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Introduction Medical Ethics (IME-1) English Stream

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R.A.H Guerrero

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Transcript of Introduction Medical Ethics (IME-1) English Stream

Minor Medical Ethics
(IME-1)

Medical Ethics
Why Medical ethics
Casus 1.
Human Radiation Experiments




On January 15, 1994, President Bill Clinton announced a new openness policy for the Department. The policy led almost immediately to the release of over 1.6 million pages of classified records. The records made clear that since the 1940s the Atomic Energy Commission had been sponsoring tests on the effects of radiation on the human body.

American citizens who had checked into hospitals for a variety of ailments were secretly injected with varying amounts of plutonium and other radioactive materials without their knowledge. Most patients thought it was "just another injection," but the secret studies left enough radioactive material in many of the patients' bodies to induce life threatening conditions.

Such experiments were not limited to hospital patients, but included other populations such as those set out above, e.g., orphans fed irradiated milk, children injected with radioactive materials, prisoners in Washington and Oregon state prisons. Much of the experimentation was carried out in order to assess how the human body metabolizes radioactive materials, information that could be used by the Departments of Energy and Defense in Cold War defense/attack planning.

Argumentation
What is Medical Ethics
Medical practice is full of dilemmas
We are not used to ponder openly about these moral questions.
We have a natural preference for protocols, efficiency. Moral lazyness.
We are "theoretically morally ignorent".
In our moral judgement, intuition plays a big role
In other words, we often don't know why we have certain moral conviction. So why medical ethics:

1. To figure out the grounds of our standpoints
2. To justify, adapt and fine-tune our standpoints.
3. To understand what kind of argumentation we use.
A young academic discipline with deep and long roots in moral philosophy.
Modern Medcial Ethics, as an academic discipline, only starts to develop after certain biological discoveries and tehcnical inventions after 1800.
Invention of Rontgen radiation and the first Rontgen machines.
Florence Nightingale
Her books and practice innovated the form and image of nursing.
The first small medical thermometer
I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

Publication of the first Ethical Codex for Medical Ethics by Flavius Magnus Aurelius Cassiodorus Senator. The book describes mostly the obligation to keep learning and bettering himself.
500 nChr Formula Comitis Archiatrorum.
The Oath of Hippocrates
st Thomas van Aquinas.
Focuses in many of his works on medical ethical dilemmas and casuistics and incorporates Christian Theological elements in the protocols of "docters" of his time. Care for the "soul" starts to be a major focus point in the texts.
Medical Ethics is an applied form of the more abstract discipline of Philosophical ethics.
Defintion Ethics: thinking about good and evil.
Definition Medical Ethics: thinking about good and evil (right or wrong) in the specific context of medical cases aimed at defining rules, protocols and behavioural-codes to use in medical practices.
Definition Philosophical Ethics: the systematic (meta)-reflection about good an evil en the analysis of values and norms.
Differences
Philosophical Ethics
Medical Ethics
Theoretical
Practical
Insight Driven
Aimes at Sollutions
Needs no answer
Needs answer
Some things are "taboo"
since laws and protocols
inhibit our actions
No thought is Taboo
Arguments are most
important
What are we going to do ?
We have to learn how to crawl before we can walk.
By R.A.H Guerrero
Virtue-ethics
Deontology
Utilitarian Ethics
Existentialist Ethics
Discours Ethics
Religious Ethics
A classical form of ethics that focuses on "virtues". A virtue is a personal characteristic that we call "good" and of which we say that one has to cultivate it.
Most famous virtue-ethics is Aristotelian virtue-ethics. Described in Nicomachean Ethics and Eudaimonian Ethics.
1. Aristotelian Ethics = Teleological

2. Highest virtue = Eudaimonia or, The Good Life.

3. The Good Life understuud as follows: to do that which one is meant to do, as good as one can.
Aristotle
A good act . . .
"Is an act that is done by the right person under the right circumstances in the right way on the right moment"
"Is an act that is the "middleground" in between two vices".
cowardice - courage - recklessness
fear - carefullness - regardlessness
indirect - direct - rude
To become virtues one has to mimic. The "good" one accomplishes by watching "virtues people" in their actions and copying their words/behaviour/actions. According to Aristotle, a virtues act is a tempting thing.
Summary
There are an endless amount of virtues
What a virtues act is, is dependant of the situation, person, place, time
It is possible to learn how to be a "good" person, by mimicing.
Virtues acts need to aim at reaching "Eudaimonia".
A virtue is the middleground between two vices.
Medical ethics and Virtues
Many protocols in your future working area aim at certain values like:

Good Health
Autonomy
Justice
Transparancy
These values can be understood as virtues in the Aristotelian sence. In other words as the "good" towards a certain practice or collection of (medical) actions is aimed at.
A certain new method of treatment that requires the accumulation of a lot of biometrical data
+
Virtue at stake: Privacy
+
Reasoning based on what is too much and too little of this virtue
=
Result, new method is or is not acceptable when confronted with our thought in the context of this virtue.
In Practice
Duty-Ethics (deon=duty) is a theory of ethics that was mostly developed
and applied by Immanuel Kant. According to Kant ethics should not me
heteronomous (in other words, forfully tought or indoctrinated) but should
be autonomous (in other words, ethics should be self-imposing, reasonable).

