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Med Ethics Midterm Review.docx
Med Ethics Midterm Review.docx

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Wilfrid Laurier University
Mary Anne Banks

Unit 1: Medical Ethics I. Arguments i. Conclusions and Reasons
A conclusion is a statement that someone is trying to prove true. We often use words like "claim" and "position" to refer to a conclusion. o Now, a rational person doesn't accept a claim just because someone asserts it: we want to be given reasons for agreeing with a conclusion. o An argument is a set of reasons given in support of a claim.  If an argument works (is sound, or informally, good) then it proves that the conclusion is true. 
The most important point here is simply this: arguments and conclusions are not the same thing! Remember, an argument is the set of reasons given for accepting a conclusion; the conclusion to an argument is what it aims to prove. A conclusion can be true even if an argument is not sound; but if an argument is sound, the conclusion must be true. Again: whether an argument is good and whether a conclusion is true are two different questions. A consequence is that when we look for counter-arguments or responses to arguments for a particular conclusion, it will not do simply to attack the conclusion: it is the argument, the reasons given for accepting the conclusion, that we need to attack. Only if the argument is unsound can the conclusion be false (of course, showing that an argument fails is only half the job: one must still show there is no other argument that will establish the conclusion). Premise 1: Xanthippe is a woman. Premise 2: All dogs have tails. Conclusion: Therefore, Xanthippe has a tail. Clearly, the conclusion doesn't follow-it's a complete non sequitur. Some arguments fail in more subtle ways, of course; the Sorites Fallacy is one which we will see in a few weeks. ii. Reading Arguments For example, if someone says, "Assisted suicide? Soon we'll be leaving our elderly to die in the wilderness!" she has compressed a difficult argument into a very small space. The conclusion is presumably meant to be that assisted suicide should be illegal. o There must be at least two premises: o first, that legalizing assisted suicide will lead to leaving the elderly to die in the wilderness; and o second, that leaving the elderly to die in the wilderness must be avoided. Notice that the second premise seems so obvious to the person making the argument that it is not even mentioned. As usual, we can attack the argument by denying one or both of the premises, or by denying that the conclusion follows even if the premises are true. o Again, note the difference between attacking the argument and attacking the conclusion. One might do the latter by giving reasons why assisted suicide would be a good thing for some people-but this would not show what was wrong (if anything) with the argument given. II. Descriptive vs. Normative claims (or, what we're up to) It is important to distinguish the philosophical enterprise of ethics from the anthropological one of descriptive (or positive) morality. In this course, we will be asking and trying to answer normative questions: questions about what ought to be done, or what is valuable , or what is right. These are not the same as the descriptive questions of what is understood (or believed, or decreed) to be right or valuable. So when we ask "Is abortion moral?" we are not asking whether some group of people (e.g. Canadian society) thinks so, or generally has beliefs that indicate it is so; rather, we are asking what the correct belief is. In the descriptive sense, "Killing the mentally disabled was moral in Nazi Germany" may be true; but in the normative sense it is certainly false: those who did it should not have. o Double binding: study protocol calls for when trial is proposed to all new born babies with hypotension to receive X or Y o Morality vs. ethics o Morality always relevant in medicine o Ethics: systematic critical study of basic underlying principles, values, concepts utilized in thinking about moral life  Moral response:  Expressive level o Unanalyzed expressions or feelings for themselves – mere fact that one feels a certain way about an action or practice  Pre-reflective level o Justification is offered by reference to values, rules, and principles o Norms accepted uncritically o Conventional norms are uncritically accepted and acted upon  Reflective level o Moral judgements are not based entirely on conventional norms blindly accepted but on principles, rules and values to which we ourselves consciously subscribe with regard to which we are prepared to offer reasoned moral defense o Moral perspectives – principles  rules  actions or judgements III. Judgements (and Theories) of Obligation vs. of Value Normative claims and the arguments that support them are the business of ethics. Of course, we can make further distinctions between types of normative claims, and doing so can help us understand the contrast between different ethical theories. In particular, we can make claims about what is good, and we can make claims about what is right. Let us first consider talk about goods. o Judgments of obligation: CONCERN WHAT WE OUGHT TO DO o Judgments of value: not related to action – not about the right thing to do but what about is good or has value o Theory of value: provide us with