Intro to Ethics & Health 01/23/2013
Philosophy = “The love of wisdom”
Philosophy is a cluster of questions ▯ (i.e. what is reality? what is love?)
Philosophy/ethics isn’t a science
Ethical questions are about what is right, what is wrong…
General Questions: “What actions are right? How should I live my life? What should I value?”
Specific Questions: “How should I treat other people? What profession should I pursue? How should I
Health Care Ethics
“What is the nature of the relationship between the professional and the patient?
“When can we expose patients to risks in order to gain medical knowledge?”
“Is abortion morally permissible?”
“Is euthanasia morally permissible?”
Conscientious objection: “can professionals refuse to perform an intervention if it conflicts with their won
“How should we allocate scarce medical resources?”
Nazi experimentations, African Americans suffering with syphilis were denied insulin in order to gather
data, Savita Halappanavar are examples of why we need to focus on ethics ▯ if we don’t bad things can
happen (even if these are extreme examples)
Local (less extreme example) where ICU nurses were asking the family about organ donation ▯ made the
families feel like the hospital didn’t have their family members’ best interests at heart
We don’t always have a basis for our beliefs (i.e. do you think that incest, having properly used protection,
Arguments from Nature X is natural therefore X is good or right
“Antibiotics are not natural. Our natural physical constitutions include an immune system that is designed
to detect and eliminate pathogens. When we use antibiotics, we go against nature. Therefore, it is wrong to
>> This type of argument is often used when eating meat or homosexuality
THE PRINCIPLE: IF something is unnatural, it is wrong.
THE PROBLEM: “Just because something is “natural” does not mean that it is either good or bad. Also,
it’s hard to articulate what is or is not natural.”
“Informing the patient of her true diagnosis would only cause her mental anguish. This mental anguish
would serve to worsen her condition, and she would gain no medical benefit from knowing the truth. Lying
to her has the best consequences. Therefore, her doctor should lie to her.”
THE PRINCIPLE: IF something has the best consequences, you should do it.
THE PROBLEM: Not only consequences matter.
THE PRINCIPLE: Health care professionals have a right to refuse on grounds of conscience
THE PROBLEM: Sometimes, respect for a patient’s choices may outweigh a professional’s own moral
Ethical Theories (Part 1) 01/23/2013
History of Medical Ethics
“I will use treatment to help the sick according to my ability and judgment, but never with a view to injury or
Primum non nocere
“First, do no harm.”
Began in 490 BC >> Hippocratic oath – the oath is a standard of conduct
Non maleficence – Do no harm
first thing health care people should know
Beneficence – Benefit others; don’t try and use them < All of our theories are normative theories
> Fraught with aught; implied what you aught to do
> Content of morality
we won’t be doing it; theories about the nature of nature of morality
> Don’t apply normative claims; what you ought to do
> Ask, “What is the meaning of the term right ”
> What are the psychology underpinning peoples’ moral judgements?
> “What are the nature of moral properties?” ▯ how should we understand them
• Descriptive Ethics
theory where you don’t try and get the right answer to an ethical question
> Describe what people (societal, institutional, etc.) in a certain community think that you should do
Features of (most) Ethical Theories
All ethical theories should have the following in common:
1) Objectivity: the right course of action has the best reasons counting in favour of it, and these reasons
can, in theory, be recognized by anyone.
> There are better and there are worse answers
> Ethics isn’t purely subjective; it has objective elements
2) Impartiality: reasons for action presume that everyone's needs, rights, and moral worth are roughly
> Theories that say, “men > women are wrong” “any kind of racial supremacy is wrong”
> All the ones that we’re going to consider are IMPARTIAL Ethical Theories (Part 1) 01/23/2013
A Brief History of the Purpose of Man
the good life is one that involves “justice and right thinking”
Socrates was an ancient Greek philosopher, put on trial and killed
Plato began writing dialogues as a result of this
Socrates asked, “Why should I be just?” ▯
We have the 3 mental faculties:
1) Passions: emotion and desire
2) Spirit/will: can exert control over passions
3) Reason: should be using the spirit to hold the passions
the good life is one that “contemplates the divine”
the good life is one that “maximizes happiness”
> He’s the first modern consequentialist
The good life is one that “make more mans”
An action is morally right if and only if it produces the best consequences out of all alternative actions Ethical Theories (Part 1) 01/23/2013
There are a few versions of consequentialism
An action is morally right if and only if that action creates more happiness than any other alternative.