Ethics for the enlightened man
Man has:
Rationality (calculative capability to manipulate the reality around him.
Reason (the capacity to form abstract concepts and reason with them.
Consiousness
Ergo: we should understand man as a being that is autonomous in his understanding of the world. "Dare to think". This implies according to Kant that, given this anthropology, ethics should be a set of norms and values that structures society and should not be forcefully imposed on man because that would deny his humanity.
Man must use his independent reason and rationality to figure out which moral rules are universal and therefore self-evident. In other words, which rules are an autonomous duty.
De Categorische Imperatief
Every reasonable man can understand that the following maximes are universally "valid".
1e. Definition: always act in such a way that you could wish for the maxime of your act (the general rule behind your act) to become a universal law.

2e. Definition: Never treat another person as a means to an end but always as an end in itself. (Don't instrumentalise a person for your own goals).
We can reasonably (hypothetically) understand that is everybody would follow this general rule (cat imp) there would be no more immoral behaviour nor problems.
Not the consequences of an action count or should be uses as an argument to do or not to do something since we do not have a definite way to predict the future. (non-consequentialism)

All men are capable of understanding the Cat. Imp. therefore it is sheerly a will to folow that Cat. Imp ( A good) will that can be the object of morality/ In other words. Not the consequences of an action determine if a action is good but the intention with which you start the action.
Synopsis
1. Deontologie, ethiek is zelf-verplichtend
2. C.A volgen
3. Universaliteit
4. Non-consequentialisme
5. Doel van ethiek / het goede handelen is NIET geluk, maar is het juiste te doen.
Jeremy Bentham: a British philosopher developed an ethical theory that aimed at objectifying moral dilemmas. Bentham was convinced that one could reduce one's wantings and aversions in terms of numbers.

Naturalistic Basis
Consequentialists Ethics
Hedonistic Calculus
Utility maximization
Basis for an ethical theory should be human nature. But not like Kant's "rational being" but much more simple.
Pleasure
Pain
We have a natural attraction to Pleasure
We have a natural aversion of Pain
Ethics must be directed at maximizing utility, that means, avoiding as much pain as possible and allowing as much pleasure as possible for as great as possible a number of people.
In short: greatest good for the greatest number.
Naturalistic Basis
Consequentialistic
Utilitarianism is a consequentialistic ethical theory. In other words, the intentions behind a certain action are not important, the effects are !
Hedonistic Calculus
Bentham's goal: to redefine ethics as an exact science. He wanted to become the Newton of ethics. According to Bentham it is possible to objectify our wantings.
Fish and Chips
Higher Salary
Date
Broken Toe
Diner with mother in law
Death of a personal hero
+ 1.5
+ 30.0
+ 20.0
- 15.5
- 40.5
- 15.0
- 19.5
Ergo: you are unhappy :(
Nowadays we find this a bit naive. We more or less agree about the fact that happiness and unhappiness are personal. But:

1. Historische traditie, Aristoteles, "Gelukkig" is een conclusie die pas aan het einde van het bestaan over een persoon getrokken kan worden.

2. In de praktijk wordt er in de juridische realiteit weldegelijk een cijfer (a.k.a geld) gekoppeld aan de beleving van genot en pijn.

3. Ook de kosten/baten analyse in het bedrijfsleven is een voorbeeld van een utilitaristische calculus ala Bentham.
Maar de bepaling blijft een probleem.
Dat vond J.S Mill ook
Utilitarianism
Utilitarianism is a utility orientated ethical doctrine. This means it aims at practical moral progress, in other words the maximalisation of utility.
Moral dilemma
Rationality / our calculating capacity taking into account all available knowledge while trying to predict the possible outcome of an action.
Utilitarian Maxim: greatest good for the greatest number principle.
+
=
Answer to dilemma
John Stuart Mill.
Student of Jeremy Bentham. Sees problems in Benthams approach.

1. Attribution of Points
2. The lack of a qualitative dimension
3. The dictatrial aspects of Utilitarianism.
1. Trying to exactly calculate the ammount of points a certain good or bad has for a person is a highly subjective practice according to J.S Mill.