basic for justifying our judgments of value thus ultimately our judgments of obligation o Deontological theory: teleological theories of obligation that are non-teleological o Deny what teleological assert – deny that we have one and only one fundamental duty which is to max good and min bad in actions i. Intrinsic and Instrumental Goods A good is something that is, for any reason, of value. An evil, in philosophical parlance, is something that, for any reason, is of negative value (or disvalue), or, more colloquially, is bad. Things can be good in some ways and bad in others, but many things are clearly goods or evils on balance, meaning that they are more one than the other. Health, for example, is clearly a good on balance, even though it can have some bad consequences (living long enough to see loved ones die, for example). Money is a good, but why? It isn't, for most of us, something we want for its own sake; we want money because it enables us to get other things that we value. Money is a clear example of an instrumental good: a good that is of value because it aids our pursuit of other goods. Happiness, on the other hand, is an intrinsic good: we value it for its own sake (cp. Thomas and Waluchow, 15). Note that something can be good both intrinsically and instrumentally: happiness, for example, is also good for one's health-it is an instrumental good in that regard. ii. Obligations and Values The text makes a useful distinction between judgements (or theories) of obligation and judgements (or theories) of value (Thomas and Waluchow, 12ff.) o The difference between a judgement and a theory here is just a matter of scope: theories include many particular judgements within them). o Value statements: make claims about what is good or bad, whether intrinsically or instrumentally. o Obligation statements: on the other hand, make claims about what is right, just, obligatory, one's duty, one's right, or what one should or should not do; "these have to do directly with our conduct, with how we should behave" (ibid, 13). Judgements of obligation are guides to action: they make claims that indicate the moral constraints on action. While value statements tell us about what is good or bad, they don't tell us directly what to do about it. So a theory of value tells us what to regard as good; a theory of obligation tells us what to do. The distinction can be confused by the tendency to talk about right or wrong actions as good or bad. To avoid confusion, we should say we do something morally good if we do what we should, and something morally bad if we do something we should not. So calling something good is a claim about value; calling something morally good is a claim about obligation. Similarly, we can talk about morally right actions to distinguish them from right actions in the sense that a test has right answers. Throughout the course, we will tend to simply speak of right and wrong when we mean morally right and morally wrong. iii. Obligations as Universal One of the marks of moral claims is that they are intended universally: saying something is the right thing to do implies that it would be right for anyone in sufficiently similar circumstances. Moral or ethical claims are different from judgements of taste in precisely this way: when I say food is "good", I understand that others may not enjoy it. The universality of moral claims does not mean that the same broad rules apply without variation to all people at all times: moral judgements apply only to sufficiently similar circumstances. It is certainly the case that different responses are right in different contexts (one simple example: if I have promised someone to meet him tonight, then I ought to meet him tonight--but no-one who hasn't made the promise is obligated to do the same). IV. Consequentialism, or Utilitarianism Ethical theories, then, are theories of obligation that involve universal claims. The first such theory to consider is called utilitarianism, or consequentialism (in fact, there are other consequentialist theories, but here we will use consequentialism and utilitarianism interchangeably). This is the view of philosophers like J.S. Mill and Jeremy Bentham. o Monistic teleological theory of obligation which owing to its teleological nature rests on a theory of value o Value can be itself either monistric or pluralistic o Act utilitarianism(AU): rightness or wrongness of individual actions in terms of the good or bad consequences realized by those actions themselves o Defines right and wrong of an action in terms of utility and disutility  Act is right if there is no other action I could have done which would have  A) produced greater balance of utility or disutility  B) produced a smaller balance of disutility over utility o Aids example (pg 21) o Rule utilitarianism(RU): Actions judged according to whether they conform with acceptable rules – only rules themselves are judged in terms of utility o Act is morally right if it conforms with a set of rules whose general observance would maximize utility o Difference of AU and RU: problems with RU: page 26 i. Obligation Depends on Value The distinction between theories of value and of obligation is useful in understanding this ethical stance. For utilitarians, the right thing to do depends only on the (probable) consequences of the action: obligation depends on value (Thomas and Waluchow, 13). According to utilitarianism, or consequentialism, one ought to maximize the amount of whatever is good. If it seems odd to you that there might be a difference between saying something is good and saying it is right, then you may be thinking like a utilitarian. ii. The Utilitarian Theory of Obligation 
