Ethics Flashcards
What is ethics
The science of moral decision making
Moral theories
Virtue ethics
Duty ethics
Consequentialism (utilitarianism)
Virtue ethics
Balance between the extremes (the mean)
Perception of ‘the good’ related to human flourishing
Duty ethics
Morality is a matter of adhering to fixed standards, of performing duties
Categorical imperative
People as ends, never just means
Categorical imperative
‘Act only according to that maxim whereby you can, at the same time, will that it become a universal law’
Who founded virtue ethics
Aristotle (384-322 BCE)
Who founded duty ethics
Immanuel Kant (1724 – 1804)
Consequentialism
Outcomes are what matter
Promote ‘greatest happiness for the greatest number’
No absolute prohibitions
Ends justify the mean
Who founded consequentialism
John Stuart Mill (1806 - 1873)
4 principles of ethics
Autonomy
Non-maleficence
Beneficence
Justice
Autonomy
Self-rule: the capacity to make reasoned decisions and act on them; recognising patients as people
Non-maleficence
First do not harm
Beneficence
Make the care of your patient your first concern)
Justice
Fairness, respect for rights)
Hypothesis
Believed to be true subject to empirical falsification or verification
Value judgement
Held to be true but empirical evidence/ inference cannot establish truth or falsity
Origin of values
Thick concepts
Thin concepts
Thick concepts
Descriptive + normative
‘rude, kind, sympathetic, violent’
Thin concepts
Moral judgement over facts
‘good, bad, right, wrong’
When is an argument valid
If the premises are true then the conclusion MUST be true
Does a valid argument need a true conclusion
No
Truth preservation
From true premises to a true conclusion
Fallacious reasoning
- A beautiful garden always includes a water feature
- My next-door neighbour’s garden has a water feature
- Therefore my nest-door neighbour’s garden is beautiful
Premises are true but conc false
GMC on values
Work in partnership w/ patients
Listen to, and respond to, their concerns and preferences
Give patients the info they want or need in a way they can understand
Respect patients’ right to reach decisions with you about the treatment and care
What do clinicians tend to significantly underestimate
Patient’s willingness to undergo toxic treatments to improve length/quality of life
Desire of patients to have full info even if they don’t act on it – or even believe it!
What does respect for autonomy in medicine entail
Providing accurate, truthful info
Facilitating informed consent
Maintaining confidentiality
Mill’s Harm Principles
“…the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others …over himself, over his own body and mind, the individual is sovereign”
Why is confidentiality important
Pt’s interest in taking control of their life – incl decisions about who should access personal info
Implied promise
Is autonomy and confidentiality absolute
No, may be overridden by other concerns
Confidentiality and duty
Duty based ethics:
Dr/ pt. relationship viewed as a contract
Confidentiality an implicit part of this contract
Breach of confidentiality involves the violation of terms of contract
Breach of confidentiality is a transgression against the integrity of the relationship
Important things to consider with confidentiality
Nature of ship
Some types of info deemed intrinsically personal, therefore implicitly confidential (social standards)
Motivations for sharing info
Malicious intent (incl gossip)
Benefit to an individual e.g pt, or their family
Benefitting someone else or the wider public
Attributes of the virtuous medic
Reliability Trustworthiness Professionalism Integrity Honestly Beneficence, non-maleficence
Non-maleficence and confidentiality
Harm may result from divulging personal info
Loss of personal trust in that Dr
May spread to general distrust of medical profession – pt. may undermine trust of other pt.
Anger/ distress to pt.
Sources of duty of confidentiality
English law recognises a breach of confidence. Derived from:
- Common law
- Statute: Human Rights Act 1998 – Article 8 v Article 10, Data Protection Act/ GDPR
GMC and DOH guidance
Terms of employment
Common law and confidentiality cases
Hunter v Mann [1974]
AG v guardian Newspapers No2 [1990]
Campbell v Mirror Group Newspapers [2004]
Human Rights Act 1998 - Article 8
- Everyone has the right to respect for his private and family life his home and his correspondence
- There shall be no interferences by a public authority with this right expect as is in accordance with the law and is necessary in the interest of national security, public safety …. For prevention of disorder or crime, for protection of health or morals
When can you disclose confidential info
Consent of the pt. (implied or expressed) Another member of the healthcare team In the pt.’s best interest Required by law Legislation/ statute Court order/ court proceedings Public interest W v Edgell [1990] X v Y [1998]
Disclosure in the public interest
Pt’s fitness to drive and reporting concerns to the DVLA or DVA
Reporting gunshot and knife wounds
Disclosing info about serious communicable diseases
The police and public interest disclosures
Dr’s can disclose info to police for detection or prevention of serious crime and in the interests of national security Serious crime (assault, robbery, murder) Police must make a Section 29 request
What does DOH say on disposing confidential info
Murder, manslaughter, rape, treason, kidnapping, child abuse or other cases where individuals have suffered serious harm may warrant breaching confidence
A knife attack may be sufficient to justify a public interest disclosure of confidential info even where consent is not given, where it likely to assist on the prevention and detections of a serious crime
Achieving reflective equilibrium
Critical application of moral theories & principles
Identify conflicts
Recognise and question initial assumptions
Consider counterargument
Arrive at a conclusion supported by reasons
Where are animals used in research
Universities and medical schools
Commercial organisations
Charities
Government (incl departments, NHS, public bodies, public health labs)
What are animals used in research
Creation and breeding of genetically modified animals (mainly mice) Basic research (how it works) Regulatory testing Research that translates animal-human Protection of natural environment Preservation of animal species
Species used in biomedical research
Mice Fish Rats Birds ‘Specially protected’ species (cats, dogs, horses and primates)
Moral question of using animals in research
Moral value of animals vs value of research + moral value of humans and human wellbeing
Does (potential) benefit to humans justify causing harm and suffering of non-human animals?
