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Below: The Ethical Dimensions of Medical Decisions | Withholding Food & Water | Organ Sales | Medical Disclosure | CA: Human Cloning | Key Concepts

About Philosophy 9^th ed., Chapter 5 (Part II)
Ethical Theory

The Ethical Dimensions of Medicine

The Ethical Dimensions of Medical Decisions

• Growing demand for moral philosophers as medical consultants for doctors and other medical personnel often face decisions fraught with life & death moral issues, often serving on hospitals' ethics committees.
• Example: Who gets kidney dialysis when there are more candidates than slots
  • "playing God": those refused will die unless they get transplants
  • variety of selection criteria used or proposed
    • meritarian concept: based on the person's conduct, achievements, or contributions to society
    • needs principle: allocate according to patients "essential needs"
    • ability principles: allocate according to various patient abilities, e.g., ability to pay
    • compensatory justice: allocate according to socio-economic deprivation
    • utilitarian "ethometrics": allocate to provide the greatest benefit to the greatest number
    • egalitarian principle: allocate in such a way that each candidate has an equal chance of selection (e.g., by lottery)
• Other examples medical-ethical decisions
  • which patients get organ transplants.
  • whether to keep terminally ill patients alive.
  • what to tell terminally patients about their conditions.
  • whether to have (or recommend), or perform abortions
  • whether to assist a patient who wants to die.
  • whether to use aborted fetuses for stem-cell and other potentially life-saving research
  • whether to screen patients for genetically inherited diseases and what to tell them
  • whether to use genetic techniques to influence the sex or other characteristics of a fetus
  • what role patients should play in choosing their treatment
• All of us have or will face decisions like these as consumers of medical treatment
  • average life-expectancy in wealthy societies has almost doubled in the past century
  • cures and treatments for all kinds of formerly fatal ills: "once you can do something, there is no avoiding the question of whether you should do it" (p. 260)

Withholding Food and Water

• Euthanasia aka "mercy killing" (from Greek roots meaning good death)
  • active {killing} v. passive {letting die}
  • voluntary v. nonvoluntary
    • voluntary: killing a patient capable of consent with their informed consent
    • nonvoluntary: killing patients incapable of consent (e.g., infants & the comatose)
• Dilemma: Medical practitioners are supposed to be care givers not care withholders.
• Types of cases in question: passive nonvoluntary
  • "a newborn infant who lacks the organs necessary for survival and can be kept alive only by continual, heroic, life-saving measures"
  • "a terminally ill brain-cancer patient who has slipped into and irreversible coma"
  • "a patient so severely burned over so much of her body that doctors are unable to perform skin grafts or other procedures and cannot even find a way to keep the patient alive without terrible pain for very long"
• Con Issues
  • trust in medical providers being care givers being at stake
  • knowledge of the circumstances being doubtful
    • diagnoses are sometimes wrong
    • "miracle" recoveries do happen
  • professional principles of care givers at stake: "Above all do no harm."
• Pro Issues
  • problem of allocating scarce resources: these are all hi-cost lo-benefit patients
  • limitations of medical science: humans remain mortal
  • needs of loved ones: for closure.
• Lynne & Childress
  • before intravenous feeding and nasogastric feeding tubes "malnutrition and dehydration must have accompanied nearly every death that followed an illness of more than a few days"
  • now we can provide food & water: should such provision ever be withheld
    • controversial cases
      • newborn conjoined twins sharing abdominal organs?
      • a patient with severe brain damage due to oxygen loss following surgery
      • Down syndrome infant with "tracheosophagael fistula"
    • Atty. Gen. Dr. C. Everett Koop "stated that there is never adequate reason to deny nutrition to a newborn infant" (L&C).
  • G.E.M. Anscombe
    • "For wilful starvation there can be no excuse."
    • "The same can't be said quite without qualification about failing to operate or to adopt some courses of treatment."
  • Informed consent rules in voluntary cases: when the patient is competent to decide: "Patients who are competent to determine the course of their therapy may refuse any and all interventions proposed by others, as long as their refusals do not seriously harm or impose unfair burdens on others." (L&C)
    • refusing food & water does not seriously harm or unfairly burden others
  • Nonvoluntary cases (where patients are not competent to decide for themselves) are the sticky cases
    • one guiding notion: "the standard by which other medical decisions are made: one should decide as the incompetent person would have if he or she were competent"
    • L&C's Conclusion: "surrogates, in close collaboration with their physicians and other caregivers and with careful assessment of the relevant information, can correctly decide to forego the provision of medical treatments intended to correct malnutrition and dehydration in some circumstances."
  • Last word: "Medical nutrition and hydration do not appear to be distinguishable in any morally relevant way from other life-sustaining medical treatments that may on occasion be withheld or withdrawn."