Here is a statement of the utilitarian theory: "An act is right if, and only if, there is no other action I could have done instead which would have produced a greater sum of utilities." The word utilities here is a synonym for values and goods. The idea is that if we could measure the value of everything that would result from each possible action, then add up all those utilities (or, if the value is negative, disutilities), then the right thing to do is the choice that results in the largest total. What is right depends for the utilitarian on the utility consequent on each possible action: so we need a theory of value before our obligations are known. The classical utilitarian position is that the only intrinsic good is pleasure (or happiness) and the only intrinsic evil is pain (or suffering). Usually, then, the utilitarian tries to maximize the amount of happiness in the world and minimize the suffering.
 IV. Consequentialism, or Utilitarianism (cont.) iii. Everyone Counts Equally According to the utilitarian, it is crucial that every bit of utility counts equally, no matter how it is distributed (Thomas and Waluchow, 19-20). This means that a given quantity of happiness is valued equally regardless of whose happiness it is. It also means that one common way of expressing the utilitarian theory: "the greatest good for the greatest number" is wrong. What the utilitarian seeks is simply the greatest good. It may be that making one person very happy results in a greater sum of utilities than making several people slightly happy; if so, then it is the former we should choose. Generally, though, choices that impact many people positively are to be preferred because their resulting aggregate (sum) happiness is very large. IV. Consequentialism, or Utilitarianism (cont.) iv. Problems with Utilitarianism o Ignores the moral weight of certain relationships and commitments (Thomas and Waluchow, 20-21). A promise, most people feel, ought to be kept at least partly because it is a promise. o The utilitarian recognizes no such moral weight: the only reason to keep a promise is because breaking it will tend to have bad consequences (The Desert Island Promise scenario, in Thomas and Waluchow, 22-23, is intended to illustrate this problem). –(giving money to younger child because he needs it for research) But doesn't the promise have a moral weight independent of its good consequences? This suggests that a theory of obligation based only on consequences is not good enough. Utilitarians, of course, can simply deny our premise: promises, they will say, do not have the kind of independent moral importance we claim. o scapegoat problem in introducing rule utilitarianism (Thomas and Waluchow, 24-25. We will not explicitly consider rule utilitarianism in this course). The problem here is that by consequentialist reasoning, it seems we ought to do something terrible to an innocent person if it will prevent the suffering of many others. Some interpret this as showing that utilitarianism lacks any notion of justice. Justice, one would think, would prohibit the punishment of innocent people. o Sneaky people who can benefit by "gaming the system" should do so, provided the system still works well enough that others aren't harmed (Thomas and Waluchow, 23-24). This kind of behaviour is called taking a "free ride". Most people find it morally objectionable, but the utilitarian seems to have to say that it is morally required! Many, perhaps all, of these objections can be answered by appeal to indirect consequences: there are disutilities incurred by breaking promises, free-riding, and scapegoating, that the above analyses haven't considered. In general, such unjust actions will tend to undermine the overall level of trust, and thus happiness, in a society. This very broad effect may be sufficient to outweigh the more immediate benefits. I. Strong Deontology i. Obligation is Unrelated to Value
 o The strongest form of deontology is Kant's theory, which claims that our obligations have nothing to do with the consequences of our actions (as is often the case, "strongest" here doesn't mean "best"; it refers to the fact that Kant's is the most extreme version). Kant gives a definition of right action that we are supposed to follow even if it will cause bad things to happen. What is important, according to Kant, is doing one's duty, not what results. So, for utilitarians, our obligation is to maximize utility; for Kant, our obligation has nothing to do with utility. I. Strong Deontology (cont.) ii. The "Maxim of an Action"
Kant calls his definition of duty the categorical imperative, meaning a command that admits of no exceptions. To understand the categorical imperative, we need to understand what a maxim of action is. The maxim of an action is the statement someone might give about why they are doing something; it is "a general rule or principle which specifies what it is I conceive myself as doing and my reason for doing it." (Thomas and Waluchow, 28). It isn't always perfectly clear what someone's maxim is for a given action, which can make it difficult to apply Kant's theory. 