Necessity argument for using animals in research
In-vitro or in-silico investigations simply cannot replicate the function of complex living systems
Comparative moral value argument
Human wellbeing is paramount, and it is even less morally acceptable to experiment on humans
Animal v human subjects for research
Paying research subjects risks selecting for the neediest, vulnerable groups (economic coercion)
Many do regard people as having more moral work than other animals
BUT should we trade lives, pain and suffering for human knowledge? However altruistic the aim?
Principles put in place by Animal Welfare Ethical Review Board (AWERBS)
Replacement
Reduction
Refinement - bredding, accom and care, methods mand procedures used
Factors for consideration for vivisection
How important is the possible result (cancer vs eczema)?
How likely is it
Possible benefit vs certain harm
Act certainty v omission possibility: animals will surely suffer by the act, human might suffer without the research
What % of drugs shown dafe and effective in animal,als fail human trials
92%
Tuskegee Syphilis experiment
1932 -1972, US
399 AA men w/ untreated syphilis monitored for 40 years
Told only that they would be getting free medical care
Not told of their dx – given placebos rather than treatment
HeLa cell line
AA woman’s cancer cells grown in culture
An ‘immortal’ human cell line
Consent from her or her family never sought
Total mass of HeLa cells > 50 million tonnes
Still in use today
Nazi experiments on prisoners
Nazis claimed not to see some people as fully human but still used for medical research
Denial of humanity Indifference to suffering
Some experimental results still in use today
The Nuremberg Code
Ethical guidelines to ensure that medics never again participate in atrocities
Forerunner of ‘four pillars’ approach
Enshrines (first rule) voluntary consent of the subject
Not officially adopted in any jurisdiction
Five “rules” of ethical (human) research
Not transferable to non-human subjects
- Obtain informed consent
- Minimise risk of harm to ppts
- Protect anonymity and confidentiality
- Be transparent to subjects (avoid deception)
- Respect ppt right to withdraw
When did the UK lose their ‘Measles Free’ status
2019
Cases and deaths of measles in 2018
353, 236 cases worldwide
Although most deaths have been in developing world, 72 children died in Europe
Pro-compulsion - vaccines
Beneficence – good for the individual
Utilitarian – “herd immunity” (60-70%) leads to general reduction in suffering
Non maleficence – unvaccinated individuals are at risk of harm
Justice – compromising herd immunity by refusing to be vaccinated or to vaccinate one’s own child is not fair to others
Con compulsion - vaccines
Autonomy – individuals right to choose or parent’ right to make treatment decisions for their children
Fear of “other kinds of harm”
Distrust of medical profession
Distrust of ‘big pharma’
Vehemence (sometime violent) of some anti-vaxxers
Wakefield scandal
1998 – paper linking MMR vaccine with conditions incl autism published
2004 – co-authors withdraw support
2010 – Wakefield struck off
2010 – present: Wakefield stands by conclusions
Public health v individual liberty - vaccination
Measles vaccination target for herd immunity 95% (WHO)
Threshold for COVID-19 not known (WHO)
Should the state override the pt.’s or parents’ decisions?
Is the state entitling to restrict individual liberties to protect the group?
Hard problems of a parent - vaccination
Harm vs Benefit – will the vaccine benefit my child
Will it harm my child (e.g., MMR “controversy”)?
Knowledge vs belief – “do you know that the vaccine is safe?”
Individual vs population vs pt autonomy – “why should I put my child at risk for the sake of this ‘herd immunity’?”
Autonomy and parental rights
Parenthood needs imply and absolute right to choose for children
Questioning autonomy when it comes to vaccination
Can parents choose to risk harm to their own children
Is it morally permissible to override parental autonomy if their actions harm their children or others?
Is a failure to vaccinate a child ‘harm’ in the same category as abuse or neglect?
Consistency – should we override parents’ decisions about education? Or religion? Food?
From a parent’s, what is risking possible harm by omission different from
Causing (albeit unlikely) harm by a +ve arc
Trust and knowledge - vaccination
How can one prove that something is safe – or establish relative risk?
How do we know that journals, clinical trails are reliable - Wakefield
Do Dr’s always tell truth - Harold Shipman
Do policymakers always tell the truth?
Do doctors/ policymakers always know the truth?
Vaccine ‘passports’
Certificate to permit access to some venues or transport etc
Refusal to admit those without a passport
Issues with vaccine passports
Not everybody can be vaccinated
Might lead to some “collateral damage”
- Alienation from health services and professions
- Discrimination against groups or those refusing vaccination
- Some might feel compelled to get vaccinated
Reasons for mandatory childhood vaccination
Herd immunity more important than individual freedom
Good for community
Good for individual child
Concerns against vaccines irrational/ ignorant
Reasons against mandatory childhood vaccinations
Individual freedom is more important than herd immunity
Right not to vaccinate on a par with other civil liberties
Bad for child if there if there are real worries related to vaccines
Who founded consequentialism ethics
John Stuart Mill
When is an action right according to virtue ethics
If, and only if, it is what a virtuous agent would do in the circumstances
When is an action right according to duty (deontological) ethics
If, and only if, it is in accord with a moral rule or principle
When is an action right, according to consequentialism ethics
If, and only if, it promotes the best consequences
Paternalism
A decision made for the sake of someone’s best interests, against their will
Soft/ weak paternalism
Situations where a pr’s capacity and understanding of a situation are not known
E.g. in emergency situations
Hard/ strong paternalism
A pt’s wishes are ignored even though they have relevant facts and capacity
