Weeks 6-9 Flashcards
Why do we Conduct Research
Research involving humans is based on a fundamental moral commitment to advancing human wellbeing, knowledge, and understanding to examine cultural dynamics
3 Purposes of Research Ethics
- Correct past problems and abuses
- Prevent new problems and abuses
- Law is not enough
Which 2 major past atrocities lead to the advancement of healthcare ethics?
- Nazi science
- Tuskegee Institute (Alabama)
- study the untreated syphilis patient from the beginning of the disease to the death of the infected person
- no informed consent
- risky & inhumane treatment
- study the untreated syphilis patient from the beginning of the disease to the death of the infected person
Declaration of Helsinki (1964)
- physician and treatment focused
- the World Medical Association established recommendations guiding doctors to protect the rights of research participants
Therapy vs Research
Patient vs research subject
Patient is treated, research subject is used to find outcome
- As a patient, your consent should be respected
- As a research subject, your consent must be scrutinized and (in the right cases must) be rejected
Right to Standard of Care (Declaration of Helsinki Amended in 1996)
Every patient including those of a control group, should be assured of the best proven diagnostic and therapeutic method
Do not expose them to tremendous risk
Right to Standard of Care (Declaration of Helsinki Amended in 1996)
Every patient including those of a control group, should be assured of the best proven diagnostic and therapeutic method
Do not expose them to tremendous risk
TPS (Tri-Council Policy Statement) - AKA “Tri-Council Code”
Joint policy expresses the continuing commitment of the three Councils to the people of Canada, to promote the ethical conduct of research involving human subjects
Tri-Council Code 4 basic principles
- Respect for persons - actively respect patients autonomy
- Non-maleficence
- Beneficence
- Justice
9 Guiding ethical principles
Human dignity
Free and informed consent
Vulnerable persons
Privacy and confidentiality
Jhusticeand inclusiveness
Balancing harms and benefits
Non-maleficence
Minimizing harm
Maximizing benefits
Researchers responsibilities
The researcher is obligated to examine your consent for hidden reasons
If one becomes apparent, the researcher should refuse you
Your consent to experimentation is not the same as it is for medical treatment
Coercion
Expectation of favour - reference for parole, example of good behaviour coincides with treatment
Vulnerable populations
Groups who have structural/systemic vulnerability to the powerful who may want to research using them
Why are vulnerable populations more susceptible to influence/coercion?
- Institutionalized disparity of power
- An inability to respect their own interests
Inducement
Reward received , but ultimately your choice
ex. something, a gift, a reward etc
- Seems irresistible
- Inducement causes taking unusual risk
- the risk- taking creates unethical or risky situations
Coercion vs. Inducement
Coercion = Forcibly, against your will
Inducement = offering someone a reward, to persuade them to make a certain choice (ultimately your choice)
Characteristics of valid informed consent
Potential participants should understand the…. risks, potential benefits, procedures, and alternatives
3 facts participants must understand
1) research contribution - those who enroll in the study will be contributing to a project designed to gather generalizable knowledge to benefit others in the future
2) research relationship - the investigators will rely on participants’ efforts to gather the generalizable knowledge to benefit others
3) research impact - the extent to which participating in the study will alter what participants do and what happens to them
Purposes of Informed Consent
The requirement for informed consent allows competent individuals to decide whether participation in research is consistent with their interests
- allows individuals to decide for themselves whether they will enroll in the study in question
Speciesism
The unequal and unjust treatment or consideration of individuals who are not part of a particular species without valid justification.
3 reasons why Speciesism needs to be refined
- Speciesism can discriminate against those who do not belong to a single species
- Speciesism is exclusion-oriented
- it only focuses on discrimination against non-favored species and does not include discrimination against disregarded species
- The concept of species is difficult to define
Lappé’s Protein Theory
Her central thesis in the book is presented as dietary advice but also has a strong moral tone to it
Protein Theory
1. Scarcity of food in the world
2. Animals are fed excessive protein in order to grow meat protein
3. Humans don’t need to eat animal protein to be healthy
Conclusion: eating animals is short-sighted, ultimately harmful to us and others
How much meat do we consume on average ?