Buying and Selling Human Organs

• The age of transplants is upon us: kidneys, hearts, livers, and lungs can all be transplanted.
• Questions this raises
  1. Should be permit organ transplants?
  2. Who should get an organ when it becomes available?
  3. Should individuals be permitted, encouraged, or even required to consent to the donation of their organs when they die?
  4. Should a market price be put on human organs?
  5. Should individuals be permitted to sell their organs to those needing transplants?
  6. Should doctors be permitted to harvest organs from dead people without their prior consent?
• Wolff's strong negative response to 4: "there is something obscene about the idea of a market" in body parts
  • signing an organ donor card is one thing
  • but "should I be allowed to leave a little nest egg for my children by stipulating that they sell off parts of me before what gets left gets buried?"
  • "how about allowing poor people to sell spare body parts to rich people who need transplants" ( Movie: Dirty Pretty Things)
    • Rotten Tomatoes
    • IMDB
  • there are not-so-distant precedents for this
    • the homeless selling their blood
    • surrogate mothers renting their wombs to childless couple
• First Pro Argument: autonomy based: my body is my "property"
  • my body is mine to do with as I please
    • to be a body builder or a couch potato
    • to die my hair or pierce my navel
    • engage in high risk activities (commit suicide?)
    • to be cremated not buried,
    • etc.
  • organ donation is permitted
  • therefore organ sales should be permitted
• Second Pro Argument: utility based
  • there's a shortage of organs available for transplantation
    • tens of thousands of patients die every year for lack or transplants
  • allowing organ sales would increase the supply saving many of these
  • so organ sales should be permitted
• First Con Argument: equality based
  • Such a practice would be inegalitarian: "would put unbearable pressures on the poor"
    • "It is bad enough that the rich can eat drink an be merry while the poor struggle to survive."
    • "Should the rich also have the right to bribe the poor to give up parts of their own bodies?"
  • so organ sales should not be permitted
• Second Con Argument: utility
  • if organs were for sale then they'd be distributed on the basis of ability to pay not medical need
  • this is inefficient
  • so organ sales should not be permitted
• Metaphysical question: "When I agree to sell my brain to a buyer and have it transplanted into her body, who emerges from the operation, the buyer or me?"

What Should the Doctor Tell the Patient

• "[A]s long as there have been doctors ands patients, doctors have struggled with what to tell the patient and the family"
• Questions
  • "Does a doctor have a right to withhold vital information from a patient or family members?"
  • "[D]o patients have an absolute right to an honest answer when they ask, 'How bad is it, Doc?'"
• Beauchamp and McCullough: "Informed Consent"
  • Bernard Berkey case
    • suffered a neck injury which later became aggravated
    • Dr. Anderson advised a myelogram to see if there was damage to the spinal cord
    • B asked whether the procedure would be similar to the electromyelograms he had already undergone
    • Dr. A reassured him that the procedure would not be painful but neglected to mention that it involves a spinal puncture, unlike the electromyelogram.
    • B experienced pain, injury, and loss of function: "rubber leg" and "foot drop
    • The arguments in court
      • A: that his behavior was consistent with the "general standard of what other physicians routinely disclose"
      • B: "'the reasonable person's' needs for information set the standard, not simply the community of physicians"
    • The court sided with B
  • Risks and Benefits of Disclosure
    • Factors impacting the quality of communication in the doctor-patient relationship
      • duration of prior contact
      • the state of the patient
      • how well the physician relates to the patient and their family
    • Most doctors believe "that time constraints and other pressing obligations justify departures from such abstract, oversimplified, principles as ... 'Don't deceive,' or 'Always tell the truth.'"
    • Hoary justification for deceit: to spare the patient distress': they can't handle the truth
      • "adverse reactions might result from information given during an informed consent discussion"
      • placebo effects show the importance of beliefs and attitude to treatment outcomes
      • "In a crisis many people would prefer compassion to total frankness, which can have a devastating emotional impact."
    • Beneficence vs. Autonomy
      • Beneficence (kindness) : sometimes patient's really can't handle the truth, and in these cases it's better (for the patient) to withhold information
      • Autonomy (self-determination): patients are owed the information they need to make decisions concerning their own life, death, and suffering. Withholding information violates their right of self-determination.