By way of illustration, let us try to identify maxims in following cases: • Since I promised to return the book today, I'll return it today. This one is straightforward. The maxim would be: "Do what I promised." • I'm bored, so I'll call a friend. The maxim seems to be something like this: "Phone a friend in order to ease my boredom." But it depends what we are assuming; if this is a friend that can't say no, the maxim might be: "Force someone to do something if it will make me feel better." • The only way to get into this party is to lie, so I'll lie. Here, the maxim would be something like, "Lie if doing so will make someone believe something that I want them to believe." • I don't want this patient to be an addict, so I'll take away her cigarettes. o The maxim here might be, "Force someone to do something if it satisfies your goal of benefiting her." iii. Categorical Imperative I and Universalization o We now have some notion of what a maxim of action is; now let us see what use Kant puts them to. As we have seen, it is a characteristic of moral judgements that they apply not just to the person in question, but to any similar situation. Thus, according to Kant, we can only be acting morally if it is our intention that our maxim be universalized: if we intend it to apply always and everywhere. This produces one version of Kant's rule for action... I. Strong Deontology (cont.) Categorical Imperative I: Act such that you can at the same time wish your maxim to be universal.
This is a paraphrase of Kant's own formulation, given in the text (Thomas and Waluchow, 29). To universalize a maxim, any references to particular people, times, places, etc. have to be removed; you can think of this as a rule against partiality, such that no one gets an exception just because it is convenient. Kant's test, then, is to see whether the universalized version of your maxim is compatible with your intention in performing the particular action: can you want to do what you're doing and want everyone to do the same? Another way of putting this: can you reasonably want your maxim to become a law of nature, so that the world always works that way? (ibid)
Let us return to our examples from above, and see if the maxims we found can be universalized. • I'm bored, so I'll call a friend. If the maxim is "phone a friend to ease my boredom," we don't seem to have a problem: the universal version would be "Everyone may phone a friend when bored." This is quite compatible with me doing it now.
On the other hand, if the maxim is "force someone to do something if it will make me feel better," then the universalized version, "everyone may force others to do things if it will make the actor feel better" seems to be in conflict with itself: if my friend doesn't want to talk, then the universal rule says he can force me not to talk, and I can force him to let me. I can't want both of those things at once, so my intention--that I get my way, but he doesn't get his--is not moral. In general, the categorical imperative seems to rule out the use of force, since force is inherently partial; i.e., in most cases someone who attacks another is intending to gain an advantage for himself; an advantage this aggressor would not want to grant to others. Such attempts at selfish advantage are just the kind of thing that cannot be universalized. • The only way to get into this party is to lie, so I'll lie. Here, the universalized maxim seems in conflict with the particular one: I want to get my way by lying, i.e. to convince someone of something by saying untrue words. But if everyone behaved that way always, there would be no reason to believe any words spoken, and so my words would not have the effect I want. I can't want both to lie successfully when convenient and for everyone to lie when convenient, so my action is not according to duty (compare Kant's own example, Thomas and Waluchow, 30). • I don't want this patient to be an addict, so I'll take away her cigarettes. Even though it is my aim to benefit the patient, according to Kant's logic this one seems to work out just like the use of force for selfish reasons. If my aim is to achieve my goal by force, then I must intend others (including the patient) to achieve their aims as well, although those aims conflict with mine; and so the maxim cannot be consistently universalized. iv. Categorical Imperative II