Hedonistic – only pleasure matters
Happiness = pleasure in the absence of pain
Why is murder wrong? It creates pain and doesn’t add pleasure to peoples’ lives
Lying is pretty much okay… So is bestiality
Jeremy Bentham (17481832)
WE should create bodies into “autoicons”; burying people is wasteful
Mummified his body, donated his body to a university
Founder of Modern Utilitarianism
People and governments should be following this
We need a smallest unit of pleasure; called a “hedon” ▯ about the pleasure you get from eating an apple
More intense, longer lasting, closer to you… all these pleasures are worth MORE
John Stuart Mill (18061873)
Wrote: Utilitarianism” >> written to persuade people to be utilitarians
Had quite a large impact on the social conduct
Wrote: The Subjection of Women ” ▯ views of women are incorrect; one of the earliest published
Also wrote On Liberty ” ▯ talked about Liberal ideology; the government should stay out of your life
unless it is to protect you from harm
Higher/Lower Pleasures Ethical Theories (Part 1) 01/23/2013
Major difference between John and Jeremy is… higher/lower pleasures
Bentham: if I really enjoy videogames and sex, that’s ALL that I should do
> Everything else should be a waste of time
> Mill didn’t agree with this; other things are important… The “piggish” kinds of pleasures don’t give us as
much meaning, there are things considered to be “higher pleasures”
Problems with Utilitarianism
1) Real Distinction Between People:
You can’t just trade off the goods of one person to make another worse off (kill one person to harvest his
organs and save 5 peoples’ lives… Utilitarian’s say YEAH this is a great idea)
Jim finds himself in the central square of a small South American town. Tied up against the wall are a row
of twenty indigenous people, most terrified, a few defiant, in front of them several armed men in uniform.
A heavy man in a sweatstained khaki shirt turns out to be the captain in charge and, after a good deal of
questioning of Jim which establishes that he got there by accident while on a botanical expedition, explains
that the indigenous people are a random group of the inhabitants who, after recent acts of protest against
the government, are just about to be killed to remind other possible protesters of the advantages of not
However, since Jim is an honoured visitor from another land, the captain is happy to offer him a guest’s
privilege of killing one of the indigenous people himself. If Jim accepts, then as a special mark of the
occasion, the other indigenous people will be let off. Of course, if Jim refuses, then there is no special
occasion and Pedro here will do what he was about to do when Jim arrived, and kill them all.
Jim, with some desperate recollection of schoolboy fiction, wonders whether if he got hold of a gun, he
could hold the captain, Pedro and the rest of the soldiers to threat, but it is quite clear from the setup that
nothing of the sort is going to work: any attempt at that sort of thing will mean that all the indigenous people
will be killed, and himself.
The men against the wall, and the other villagers understand the situation, and are obviously begging him
to accept. What should he do?
example of a foreigner being invited to kill one person, if you don’t do that the government will kill them all.
Utilitarianism says that YEAH he should do it. Issue here is that it doesn’t give the people moral autonomy
or integrity. Basically, doesn’t give you an answer to the “whole question”
3) Pleasure Monster:
If someone gets more pleasure out of something than someone else does, than you should let the person
who gets more pleasure from the thing than the other guy (i.e. give Adil, Nitsa because he will get more
pleasure out of it vs. Sujie) Ethical Theories (Part 1) 01/23/2013
If someone would really enjoy my money, or do something with it that would create more happiness than I
could, that I’m required to give it to him, as per Utilitarianism.
General idea “Make more happiness” Ethical Theories (Part 1) 01/23/2013 Ethical Theories (Part 1) 01/23/2013 Ethical Theories (Part 1) 01/23/2013 Ethical Theories (Part 1) 01/23/2013 Ethical Theories (Part 1) 01/23/2013
The morally right action is that which obeys the set of rules that, if followed by everyone, would have the
If everyone follows the “keep your promise” rule and “don’t lie” rule, things will have the best consequences
Makes more sense; we ourselves value rules more Ethical Theories (Part 1) 01/23/2013
Tries to find/investigate/discover sets of rules that we should follow
Not justified by consequences
Deon = duty
Deontology = the study of duty
More accurately: A class of theories that tries to formulate and defend sets of rules that answer moral
German philosopher, very peculiar = walk, never left 100+ miles of his home town
Groundwork of the Metaphysics of Morals: Theory of things that are right/wrong/virtuous ▯
groundwork = first step towards getting an answer towards those
Critique of Practical Reason
Metaphysics of Morals expands on the groundwork
NOT only the consequences of your actions that matter; making informed, rational decisions is important
Imperative = an expression giving a command or a prescription
E.g. “Shut the door”
“Do your homework”
“Attend your tutorials”
...and so on
Hypothetical = Conditional on certain external factors, such as desires, emotions or other contingent facts
(“If you want to have a comfortable retirement, you should start putting money into an RRSP”; “If you like
beer, then you shouldn’t buy Bud Light”; “If you want to do well in this class, you should attend lecture and
> Conditional on your certain moral constitution; not everything applies to you!