Chicken 30.6 kgs
Beef 30 kg
Pork 28.1 kgs
Turkey 4.3kg
Veal 1.1kgs
Lamb 1.0 kgs
96.8 kgs of meat per person per year
Is meat more popular now or in the past?
Meat is more popular now than ever - since 1972 chicken consumption has increased 84% and everything else has stayed the same
Ecological impacts of animal farming
- Overpopulation of cattle and methane expulsions effect the ozone
- Fecal run off into water supplies
- Grazing lands for cattle causing permanent damage to land surfaces (we can’t grow anything else on that land, even after the beef farm disappears)
Benefits of organic farming
- Limits exposure to pesticides and anti-biotic resistant bacteria
- Limits exposure to chemicals - better for health
“Inhumane” Conditions in “Factory Farming?”
- Production of animal products
- Treatment of animals in factory farms
- High density farms
Trying to save money and being efficient = inhumane animal treatment
What does factory farming often lead to?
A lot of animals in one place - worries about animal diseases
The emergence of Zoonotic Infections - SARS, bird flu, etc
Pathogens exposed to humans from animals
Peter Singer theory
- Believes that “personhood” could include higher-order mammals but also exclude some disabled or damaged humans→any person had always been human however not all humans are all people
- Equality is about the equal consideration of interests, but humans ignore the interests of higher order mammals in order to suit their own comforts and pleasures.
- Singer is a strict utilitarian (greatest good for the greatest number).
- All he is doing is expanding the membership of the “greatest number” – instead of just humans, it is mammalian persons
Speciest
Someone who discriminates against another’s rights based on their membership to a different (non human) species
Singer’s Concept of Personhood
A person is any creature (Human or non-human) who meets all of the following criteria:
1. Feel pain
2. Make own decisions
3. Foresee a future
4. Able to communicate
5. Ability to reason
6. Self-aware
7. Autonomous
Claims about animals supporting singers theory
- Sheep developed deep friendships
- Cows are problem solvers
- Animals have both reason and emotions in a relationship that is similar to our own
- Cows brains show signs of anticipation and excitement while waiting for a food reward in classic conditioning experiments
Could a severely brain damaged person be a person?
A severely brain-damaged man wouldn’t be a person, but an animal could be
Singers conception of personhood on abortion
Acceptable, he feels that humans don’t reach personhood until at least 3 months after birth
Singers conception of personhood on euthanasia
Acceptable and encouraged - humans who are below personhood status should not occupy resources which could be used for people
Singers conception of personhood on animal research
Disallowed, since monkeys could be persons, you could no more use them for research than you could any human
Singers conception of personhood on xenotransplantation (transplant of animal organs into humans)
Disallowed, mammals who qualify for personhood can’t have their insides defiled for another ‘person’, even if he/she is human
Richard Posner opinion
We should alleviate those pains (of animals) without reducing our standard of living and without sacrificing medical or scientific progress
Distributive Justice
Scarcity is a reality
- There is never have enough for everyone; you have to pick who gets what under which circumstances
- becomes an issue of how do we distribute resources equitably
Distributive Justice
Scarcity is a reality
- There is never have enough for everyone; you have to pick who gets what under which circumstances
- becomes an issue of how do we distribute resources equitably
Aristotles view on distributive Justice
He said: “equals should be treated equally and those who are unequal should be treated unequally”
- Everyone should be treated as equals bc there is not relevant distinguish features that makes one more deserving of something than another
Another meaning of discrimination?
- Evaluating and choosing between possibilities
- Equal consideration
- Free from intentional bias
Treated differently because of who you are - not always negative
Unconscious Bias
Everyone has bias that we are not aware of until they come to the forefront
William James belief
Ethics is dead until its alive
Ex. having a kid, don’t realize unconscious bias until this (ie. don’t want kid to be gay)
Alfred Bader
Was not allowed to attend queens university because he was jewish
- was excluded for irrelevant prejudicial info
Example of discrimination in university and how does it relate to healthcare
Academic performance to get into university
discriminate again those with lower grades?