The last example above suggests another version of the categorical imperative, one that is often more useful in practice. I cannot want to impose my goals on others and want them to impose their goals on me; so I cannot morally aim to impose my goals on others. This seems to be roughly the connection between Kant's first version of the categorical imperative and his second... Categorical Imperative II: Never treat a person as a mere means to an end Keep in mind that there is only one categorical imperative; Kant's claim is that it can be stated in these two different ways. Many philosophers, we should note, are not convinced that the two are really equivalent. In any case, this version tells us that we cannot use people: we have to let them decide for themselves what they will do (Thomas and Waluchow, 31-32). I can ask someone to do something for me (or for herself!), even give reasons why she should, but it is up to each person to choose. o The phrasing of the last sentence was not accidental: the term person has a particular importance for Kant, and for ethical theory more generally. For Kant, a "person" is any rational, self-directed being. There could be persons who aren't human (intelligent aliens, for example), and there could be humans who aren't persons (controversially, humans in a persistent vegetative state). It is persons that are protected by Kant's categorical imperative. One of the central concepts of medical ethics is embodied in Kant's second version of the categorical imperative: autonomy. This term comes from the Greek: auto-, meaning "self", and nomos, meaning "law". So autonomy is, most literally, self-law. The metaphor here is a political one: instead of being ruled by some outside force, we should each rule ourselves. Philosophers differ over what exactly counts as autonomy, but in general it is more than just freedom from coercion. It implies the ability to decide and act based on one's own reasons (cp. Thomas and Waluchow, 32). o Autonomy, then, is closely related to freedom, but is not the same as freedom in the simplest sense. Someone who has carefully thought through a decision, who is well-informed, and who is under no threats or other pressure, is presumably acting autonomously. But someone who makes a decision simply because, for example, they have been taught that they ought to, is not autonomous according to Kant. Pink Floyd fans might recall the line from Welcome To The Machine: "It's alright, we told you what to dream." A person whose goals have been set by others may make choices, but they are not autonomous choices. Ideally, from a Kantian perspective, our goals and values as well as our decisions should be, in some sense, our own. Achieving this kind of full autonomy must surely require that we critically evaluate our most basic values and beliefs to ensure that they are not simply "borrowed" from our parents, our friends, or our society. This, it happens, is precisely the goal of philosophy as it challenges and questions. In the end, the point of philosophical arguments, some would say, is not to win: it is to become more free . On the surface, arguments aim to convince, but we should not forget that it is even more important to be changed by them, to learn more about and perhaps modify the values that motivate us. Without this process of critically examining our beliefs, we may be just playing out someone else's ideas: we might say that we aren't really living our own lives. It is likely for this reason that Socrates, speaking at the beginning of the history of philosophy, famously said, "The unexamined life is not worth living." v. Problems with Kant's Theory We saw that utilitarianism faces some challenges; Kant's theory does too. We'll consider three here. First, Categorical Imperative I is unclear. We saw above, in the case of the bored telephone call, that the way we describe the maxim could make that same action either moral or not-so how do we know just what the actual maxim is? Kant does not give us much guidance here, so applying his rather abstract principle is very difficult in practice. Second, Categorical Imperative II is not obviously equivalent to Categorical Imperative I. The second version of the categorical imperative, enjoining us to respect autonomy, to not treat people as ends, is often more clearly applicable to real ethical problems. But it isn't certain that the two versions always agree. So if they give different prescriptions, which are we to follow? Third, and perhaps most seriously, Kant's theory has been criticised for its rigidity. It is a system that admits of no exceptions; Kant believed we should do justice even if the world will be destroyed by it. According to Kant, for example, lying is always a violation of one's duty, no matter how bad the consequences of telling the truth (Thomas and Waluchow, 34). One cannot lie even to save the world from utter destruction. One cannot break a minor promise to save a life. To most people, this seems too extreme. We have gone from a utilitarian account that ignores the independent moral weight of truth-telling and promises, to a deontological account that seems to overemphasize it. vi. Autonomy in Utilitarianism Before turning to pluralism, we should note that while autonomy plays a central and explicit role in deontology, it can also figure prominently in utilitarian moral theories. J.S. Mill, the classic defender of utilitarianism, also spoke eloquently of the importance of finding and following one's own life path. Why? Because only by doing so can one achieve the most valuable kind of life; plus, interference with autonomy tends to make people feel oppressed and unhappy. So while utilitarians might not accord independent weight to autonomy, they generally recognize that it has, at the least, enormous instrumental value. II. Weak Deontology, or Pluralism We turn now to a theory that attempts to reconcile the extremes of utilitarianism and strong deontology. This middle ground is attractive, but we will see that it has problems of its own. i. Prima Facie Duties and Actual Duties