> Kant says that “it doesn’t matter what you want/feel, moral claims are true for you and true for everyone”
Kant’s Central Insight:
Morality does not seem to be composed of hypothetical imperatives.
Categorical – means universal/independent Ethical Theories (Part 1) 01/23/2013
CI = The ultimate moral principle.
Is not conditional on any external factors.
Has 3 (or maybe 5?) formulations.
Categorical Imperative 1
“Act only on that maxim by which you can at the same time will that it become a universal law.”
> You can only do something if it can apply in every context
> Always ask yourself: what if everyone did that all the time? What would the consequences be?
Least applicable to medical professionals
Maxim = principle on which you’re acting (i.e. “cheat on midterms”… well, what if everyone did that? If
everyone cheated on tests, I wouldn’t have a test – because there would be no point to have more tests –
not really testing knowledge, but testing cheating abilities)
Note: he’s saying ▯ could that (aforementioned example) statement even occur? If everyone did X, would
being able to do X even be possible? – so if everyone cheated, would it even be possible to cheat then?
Lying (even when axe murderers are involved)
i.e. guy wants to kill Bob, you tell the murderer where he is ▯ you’re not responsible for other person’s
Believes that there is a distinction between perfect/imperfect duties
Perfect duties: It is ALWAYS morally wrong to do X.
(i.e. always wrong to do rape, murder, etc.)
Imperfect duties: It is morally wrong to NEVER do X, but you do not always have to do X.
(i.e. giving to charities ▯ sometimes, but not always)
Categorical Imperative 2
More plausible than any of the others
“Act so that you treat humanity, whether in your own person in that of any other, always as an end and
never as a means only.”
Don’t treat humans as a means to an end refers to any action (the means) carried out for the sole purpose
of achieving something else (an end) Ethical Theories (Part 1) 01/23/2013
Do the ends justify the means?
Kant says no, you can not just treat people as a means, no matter how good the end is!
Immanuel Kant's theory of morality, the categorical imperative, states that it is immoral to use another
person merely as a means to an end, and that people must, under all circumstances, be treated as ends in
themselves. This is in contrast to some interpretations of the utilitarian view, which allow for use of
individuals as means to benefit the many
Prima Facie Moral Principles
Prima facie = “at first appearance”
A more useful definition of how philosophers use the term: “may be overruled at some other time.”
Originated with W.D. Ross
When you get into a moral dilemma, you need to think of tcontext of the situation
MORE Ethical Theory!
Relativism Ethical Theories (Part 2) 01/23/2013
Respect for autonomy
right thing to do is to produce great amt of happiness – doesn’t make room for things abt killing ppl and
harvesting their organs – e.g. already killed a baby and you would enjoy eating it, then you should eat it
allow ppl to live their lives the way they want as long as they don’t end up killing ppl
respecting autonomy – consequences don’t matter as long as you resect human beings – “means to ends”
quote – just means that you have to respect ppl
not abt what we want – whether we can consistently do this and everyone can do this – e.g. can I not cheat
on a test in a world where everyone cheats – no you can’t – in this world no one writes tests b/c not a great
– can’t successfully lie to ppl who lie b/c they won’t trust me – can’t kill ppl in a world where ppl kill b/c I
wouldn’t survive in the first place
find the right action, then find the right theory and then act based on the theory – maybe all parts of these
theories are true
Why we have the opinions we have – other people have said on the topic + your own opinion – help to have
2 different sections (structure the essay) – also use the making sense book
didn’t have anything left to offer b/c were morally bankrupt (misguided) – trying to find a set of rules that
would be a legal code but essentially a moral code – telling you what’s the right thing to do
trolley example – trolley is running under the bridge (where there are 5 ppl standing), I can use the switch to
change the path of the train or push the large individual
* ethics is still important – how do we find a theory that will tell us the right thing to do in every situation*
Aretaic Dealing with excellence
Emphasize the character of persons, rather than their actions in isolation Ethical Theories (Part 2) 01/23/2013
ask questions abt people’s motivations – what motivates them?