2. Utilitarianism needs a qualitative dimension. Listening to Bach is a higher form of pleasure than listening to 50 cents.
But this kind of qualitative dimension might lead to the moral rule of the elite over the masses and without the dimension Utilitarianism might lead to the rule of the masses over the "strange" individual. Althought Mill states that the eccentric intellectual with his refined taste should be appreciated more than lower forms of taste, still the freedom of an individual to choose that which he finds most pleasurable is of more value to him, no matter how stupid this conviction might be.

3. Utilitarianism leads to the rule of one over many or of many over one.
A redefinition of Utilitarianism
Utilitarian Maximilisation by the state is only allowed when it is necessary, that means when our freedom to act supresses or limits the freedom of another.
The Harm Principle
Someones freedom can only be limited if his freedom "damages" others (physically) or limits their freedom of action.
Existentialism starts out as a post-modern critique on the concept of essentialism. The idea that "man" is definable through scientific or religious definition. According to Existentialists, this "defining" forms the greatest threat for human freedom and identitity.
Essentialism: The Identity of man is definable. Essence is primal, existence is what follows.

Existentialism: The identity of man is undefinable. Through self-consciousness man escapes all forms of definition. Existence is primal, essence is what follows.
Absolute Freedom
Consciousness
Etre de mauvaise foi - Dishonest
Negative Identity
Absolute Responsebility
Morally neutral but not Nihilism
To assign any capacity or attribute to "man" is a limitation of his freedom. There exists no pre-set identity, no definition is possible. There is only a negative definition Man is not this ....nor this....etc.
"Nietzsche: Man is an undefined animal"
Consciousness is the key. The fact that man is conscious
gives us the capacity to question every definition that "chains" us.
This also means that it is impossible to hide behind definitions.
"I"
Definition X: you are such
and such....
Consciousness: so they say
I am such and such. Well,
the hell I am, I don't want
to be.....he he he...
Action against the
definition
To hide behind your definition, your essence is what Sartre calls "Mauvaise Foi". You are denying your humanity according to Sartre since you have the capacity to deny any definition.
Man, because of his capacity for consciousness, is burdened by "Absolute Freedom".
Man is:
1. A "Thrown Design": (historically, psychologically genetically etc).

2. But always has a "free choice" despite these fixed contours. Man's only positive definition is his obligation to be free.
Morality is but convention. Ethical rules are never binding or absolute. But your freedom is absolute and you will have to carry the consequences of your actions without the possibility of hiding for them. No "Mauvaise Foi" but....
In a Medical Ethical context
1. Consequences of your actions and the responsebility are always yours to carry.

2. If you negate the responsebility, you deny your humanity

3. You cannot hide behind fixed rules or definitions, job descriptions or laws. If you do something of which the effects are bad (that is, afterwards are defined as bad) than you'll have to deal with it.
Post-moders philosophers are right: "truth" and "universality" are concepts for an exact reality. That reality doesn't "exist", not even in beta-sciences.
Ethics is a matter of convention therefore we need an adaquate way of discussing normative questions. We need to structure them, we need a linguistical and logical framework.
The singular principle of "truth" is devided into three "Truth-claims". That means that you don't speak the truth but you claim, when you say a sentence, one of three forms of thuth. Any statement within the three domains of truth can always be contested. There is never a final "truth". We can never claim absolute validity.
1. Objective truth-claim: this is a prezi presentation.

2. Intersubjective / Normative validity-claim: prezi presentations should be forbiddden.

3. Subjective honesty-claim: a prezi presentation makes me depressed.
Ethics and ethical discussions always circle around a normative validity claim.
Habermas describes a way of discussing that makes it possible for us to reach a concensus based on logical argumentation
and structured discussion: a discourse. the goal of which is to reach a concensus. An agreed upon definition of a situation and the norms and values we wish to use in this situation.
Foundational Discourse
Application Discours
Medical-ethical-
dilemma
-X-
Question: how should we apply norm
-Y- in situation -X- ?
In an application discourse all people who will be affected by a certain norm should speak about case -X- and try to figure out an application of norm -Y- The general rules of a discours should be used to reach this accepted application.