To take a middle path between strict consequentialism and strict non- consequentialism, Ross suggests that we have a number of independent duties: we should, among other things, try to maximize utility and try to respect autonomy. Now, inevitably, there will be times when these duties come into conflict, as when we must break a promise to save a life. According to Ross, we must then weigh the conflicting duties and do what the more serious duty in that situation demands (Thomas and Waluchow, 34). The duties that are weighed against one another are called prima facie duties (roughly translated, "on the face of it"). A prima facie duty may conflict with other prima facie duties, in which case some of them will be overridden. The prima facie duty that, in a given situation, outweighs the others is one's actual duty. In analyzing a situation in Ross' style, then, we first look for the prima facie duties:the duties that various actors would have, all else being equal. We then note where they conflict with one another, and use our moral intuition to work out which is most important; this is the actor's actual duty (or, simply "duty"). ii. Problems with Pluralism While it is intuitively plausible that we have a number of basic duties, pluralism has at least two serious difficulties. The first could be called the "apples to oranges problem": Ross has no principled explanation of how we are to compare prima facie duties (ibid, 36). What is more important, telling the truth or preventing harm? Keeping a promise or treating people fairly? It often seems as though these various duties are incommensurable, as though there is no common scale on which to compare them. It's like comparing apples to oranges. As the text points out, utilitarians may at this point offer to help: if two prima facie duties conflict, they might suggest, the one that most promotes utility is the actual duty (ibid, 37). But this simply turns pluralism back into utilitarianism. In fact, all of Ross' prima facie duties can be justified on utilitarian grounds, since they will tend to promote happiness. So there is some worry that Ross hasn't made any real progress here over utilitarianism III. Feminist Ethics We turn now to feminist theory. It can be confusing to try to understand just what a feminist ethical theory is. Unlike utilitarianism or deontology, there is no core example of a feminist theory to turn to. In fact, it is probably better to think in terms of the kinds of questions feminists ask and the kind of issues to which they draw our attention. The guiding idea of most feminist theorizing is that male-dominated societies have developed theoretical blind spots: important areas of reality that tend to be overlooked or minimized. The main role of feminist concepts in theoretical work is to draw our attention to these blind spots, and to sharpen our sensitivity to biases that tend to tell against women and other oppressed groups. We will focus here on three such concepts. i. Androcentrism Little points out that the standard conception of human (or person) has typically been male (29a). Women must then be seen as the exception, as deviant. In particular, women come to be defined by their differences from "regular people"; the most salient characteristic of a woman may come to be seen as her reproductive capacity, her ability to nurture children, or her physical beauty (ibid, 30b-31a). Little doesn't mean to say these things are unimportant, but that it is a very narrow view that takes them to be all that counts. In medical practice, androcentrism, this assumption that the male is the standard human, has led to dramatic under-representation of women in research (ibid, 30b). ii. Gendered Concepts Little claims that much thinking is based on gendered concepts (33a). She uses this term to refer to the set of dualisms by which we tend to order our world: male/female, reason/emotion, active/passive, etc. In each case, the term in the pair that is associated with the feminine tends to be regarded as less valuable (ibid, 33b). In ethics, a consequence has been the omission of emotion from most discussions (34a-b), as well as a focus on the public, impersonal, "juridical" world (traditionally male) as opposed to the private, personal, domestic world (traditionally female) (ibid, 35b-36a). Little suggests that this has influenced the models we use to think through ethical situations. Another value that has been largely overlooked in medical ethics, perhaps due to the impersonal focus, is caring (ibid, 35b). iii. Contexts of Power 