emphasis isn’t on
not abt the outcome of their actions but how their psychological disposed to do in any given circumstance –
are you disposed to being nice to all ppl you come across – meaning that you’re a good person and should
be forgiven for
we are in control of our habits – but not entirely in control of our motivations and dispositions
we can change are habits over time e.g. allow myself to lie – over time will develop a habit to lie
that you act in certain kind – assess person as a whole rather than their individual thought and action
want physicians to have certain types of habits and dispositions
Student of Plato (most important philosopher)
Aristotle didn’t write dialogues, but books – natural scientist – wrote on physics, biology – first to write on
accurate taxonomy on animals – claimed really stupid things as well e.g. women have less teeth than men
(could’ve just counted)
we don’t have the original texts (they were burned) – these texts aren’t his original works, but his lecture
he’s a virtue ethicist
The Mean: Finding the proper balance between two extremes in order to develop virtuous character traits
Means happiness – not a psychological state but a type of existence – highest kind of happiness – not only
happy, but you are doing goods things – reasoning was highest function of humans
In order to achieve eudaimonia we need to achieve “the mean” Ethical Theories (Part 2) 01/23/2013
Foolhardiness vs. Cowardice (Courage)
Foolhardy – rash or foolish e.g. want to help my land, but don’t want to be foolish and overconfident to take
out a sword and go fight an army of 1000’s alone
Cowardice – hide away
Middle of foolhardy and cowardice = courageous – good person and have achieved something like
eudaimonia – right balance of caution and bravery
Wastefulness vs. Stinginess (Generousity)
Wastefulness – waste resources
Stingieness – don’t give enough back to yourself and other people
Genourosity Want to preserve for the future – but want to share wealth with others (not to be stingy) and
be a good person
Vanity vs. Meakness (Pride and SelfEsteem)
Vanity excessive pride in or admiration of one's own appearance or achievements
Meakness u kindness, spitefulness, or unfairness
Pride and selfesteem – the middle ground
Situationism (didn’t know that they were being studied)
humans have fixed character traits that can be worked on over time
made them go make a phone call at the pay phone – after making the phone call, they would receive
75% of ppl that received a coin were more likely to help the man gather his papers back – far more likely to
help ppl, if they just got something for themselves
trying to experiment – influence that authority have that ask ppl to do atrocious things
every time they make a mistake, they get shocked – and as they keep making mistakes, they get shocks –
whether or not ppl would do something morally wrong if an authority figure told them to keep going – we
don’t really have a fixed character – environment really develops and impacts our character heavily – 65%
kept administering the shocks when the authority figure told them to continue – only 23% refused to
administer the shock even when authority told them to continue
if saw a person that got a heart attack fall to the ground in front of them (faked it) if they were in a rush,
more likely to keep going – but if weren’t in a rush
developing virtuous habits isn’t what we should b/c we don’t have set character – it depends on the
situation and what’s going on around us that determines our actions Ethical Theories (Part 2) 01/23/2013
genetics and experiences (things that we don’t have control over) determines our actions
we need to work on developing certain kinds of habits and traits
Achieve theoretical understanding of women’s oppression with the purpose of providing a route to ending
women’s oppression, and
Develop an account of women’s moral experiences (Brennan 1999, p. 860).
Explicit: Institutions and practices that disadvantage or otherwise harm women.
Implicit: The perpetuation and maintenance of biases against women.
women were historically oppressed
had many expectations – take care of house, family – didn’t have full of body
explicit: institutions and practice that disadvantage or otherwise harm women
still the case that jobs are still structures 95 – don’t make room for parenting – have to take mat leave
e.g. b/c women weren’t allowed in public life
women would be underrepresented in clinical trials
Endorse opinions – “make me a sandwich” – even as a joke, there might be a man in the audience that is a
Lawrence Kohlberg: Psychologist whose work suggested that women did not fully moral development.
Psychologist whose work suggested that women did not fully moral develop
He took ppl of all age groups and asked them certain moral dilemmas – and would explain their actions in
the certain situations
Most ppl he tested said that they would steal the drugs Ethical Theories (Part 2) 01/23/2013
Heinz Dilemma: A woman was near death from a special kind of cancer. There was one drug that the
doctors thought might save her.
It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive
to make, but the druggist was charging ten times what the drug cost him to produce.