Contemporary Application: Human Cloning

• CBS News Videos
• "A clone is an exact copy. In genetic terms, a clone is an organism with exactly the same DNA, exactly the same genetic code as the original."
• Present state of the art: Sheep already (Dolly); humans (coming soon).
• Clones = Artificial Identical Twins: "we are talking about genetically replicating a human being, in much the same way that nature does every time identical twins are born."
• Coming soon:
  • "'designer babies' -- fetuses deliberately crafted by medical technology so as to have certain genetic components, such as gender, hair color, skin color, height, weight, and perhaps -- though this is much less clear -- even musical talent or athletic ability."
  • "Already efforts are underway to remove from fetuses genes that cause fatal or debilitating hereditary diseases."
• "Cloning seems to be the next logical step."

Stop Cloning Around

• by John F. Kilner
• "We have now learned that the partial genetic material in an unfertilized egg cell may be replaced by the complete genetic material from a cell taken from an adult. With a full genetic code, the egg cell behaves as if it has been fertilized."
• "that is how Dolly ... came to be": why not extend the technology?

The Costs of Clones

• "the experiments of Nazi Germany and the resulting Nuremberg Trials and Code taught us long ago that there is some knowledge that we must not pursue if it requires the use of immoral means"
• the pursuit of the know-how to clone humans requires the use of such immoral means: "cloning will cause the deaths of human beings".
  • " Human embryos and human infants ... would ... be lost as the technique is adapted to our race."

Gold Rush

• "[H]uman beings, made in the image of God, have a God-given dignity that prevents us from regarding other people merely as means to fulfill our desires. We must not, for instance produce clones with low intelligence (or low ambition) to provide menial labor, or produce clones to provide transplantable organs (their identical genetic code would minimize organ rejection. We should not even clone a child who dies tragically in order to removed the parents grief, as if the clone could actually be the child who died."
• "Valparaiso University's Gilbert Meilaender told Christianity Today, this further separation of procreating from marriage is bad for children. 'The child inevitably becomes a product,' says ethicist Meilaender, 'someone who is made, not begotten.'"

Xeroxing Michael

• "The problem with cloning is not the mere fact that technology is involved. Technology can help us do better what God has for us to do. The problem arises when we use technology for purposes that conflict with God's."
• "When human cloning becomes technically possible, who will control who clones whom and for what ends?"

Pause for Philosophical 'Speed Bumps' on Cloning

• by Paul Ginnetty
• Horrors: "The ethically troublesome notions of exploiting clones for fetal tissue implants or organ transplants gained an eerie aura of relevance with the recent genetic engineering of a headless tadpole, a prototype -- some have suggested -- of future anencephalic humans from which we could gleefully 'harvest' spare parts."
• "I'm reminded of Stephen King's Pet Semetary, which explores the unnatural, ghoulish lengths to which one might be tempted to go to reclaim a child from the dead."
• "[P]eople are probably best thought of as irreplaceable, unrepeatable events."
• "Weren't family roles complicated enough before this biotech?"
• "A biotechnology that becomes unhinged from a human vision of person, family, and life cycle becomes morally bankrupt in its expediency."

Second Thoughts on Cloning

• by Laurence H. Tribe
• formerly "I leaned toward prohibition as the safest course."
• Question scientists are raising: "whether human cloning isn't just an incremental step beyond what we are already doing with artificial insemination, in vitro fertilization, fertility enhancing drugs, and genetic manipulation."
• Why his prohibitionist ardor has cooled: "my concern is that the very decision to use the law to condemn, and then outlaw, patterns of human reproduction -- especially by invoking vague notions of what is 'natural' -- is at least as dangerous as the technologies which a decision might be used to control."
  • "to ban cloning as the technological apotheosis of what some see as culturally distressing trends may, in the end, lend credence to strikingly similar objections to surrogate motherhood or gay marriage or gay adoption."
  • since no prohibition is ever airtight, it "requires us to think in terms of a class of potential outcasts -- people whose very existence society will have chosen to label as a misfortune and, in essence, to condemn."
  • "There are few evils as grave as that of creating a caste system, one in which an entire category of persons, while not perhaps labeled untouchable, is marginalized as not fully human."
• "If human cloning is to be banned, then the reasons had better be far more compelling than any so far advanced."

There's No Reason to Fear Cloning

• Harry Binswanger
• "Twins of the same age do not frighten us, so why should twins separated by a generation?"
• "The Boys of Brazil? It was not Hitler's genes but his choices that made him a monster."
• "Natural? It is man's nature to 'play God' by reshaping matter to produce the food, shelter, tools, cars, and power stations that sustain and enhance our existence."
• "At the threshold of exciting biomedical advances, we must not let irrational fears slow progress in the battle to enhance and extend human life."

Above: The Ethical Dimensions of Medical Decisions | Withholding Food & Water | Organ Sales | Medical Disclosure | CA: Human Cloning | Key Concepts
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