While Little focuses on the theoretical ramifications of gender, many feminists take a very practical and political stance. Ethical decisions do not happen, as often seems to be the case in textbook examples, in a vacuum-rather, they take place in the midst of societies rife with oppression in various forms (Thomas and Waluchow, 47-48). Attention to these contexts of power may be vital to making the right decisions. For example, consent to be part of an experiment might need to be treated very carefully if the subjects are a group with little power in general. It is this concern with power relations that causes many feminists to both value and question the ideal of autonomy. On the one hand, respect for autonomy is something women have often been denied. On the other hand, the classic Kantian conception of autonomy tends to treat humans as completely independent from one another, and may thus lead us to ignore contexts of power (the Sherwin article in Unit II discusses this tension further). I. Three Principles of Medical Ethics In their article, Faden et al offer three moral principles that apply to most issues in medical ethics. These are principles we should keep well in mind throughout the course. Notice that the authors take a pluralistic approach, at least on the surface (Faden et al, 10b ff.). Whatever the ultimate correct ethical theory, we can treat these principles as having prima facie status; we will see that many problems in medical ethics revolve around a conflict between two or more of them. i. Respect for Autonomy
 The first principle is respect for autonomy (ibid, 5b-6b). We have already seen this idea in our discussion of Kant, specifically the second version of the Categorical Imperative. Note that for a pluralist, autonomy is not absolute, but "the burden of moral justification rests on those who would restrict or prevent a person's exercise of autonomy" (ibid, 6b). In general, autonomy in medical ethics is associated with informed consent, which is the main topic of Unit II. ii. Beneficence i. The second principle is beneficence, which means "doing good" (ibid, 6b ff.). Just as respect for autonomy is Kantian in tone, the principle of beneficence has clear utilitarian roots. In medicine, it has a long history-longer than autonomy, since not too long ago doctors were expected to do what they judged was best, regardless of their patients' wishes. ii. Justice 
 The third and final principle is justice. As the authors indicate, this term can be confusing (ibid, 9b). Sometimes, philosophers use "justice" to refer to moral action in general. But the sense in which it is a distinct principle has to do with distribution (something that neither Kant nor the utilitarians consider directly). How should goods and evils be distributed among people? Should we all have more similar incomes, for example? Should morally good people be rewarded? On what other bases should goods be allocated? In medical ethics, justice may come into conflict with beneficence in allocation decisions: the most efficient way to arrange things may not be the fairest (ibid, 10a). II. Three Kinds of Medical Ethics Issues It can be useful to have a way to classify issues as you encounter them; here is one way to do this for medical ethics. Most (but not all) issues in medical ethics have to do either with autonomy or with allocation of resources. When it comes to autonomy, questions can be either about when we can do something against a patient's wishes, or when we cannot do something even though a patient wishes it. This gives us three categories of issues. First, there are issues of autonomy and informed consent. Here, we meet questions about what must be done to protect autonomy, and when, if ever, respect for autonomy may be outweighed by beneficence. These issues arise, for example, when subjects are asked to consent to research, or when it seems best to force treatment on a patient. Second, there are issues of the limits to medicine: what may medicine not do, even with consent? Highly controversial topics like abortion and euthanasia fall under this heading. Third, there are allocation issues, which in turn divide into two categories. There are micro-allocation questions, dealing with who should get access to scarce resources like organ transplants, intensive care beds, and new treatments; and there are macro-allocation questions, dealing with how much funding should be made available, from where, and for what programs. In this course, Unit II deals with issues of autonomy and informed consent, Modules A and B deal with limits to medicine, and Module C deals with allocation. III. Metaphors and Analogies in Ethical Reasoning While we have so far focused on ethical theories and principles that are useful in medical ethics, we now turn to a look at how philosophy is written. The more sensitive we are to the ways in which arguments are made and ideas stated, the more accurate and focused will be our responses. To this end, let us look at how philosophers, medical ethicists in particular, use metaphors and analogies. i. Metaphor