He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's husband,
Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is
half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him
But the druggist said: "No, I discovered the drug and I'm going to make money from it." So Heinz got
desperate and broke into the man's store to steal the drug for his wife.
Kohlberg’s Three Levels
focus on things that it’s bad to steal – good person would help his wife – good girl/boy and bad girl/boy
focuses on social norms
looks at authority – if everyone stole, life would be in havoc
focus on interpersonal harmony – everyone loves their wife so much that of course he would do something
like that for her
1. not everyone could do that – universal law that everyone has to follow
*most women don’t make it to the postconventional stage*
suggested that women just don’t fully morally develop
Ethics of Care
We should approach moral dilemmas from the perspective of “a network of connection, a web of
relationships that is sustained by a process of communication” (Gilligan 1983 p. 32)
Was a misogynist Ethical Theories (Part 2) 01/23/2013
If you’re socialized a particular way, you’re going to think about certain things a certain way
Different from other views – rather than your individual character and thought, but we should approach
moral dilemmas from perspective of “a network of connection, a web of relationships that is sustained by a
process of communication”
Also very important for medical and healthcare ethics – want them to be caring and human beings and
maintain a relationship with their patients
Liberalism and Communitarianism
Liberalism: Focuses on what rights we have in virtue of being citizens of certain moral, political, or social
Communitarianism: criticizes Liberalism for not taking sufficient notice of certain social, communal
conceptions of the good life.
Social cohesion – what makes society work
Social contract theories (Glannon talks about)
What rights we have as being part of a society
What rights do I get by living in an academic society
Only focuses on rights we have in virtue of being citizens of certain moral, political or social communities
Criticizes Liberalism for not taking sufficient notice of certain social, communal conceptions of the good life
Thomas Hobbes (15881679)
Justified b/c it all makes us all better off – society where a gov’t controls over us
State of nature where life is “solitary, poor, nasty, brutish and short” (from book ‘Leviathan’)
Ppl thought Thomas was too progressive for the time
Leviathan: Life in the state of nature was “solitary, poor, nasty, brutish, and short.”
John Locke (16321704)
We’re all better off being protected by the gov’t – protect our property and us Ethical Theories (Part 2) 01/23/2013
First and Second Treatise of Government
Professor at Harvard
A Theory of Justice (1971)
To what extent should we tax ppl and distribute wealth, in order to make other ppl better off
Veil of Ignorance
We don’t our race, etc – anything abt ourself – we have any way to structure society
Maximize the minimum position – ensure that no matter what position where in once we come out of the
veil of ignorance – will know everyone in society will have these rights
Professor from Harvard
Anarchy, State, and Utopia (1974)
Patterned principles of justice
what patterns there are to redistribute justice in society – worse ppl are well off, that’s just
Acquisition of property (Wilt Chamberlain example)
for $5 – is it not just for him to take some money from the money collected to come see his game because
he is contributing to society through bball
1) Liberalism does not recognize that our theories of justice cannot just look at rights in isolation, but must
also include the conception of the good life endorsed by the citizens of a given society.
Really criticize the reliance that these philosopher’s emphasize – human’s have never existed without
All human’s that have survived have grown up/born in communities – we’re not mushroom men that just
pop out – we’re born and given a community and it’s from that stand point that we should view ethics Ethical Theories (Part 2) 01/23/2013
Medical ethics – one way to treat justice
2) There was no state of nature, as humans have always existed within communities. The idea of a
‘contract’ is therefore not a good foundation for ethics.
Rejection of Theories
Rather than trying to find an ethical theory, we should instead focus on particular cases, and deal with them
as they come.
Seem to be trying to find things that are right and wrong
deal with situations as they come
try to deal with that particular situation
don’t really have a value at all – no guarantee that we’re going to be consistent – e.g. one day saying
abortion is permissible and then the next day that it’s not
things like slavery are wrong
just looking a particulars and not as a whole – we’re missing out on the big picture
There is no objective moral truth. It varies from one culture to the next
If you’re in a culture that practices honour killings, then in that culture, it is moral to practice honour killings
Problems: the idea is that there are certain core principles that are recognized by all cultures – like be a
good person, be kind and don’t hurt/kill people
Sometimes genoicide is okay, if people around you in the culture believe it to be moral?? Ethically
What’s actually stopping them from doing things wrong – as long as they think it’s moral, it is moral – then
how is that truly morally acceptable???
Moral properties (like rightness or wrongness) don’t seem to exist
Murder has a property of wrongness – but there is nothing out there that proves that they exist
Argument from relativism.
