refers to the ability to perform a certain task. In order to be competent to make treatment decisions, we must be able to do the following: 1)Express or communicate a preference or choice 2)Understand one’s situation and its consequences 3)Understand relevant information 4)Give rational reasons 5)Give risk/benefit related reasons 6)Ability to make a decision If a person is competent they may give informed consent.

26. Informed Consent There are 5 elements of informed consent: 1) Competence 2) Disclosure 3) Understanding 4) Voluntariness 5) Consent Obtaining a patient’s or research subject’s informed consent is central to respecting autonomy.

27. Nonmaleficence How are physicians to do no harm? Can’t simply say not to kill, because what about euthanasia? We can’t say to always treat, because what about debilitating “heroic” medicine? We must consider each patient in each circumstance to avoid doing harm. Harm may change with context.

28. Negligence While we may not know exactly what doing no harm consists in, we know when something has gone wrong legally: 1) there must be an obligation/duty on the part of the professional 2) the professional must fail/breach that duty 3) the affected party must experience harm 4) the harm must be caused by breach of duty. Also, harm is always thought to exist when autonomy is violated.

29. Beneficence There is no sharp break demarcating where nonmaleficence ends and beneficence begins Beneficence places more requirements on professionals because they must actively pursue patient welfare instead of merely refraining from harming patients Beneficence is fostered to the extent that autonomy is fostered What is good for the patient may change from situation to situation

30. Justice Justice of course refers to fairness, desert (what is deserved), and entitlement. Justice refers to fair, equitable, and appropriate treatment in light of what is owed to people. Distributive justice refers to the fair and equitable distribution of rights and responsibilities in society. In medicine, this means fair distribution of resources, such as the attention of professionals, medication, hospital beds, procedures (time on machines). How do we determine who gets access to care?

31. Fair Opportunity Rule Properties distributed by the lotteries of social and biological life do not provide morally acceptable grounds for discrimination between persons if they are not properties which people have a fair chance to acquire or overcome. This factors into the distribution of healthcare by mandating that the disadvantaged have the most access to care, as they are the most likely to be immensely disadvantaged by being sick.

32. Summary Biomedical ethics strives to apply ethical standards to healthcare and research professions. This is necessary given the special powers and special circumstances that arise in the biomedical context. Historically, physicians and researchers have abused their power and have been slow to officially acknowledge patient rights. Beauchamp and Childress offer a comprehensive theory of Biomedical Ethics involving both principles and virtues, designed to help professionals behave morally in the biomedical context.

33. Congratulations! You’ve just completed the presentation for module 13. Once you have also completed the assigned reading from the textbook, please proceed to the “Assignments” and “Discussion” tabs in WebCT to complete relevant coursework for this module. If you have any questions please contact me.contact me