A discours is an open conversation with a few fundamental characteristics:

1. Power-free. Power, rhetorical, political, physical does not play any role in the discussion.
2. Only argumentation counts. Logic, validity etc
3. There is equal access to the discussion for all that wish to partake and are stakeholders in the discussion.
5. De discours is never fully closed, there is no final anwser, a discours can always be re-opened.
Discours
If anybody wishes to discuss the norm itself and not its application then the Application discours turns in to
a foundational discours.
In a foundational discours all the possibly afflicted try to formulate a new norm on the basis of a commonly understood and discussed central value. As soon as such value or norm is agreed upon the speakers can then turn back to an application discours and try to determine in which case the new definition of norm -Z- should be applied.
Jurgen Habermas
Crucial in religious ethics are (among other things) a few concepts like: "The Absolute", "The Body" and "The Soul".
The human soul is understood as a body/matter-independant entitiy that:

1. Is eternal
2. Is immaterial
3. Has a devine origin
4. Carries the essence of man
Soul
Body
The body is but the physical carrier of the human essence and therefore subjected to the soul. The material body is, in most religious traditions, seen as a distracting aspect of our existence. It's physical necessities should be overwon or controlled.
Examples of distractions
Food
Sexuality
Religious ethics mostly formulates norms and values that constrain the physical aspect of a person to control or structure "it". Examples: Ramadan, Marriage, Lent.
Therefore religious ethics mainly formulates rules (values / norms) for a "healthy" soul and the proper attitude we should have towards ourselves as persons and towards the others as other soul-carriers.
The Absolute
The divine message (Thora, Bible, Koran) is or describes the absolute truth. (in the case of the Koran, it literrally IS the word of Allah while the Old and New testament are conceived as bundled texts of different writers.
The message and the rules that Jaweh, God or Allah have passed on to us that govern our mental an physical health should not be trespassed.
Examples:

1. Resistance against abortion
2. Resistance against birth control
3. Resistance against vaccination
4. Resistance against euthanasia
The basic argumentation in all these cases is: Man is a creation of Jaweh / God / Allah and therefore we don't have the right to intervene in the divine creation.
This approach to religious ethics could be called the "Negative" or
" Negating" approach. There is off course also a positive one.
Religious ethics often take up the form of virtue ethics. The central role in such ethical theories is played by specific religious virtues. These virtues then function as the basic theorems to start a moral debat about any given subject.
Religious Virtues
1.Prudentia (prudence, wisdom)
2.Iustitia (Justice - rightiousness)
3.Temperantia (Temperance - self-control)
4.Fortitudo (Courage - Mental strength)
5.Fides (Faith)
6.Spes (Hope)
7.Caritas (Love - Love for your fellow man)

Christelijke Deugden
1. Injecting radioactive iodine into pregnant women seeking abortion, in order to track the mass transfer between placenta and carriers bloodstream.

2. Another experiment administered radioactive iodine to newborns.[citation needed]

3. Irradiating the heads of children

4. Feeding radioactive material to mentally disabled children

5. Exposing U.S. soldiers and prisoners to high levels of radiation

6. Irradiating the testicles of prisoners, which caused severe birth defects
Argumentation and Logic
Instruments that are needed for any discussion to remain reasonable:

1. Argumentation style
2. Logic
The form, cases and style should fit
the specific topic. When you paraphrase
or use metaphors they should stick etc etc.
The underlying structure of the argumentation should at least not be invalid. That means that you cannot use fallacies.
Formal Validity - Truth
Deduction vs Induction
O
o
o
o
o
o
O
o
o
o
o
o
Formal Validity is the correctness of the underlying pattern of reasoning in any given statement.
Truth is if something is the case. (Wittgenstein)
That means that the sentence: there is an Alien in my kitchen is true if and only if there indeed is an Alien in my kitchen.
Fallacies
Synopsis
When discussing a moral dilemma, it is your task to keep the discours as "pure" as possible. This means:

1. Use logic and argumentation
2. Differentiate between the different truth-claims and don't make any unacceptable "jump".
3. Recognise and use correctly the difference between induction and deduction.
4. Recognise and correct fallacies when you see them in your own statements or those of others. Don't be vain !!!
5. Don't aim at winning, aim at understanding.
Every sentence that starts or ends with: "Thats just how I am ....or.....I am such and such..... is as the Brittish
from the 1950's liked to say, "poppycock". A.k.a, BS.
Deductive reasoning, also deductive logic or logical deduction or, informally, "top-down" logic,[1] is the process of reasoning from one or more general statements (premises) to reach a logically certain conclusion.

Deductive reasoning links premises with conclusions. If all premises are true, the terms are clear, and the rules of deductive logic are followed, then the conclusion reached is necessarily true.

Deductive reasoning (top-down logic) contrasts with inductive reasoning (bottom-up logic) in the following way: In deductive reasoning, a conclusion is reached reductively by applying general rules that hold over the entirety of a closed domain of discourse, narrowing the range under consideration until only the conclusion is left.

In inductive reasoning, the conclusion is reached by generalizing or extrapolating from initial information. As a result, induction can be used even in an open domain, one where there is epistemic uncertainty. Note, however, that the inductive reasoning mentioned here is not the same as induction used in mathematical proofs – mathematical induction is actually a form of deductive reasoning.
Deduction
Induction
Induction
Deduction
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