Argument from strangeness.
A method for engaging in philosophical ethics.
Adjust our intuitions so that they cohere with our principles, and also adjust our principles so that
they cohere with our intuitions Professional Relationships 01/23/2013
Questions of the day Professional Relationships 01/23/2013
Is paternalism justified?
What sorts of professionals do we need?
The view that a professional's responsibility is to figure out what is in the best interests of his or her patient,
and to do that which she thinks best regardless of what her patient thinks
Essentially what Dr. House does
You're only looking what is best in their medical interests >> want to give them a right to answer these
questions for themselves
i.e. you don't want to force someone to take a religion that they believe is wrong
A patient of sound mind must be given sufficient information to make a decision. There must be no coercion
involved in the decisionmaking process
Must tell a patient who is capable of making decisions all the info you can give them
1. Professional disclosure: of diagnosis, prognosis, available/alternative treatments, risks/benefits,
disclose everything potentially relevant
2. Competent patient: can understand the information provided by the professional.
ensure that the patient can understand info that is provided by the professional >> language barriers, young
child, disabled, heavily medicated
“A schizophrenic patient who has been living on the street and has been on and off antipsychotic
medication admits himself to the hospital because of pain in his chest and arm. Coronary artery disease is
suspected. An angiogram is performed to determine whether or not to what extent there is an obstruction in
the patient's arteries. Professional Relationships 01/23/2013
This involves taking Xrays of the arteries after a dye has been injected into them. If there is an obstruction,
then the next likely step would be angioplasty. In this procedure, the femoral artery in the leg is punctured
with a large needle. From this opening, a catheter with a balloon attached to the tip is threaded into the
diseased coronary artery.
The catheter is positioned so that the balloon is at the level of the obstruction. The balloon is then inflated
for several seconds and partially tears the inner layers of the arterial wall, thereby reducing the obstruction.
Suppose that the patient has an obstruction but refuses to consent to angioplasty because it is an invasive
He refuses angioplasty, despite the fact that he consented to the angiogram, which is also invasive, though
perhaps to a lesser degree. While there is a slight risk of heart attack and death with angioplasty, the risk of
not treating the obstruction is greater. The benefit of the angioplasty outweighs its risk, given the patient's
Refuses to undergo more invasive procedure
Question of respect for autonomy
Question of beneficence also involved; not capable of making decisions, seems to be making fairly
inconsistent decisions (changes mind often)
We have to ask "is this person able to understand the long term consequences of the choices that he's
Don't always go for beneficence
The greater the risk of refusal, the more we must be sure that the patient is competent
No real obvious answer
The more invasive a procedure is the more we should respect their refusal
“At 80, R.L. lives with his wife in a retirement community. He has always valued his independence, but
recently he has been having trouble caring for himself. He is having difficulty walking and managing his
medications for diabetes, heart disease, and kidney problems.
His doctor diagnoses depression after noting that R.L. has lost interest in the things he used to enjoy.
Lethargic and sleepless, R.L. has difficulty maintaining his weight and talks about killing himself with a
loaded handgun. He agrees to try medication for the mood disorder.
Two weeks later, before the effect of the medicine can be seen, R.L. is hospitalized for a heart attack. The
heart is damaged so severely it can't pump enough blood to keep the kidneys working
Renal dialysis is necessary to keep R.L. alive, at least until it's clear whether the heart and kidneys will
recover. This involves moving him three times a week to the dialysis unit, where needles are inserted into a
large artery and a vein to connect him to a machine for three to four hours. After the second treatment, R.L.
demands that dialysis be stopped and asks to be allowed to die.”