It is very difficult to get far in philosophy without the help of metaphors (did you notice the metaphor in this sentence? "Getting far" is what is called a dead metaphor because it has become so much a part of regular speech that it appears literal. Philosophers make use both of dead metaphors and of more original ones). The ideas we grapple with often do not literally correspond to anything in our experience, so we can only get at them by means of metaphor. It may be that many metaphors can be "cashed out" in more literal terms (would philosophical writing be improved or impoverished if they were?), but as Childress argues, metaphors are more than just figurative ways of saying things. They highlight and hide features of the things we apply them to (Childress, 15a). Our choice of metaphor can act as a lens that sharpens or distorts our view. Metaphors can also be generative, in that they may lead us to insights or new ways of conceiving a problem (ibid, 22a-b). Childress' discussion of some of the metaphors of medical ethics is worth a careful read; this article is very useful for sharpening your perception when reading philosophy. ii. Argument from Analogy Childress also discusses analogies, particularly their use in making arguments (ibid, 23a). An argument from analogy is a particular form of reasoning that looks, in the abstract, like this: Premise 1: A and B are similar in certain respects (X, Y, ...). Premise 2: We treat A in a certain way. Conclusion: We should treat B in the same way. For example, one might argue that paying to have a medical test performed quickly is like butting in line, in that it puts the payer ahead of people who have been waiting longer; we regard butting in line as rude and wrong, so we should not allow paying to jump a waiting list for medical testing either. (Consider: how convincing is this argument?). An argument from analogy, then, points out a "repetition of the same fundamental pattern in two different contexts" (ibid), and concludes that these similar cases should be treated similarly. As we saw in lesson 1, universality is a characteristic of ethics: it is moral to treat similar things in similar ways, and different things in different ways. Thus, arguments from analogy make a good deal of sense in ethical reasoning. i. But finding an analogy does not often settle the issue. As Childress says, "Much...debate hinges on...which similarities and differences are both relevant and significant" (ibid). After all, an analogy always compares two things that are different, so no analogy is perfect. We can always find differences, or disanalogies. What matters is whether these differences are morally relevant. For example, you wouldn't want yourself to be thrown in jail for no reason; I'm like you in that I'm a (more or less) law-abiding adult; so I shouldn't be locked up for no reason either. Someone might object to this argument from analogy by saying that I'm not like you after all, since my hair is a different colour, for example. But clearly, this difference is beside the point; it isn't morally relevant (if I had committed a terrible crime in the past, that would be a morally relevant difference). When we encounter analogical arguments in medical ethics, then, we should be alert to whether there are any differences that might matter morally. I. Models for Medical Relationships How should a doctor or nurse interact with patients? What is at stake here is not just good bedside manner, but ensuring that both the patient's autonomy and the patient's well-being are respected. There are many models for both the physician-patient relationship and nurse-patient relationship. See the chart (Storch, 200) for a good visual summary of the models. As you can see nurses and physicians are thought to have different kinds of relationships with their patients, often with the physician thought to have the role of deciding appropriate treatment, and the nurse acting in a supporting role. Below is a brief discussion of the nurse-patient relationship as described by Storch. Paternalistic
Paternalism is a key concept in medical ethics. It is the name for a specific kind of violation of autonomy: we act paternalistically when we override someone's autonomy for his or her own good. Using someone for selfish gain is not paternalistic; forcing someone to do what we judge is best for her is. Generally, paternalism betrays a lack of respect for rational, capable, adult persons; it amounts to treating them
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