Principle of Bioethics and Ethical Analysis

Arnuparp Lekhakula M.D., M.S.Department of Internal MedicineFaculty of MedicinePrince of Songkla UniversityHat Yai, Songkhla, Thailand

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What is Bioethics?

Study of ethical issues arising from biological and medical sciences

Varieties of Bioethics

Medical ethicsPhysician-centered

Health care ethicsIncludes nurses & other healthcare professionals

Clinical ethicsHospital care decisions with aid of committees and consultants

Bioethics in generalIncludes issues in genetics, reproductive technologies, experimentation, and distribution of life-saving resources

Normative Ethics

Developing principles that tell us which actions are right, and what we are morally required to do.

Normative Theories

Deontological theoriesAssociated with German philosopher Immanuel Kant.

Consequentialist theoriesMost well-known theory is utilitarianism.Utilitarians seek to maximize general human happiness or well-being.Famous utilitarian philosophers include John Stuart Mill and Jeremy Bentham.

Deontological Theories

A type of action is right or wrong no matter what its consequences are.Moral agents have duties which oblige them to do certain types of action.Duties can be specified in the form of rules that must be universally applicable.Persons and their autonomy should be respected at all times.

Consequentialist Theories

What makes an action right or wrong are its consequences.The consequences of an action can always be measured by a common standard: what it contributes to the good of all who are affected by the actionThe right action is one that has the maximum beneficial results.The same unit of benefit to any person should be given equal weight.

What is Applied Ethics?

Use of general moral principles to test the morality of particular actions.

Problem for Applied Ethics

Presence of competing moral principlesDoes this make applied ethics subjective?

Room for reasoning, argument and justificationEthics is not a matter of taste.

Ethical dilemmas are real dilemmasThere are no easy answers.

Important to learn why people disagree

EthicsEthics is about dilemmadilemma and thereasonsreasons that we give for our choice of action “should do, ought to do”

Medicine is about that is the bestFor the patient

Doing the right thing for the patienthas not only a factual but also amoral dimension

In real life :In real life :• Deciding what to do in real life can be complicated• No easy answer• We live in an ethically diverse society• We cannot be saints all the times

Primary Goal of BioethicsPrimary Goal of Bioethics

“to enhance clinicians’performance or abilityto care for patients andfamily, leading to better quality of care”

BioethicsBioethics

• Doing good, avoiding harm• Provides a process to think through complex problems, balance competing needs, views, opinions, values and beliefs• Provides support to reduce moral distress• Provides education on ethics models and techniques• Provides education on relevant legal and policy issues• Dependent on context/culture

CASE IA 30-year-old man, with a common cold.

Antibiotics will do no good. The patient requests it.

What should you do?

Pros

Uncertain diagnosis

Placebo

Satisfy

Cons

Side-effects

Antibiotic resistance

False idea

Cost

Conflicting responsibilities

It is the apparent conflict between opposing principles or obligations that gives rise to many ethical problems in medicine.

The Core Ethical QuestionsThe Core Ethical Questions

Question 1Question 1 : What does the patient wants ?

(Autonomy)

Question 2 :What can be done for the patient and what are benefits and harms?

(Benificence / Non-maleficence)

Question 3 :

Are the patient’s requests fair and able to be satisfied?

(Justice)

Principles of BioethicsPrinciples of Bioethics

• Autonomy• Beneficence• Non-maleficence• Justice

AutonomyAutonomy• Providing patient with information• Enabling patients to make informed medical choices• Respecting patient’s right to refuse treatment• Ensuring openness with patients• Maintaining patient privacy• Helping restore patient’s independence

Some Bioethics IssuesSome Bioethics Issues

• Informed consent• Confidentiality• Truth telling• Withholding information• Substitution decision-making• Refusal of treatment• Advanced directives• Maternal-fetal conflict

Some Bioethics IssuesSome Bioethics Issues

• Double effects• Withholding life-sustaining treatment• Medical futility• Mistake• Conflict of interest• Palliative care• Resource allocation• Research ethics

The Ethical Decision Procedure1. Recognize that the case raises an

important ethical problem

2. What is the dilemma ?

3. What are the alternatives?

4. What are the key consideration?

5. Decide on a resolution to the problem

6. Consider your choice critically

Analytic FrameworkAnalytic Framework

Medicalfactors

PatientPreference

Qualityof life

Contextualfeatures

Medical FactorsMedical Factors• How was the diagnosis made?• Does it fulfill any of the goals of treatment?• What are the treatment alternatives• Is the proposed treatment useless?• What is the prognosis?

Patient PreferencesPatient Preferences• What does the patient want?•Does the patient have the capacity to decide? If not, who will decide for the patient?• Do family members feel?

Quality of LifeQuality of Life

• Quality of residual life• What is the patient’s subjective acceptance of likely quality of life?• What are the views of the care providers about the quality of life?• Less than minimal?

Contextual FeaturesContextual Features

• Social, legal, economic, and institutional circumstances• Cultural belief• Support system and availability e.g. inability to pay for treatment, inadequate social support

7. Action required : Do the right thing!

The Ethics Decision Procedure

CASE II A 46-year old patient was found to have unresectable pancreatic cancer His wife insisted that staff withhold the diagnosis from him because he is prone to depression

What should be done?

The Ethics Decision Procedure

The problem Ethical dilemma The alternatives The crucial consideration

Autonomy Beneficence

Non-maleficenceJustice

The Ethics Decision Procedure The resolution Critical considerations

Medical factors Patient preference Quality of life Contextual features

Exceptions to Disclosure Patient’s waiver

Incapacity of patient

Medical emergencies

Therapeutic privilege

The Ethics Decision Procedure

Action requiredDo The Right Thing

Useful References

Tom Beauchamp & James Childress, Principles of Biomedical Ethics (Oxford University Press, 1994)Nancy Jecker, Albert Jonsen & Robert Pearlman (editors), Bioethics: An Introduction to the History, Methods, and Practice (Jones & Bartlett, 1997)Robert Veatch (editor), Medical Ethics (Jones & Bartlett, 1997)