2 values conflicted: production of good consequences vs. autonomy Professional Relationships 01/23/2013
Person understands longterm consequences >> depressed and suicidal not looking at the consequences
Values can often be very successful and very depressed >> think about dad "I wouldn't want to end up in a
bed; if I do then just kick me in a barrel"
Talking about 2 different kinds of competency
Needs to be a long decision, just not a quick one
Respecting autonomy and paternalistic ideas conflicting here
Determine whether or not depressions means that they're competent or not (i.e. his grandmother is
comfortable with her decision)
What do we do when we judge someone to be incompetent? Their power of attorney or surrogates
someone who can make decisions on behalf of the patient
People authorized to make medical decisions on behalf of the patient
Free to decide what the patient would've done all along
i.e. I know R.L. would've done this because he's always been like that//or not; he's not being himself
Decide what you would've done OR what they think that they should do <> see if
they see what is going on & have a different opinion vs. their parents
Also say, the younger the child is, the more you have to think about what is in the child's best medical
Make a judgment based on: how much risk that it puts the child in
*We should respect patient's autonomy to a certain extent;; if the child can make decisions and it's more
serious (and decision made by parents will put them in harms way) then we need to do what is best or the
Policies in Canada are purposely ambiguous in this case to give more power to the physician
Major threat to autonomy is the illness itself >> should be physicans job to help mitigate problems Professional Relationships 01/23/2013
Physicians need to take a certain amount of control over the situation and they'll the patient what they think
that they should do >> somewhat paternalistic but can also help enhance their autonomy >> stems from a
lot of feminist philosophy
Feminists say that our autonomy is contingent on certain kinds of relationships; our autonomy is "relational"
Emmanuel & Emmanuel
Well known & respected bioethicists
Give them "value neutral" but you don't tell them values
Professional only presents factual objects
Patient and professional work together to make a decision
Doctor gives them options but also ask "so, what are your values in this case?"
Makes them think out social, personal and medical consequences of the choice
This model actually promotes patient autonomy
Many doctors (oncologists) take on deliberative roles; wellbeing of the patient and the patients family
Doctor = Healthcare professional & therapeutic professional
Being "a little bit" paternalistic seems to enhance autonomy
A professional can withhold medical information when that information would potentially be harmful to the
True info might cause them to harm themselves
It's important for them to know the truth because they'll know then how to live out their last days >> might
just cause pain
Kid doesn't have aspirations like those of an adult: oh I want to go to France or I'll contact my long lost
love/son >> kid will probably just play video games
Might be reasons to reveal BASIC information slowly… once they've processed this you can talk about
other things (i.e. treatments etc.)
3 major arguments against it
1) Physician judgment issues
2) Fails to respect autonomy of the patient
3) Reduces trust in professionals Professional Relationships 01/23/2013
A family physician, Dr. A had a longterm professional relationship with a married couple, one of whom (the
husband Jim) was terminally ill. For the past few months, Jim had been in a hospice. His doctors estimated
that he had only a few months to live.
One day the wife, Sharon, made an appointment to see Dr. A and complained of abdominal pain and
unusual vaginal discharge. She confided in Dr. A that several weeks before the appointment she stopped at
a bar for a drink on her way home from the hospice and wound up having unprotected sex with another
She was worried about an STI. Dr. A ordered an STI test. Several days later, Dr. A found out that Sharon
tested positive for Chlamydia. She had been tested recently and that test came back negative, so there was
very little doubt that the infection began after the sexual encounter Sharon described.
The law in the region dictated that any time a married person tests positive for an STI, his or her spouse
must be informed and tested, and this policy does not allow for any exceptions. It is therefore Dr. A’s
professional duty to inform Jim of Sharon’s test results.
Sharon pleads with Dr. A not to inform her husband. They only have several weeks left together and
knowledge of her infidelity would seriously change Jim’s understanding of the relationship and make their
last weeks together extremely difficult.
Also, Dr. A had extensive knowledge of Jim’s medical history and knew that it would have been physically
impossible for him to have sex with Sharon for the past several years. Even if Jim had an asymptomatic
genital Chlamydia infection, he would not live long enough to spread this to anyone else or suffer any
deleterious consequences of the infection.
Dr. A knows that she is obliged to inform Jim, but she feels that in this case it would be wrong to do so.
Informing him would not prevent any harm, but would cause both of her patients significant emotional
discomfort in their last few weeks together.
Has medically relevant info & is legally obligated to expose it…
BUT Jim is about to die!
Therapeutic privilege DOES allow him not to expose
Not as black and white >> not saying how legit therapeutic privilege is
1) Deontological: you're breaking a promise, and thus are not fully respecting the patient's autonomy.
Deontology about rules that you ought to follow >> you can't break a promise
2) Consequentialist: Patients might become less inclined to answer questions truthfully if they suspected
that confidentiality would not be respected. This could then negatively impact their health.
If someone did something they are embarrassed of (druggie, alcoholic, bulimic) >> worried if they answer
truthfully that the doctor will call their parents and that they'll get in all kinds of trouble Professional Relationships 01/23/2013
IF this was the norm, this would affect all diagnoses that go on; the whole thing wouldn't work
“In the 1976 case Tarasoff vs. Regents of the University of California...a young male student, who had been
treated at the University of California for violent and paranoid ideas, told his therapist that he intended to kill
a particular female student. The therapist notified the campus police, who detained the male student but
then released him. Shortly thereafter, he killed the female student. Her family sued the university and the
therapist for failing to take appropriate action.” (36)
Therapist violated confidentiality… But didn't go crazy (i.e. notify the person who was targeted)
“After suffering a back injury at work, Lowell Baxter has completed three weeks of physical therapy. While
unable to work, Lowell has been going three times per week to see therapist Eve Nye who has been
working for three months at a new clinic and is still learning the ropes. After Mr. Baxter's ninth treatment, his
physician, Dr. Felton Cranz, explained that he had made good progress. Lowell no longer needed PT but
was unable to return to his physically demanding job. He continued the home exercise regimen that Ms.
Nye had given him. Dr. Cranz, who was not adverse to ordering additional physical therapy if necessary,
told Lowell to call him if he had any further proble s.
One month later, Mr. Baxter called Dr. Cranz's office and told the nurse that there had been "a flare up" in
his lower back. After talking with the doctor, the nurse called Lowell and told him that Dr. Cranz ordered
another round of PT 3 times per week for 3 weeks that he should begin right away.
During his third session, while telling Eve about his recent activities, Lowell mentioned that he slipped and
fell on a rainy night while coaching his daughter's soccer team. He said that this happened "a couple of
days" before the "flare up". Eve asked if he told his doctor about this latest fall.
Surprised at the question, Lowell replied, "Well, no. Why would I? Anyway, I was having some painful
twinges in my back before I slipped. Besides I fell on the soft grass. I'm sure I didn't hurt myself when I
slipped. Dr. Cranz is always so busy and I don't need to waste his time with this. He told me after I finished
my sessions a month ago that I might need another round of PT anyway. I feel better after our therapy
sessions ….So, how about those Sharks the men in teal?"
When Ms. Nye saw Mr. Baxter on his fifth visit, he complained of increased pain with radiation down his left
leg. During her evaluation, Eve concluded that his pain was different from the pain he experienced after the
first fall and was almost certainly related to the second fall. She explained this to Lowell and suggested to
him that he talk to his doctor to ensure that he received the appropriate treatment. Lowell insisted that he
did not want to bother his doctor with this Professional Relationships 01/23/2013
Now, on his seventh visit, Mr. Baxter is visibly fatigued and shorttempered. He complains of weakness and
numbness in the left leg. Eve strongly encourages him to talk with Dr. Cranz. He adamantly refuses. "Well,
perhaps I should talk with Dr. Cranz for you. I could tell him about your fall at the soccer game and this
onset of numbness and weakness in your leg. You know, Dr. Cranz looks at the notes I write"
"No," blurts Mr. Baxter. "I don't want you to say anything. It's none of your business! This is my injury, and I
don't want to bother him with this. You have to respect my wishes. Your job is to do therapy; not to interfere.
Now, let's get on with it!"
Patient revealed something to her… No one else is being harmed but the patient, Mr. Baxter
"Question: if the patient is an idiot, can you break the confidentiality or not?"
PT's dont always have the same rights/obligations as doctors do… They can't always have the right to
refuse treatment like doctors do
Seems like the patient is only hurting himself
Shows that confidentiality
Might be reasons to violate confidentiality even when the only person who is going to be harmed is the
The Problem: How do cultural differences prevent good health care?
Negative autonomy: the right to refuse any treatment
Positive autonomy: the right to receive any treatment
What sort of doctors do we need?
1) Competent in clinical care
3) Knowledgeable about current research Research on Humans 01/23/2013
A method for engaging in philosophical ethics
Recommends that we adjust our intuitions so that they cohere with our principles, but also suggests that we
sometimes adjust our principles when they conflict with our intuitions.
Neither intuitions nor principles are prioritized.
Nuremberg Code (1946)
Appropriate risk/benefit ratio
Declaration of Helsinki (1964)
Distinction between therapeutic research and nontherapeutic research
An institutional mechanism should be established to ensure that the other principles are being followed
Family members can consent on behalf of children
The Belmont Report 1979
Respect for autonomous agents
1. Voluntary Informed consent
2. Favourable RiskBenefit Ratio
3. Equitable Selection of Subjects
4. Privacy Research on Humans 01/23/2013
Determine the toxicity of the drug (the amount humans can tolerate)
No therapeutic intention
Estimate an optimal dosing regimen.
Determine what you want to show in Phase III
No therapeutic intention
Large number of