Still relevant information
–> similar to healthcare, priority of patients who need care most
What makes people unequal in healthcare?
- Who is in most serious medical distress
- Sort people in emergency room based on priority - Likely benefit (% chance) –> what are the odds procedure will be successful for this person?
Elements of justice in healthcare
- does a decision negatively affect some more than others
- ie. you can NOT give replacement hip to 2 people –> if one is a mom, she has more responsibility than other people and needs the surgery more than someone else
- Are the risks taken mostly by one group and the benefits enjoyed by another group
- if yes = an equity issue
Preferential access to treatment
Conditions put upon people by healthcare professional before receiving a treatment
- i.e Profs dad put a condition on him to stop smoking 6 months before his bypass surgery
Issues with preferential access to treatment
People are discriminated
- Obese patient refused fertility treatment until they loose weight –> discriminating against obese people?
Substantive vs procedural question of justice
1) Substantive or material question of justice
- Answers the question ‘who should receive care first’
- It states what we value and why we choose one over the other
2) Procedural or process question of justice
- Answers the question ‘how we apply the answer to who goes first’
- It is the application in real life, of our beliefs that answer #1
5 aspects of substantive questions of justice
Need, equality, utility, liberty, reinstitution
Need
Illness is a major impediment to happiness
A measure of a societies justice is how well it looks after the needs of basic or essential health of its population
Resources should reflect need
Acuity should be the determinant
Equality
“Horizontal equality” = equal resources for equal need
“Treat cases alike”
Utility
Do that which will yield the greatest result and helps the greatest # of people
Liberty
Bases allocation on deserving it
You can disqualify yourself from access by your decisions (your decisions still matter)
Restitution
Access and share reflect past wrong-doings deprived them of that same thing
- restore the harm caused to people in the past
Ex. access to healthcare or education with a focus on those who have been traditionally/historically denied or treated unjustly
Resource allocation during COVID 19
Burden of particularly difficult resource allocation and clinical decisions should be lifted from the front-line care providers and placed upon clinical triage teams
Clinical triage teams
1) have an understanding of ethical principles
2) have clinical expertise and sound reasoning
3) can communicate with transparency and clarity
ethical principles applied to the pandemic
principles still exist, but the application of them may need to change
ex; no longer focusing solely on the well-being of individual patients, but rather focusing also on the well-being of many patients and the larger affected society
7 Fundamental values to apply during a pandemic
1) Maximizing benefits
2) lIfe-years gained
3) Save lives
4) Equal treatment
5) prioritize the worst off
6) Lottery system
7) First-come, first served –> favors those with financial resources, influence, or connections
(MLSEPLF)
Suggestion on how to relieve stress on front line workers during pandemic
Establishing a locally designated triage team working with multiple stakeholders in developing an allocation framework to guide decisions –> These teams can then help make the difcult decisions, relieving the frontline health care professionals of having to do so
Purpose of therapy
Restore you to health as much as possible
If situation is not repairable - do best possible /make accommodations
Sandel opinion on enhancement
‘Species typical functioning = normality
Enhancement historically
Has always been there
Performance enhancing drug use
1. predates history
2. was/is universal
3. Seems to serve the same purpose
Why were drugs used back then and why are they used now?
Back Then
1. fix someone’s health
2. religious reasons
3. work harder if you take them
Now
Functionally - we have an intended purpose for it
Use of enhancement drugs in history
Beer - historically used as a performance enhancing drugs (more energy/courage)
Fungus (psychedelic mushrooms) - used in sports
Alcohol became banned from ancient Olympic sports
Milo of croton - ancient Olympian who was famous for consuming 10 gallons of red wine
Most popular drugs in cycling (1860-1930)
Caffeine
Cocaine
Heroin
Ether
Digitialis
Alcohol
Strychnine
Opium
Oxygen
Fungi
Thomas Hicks
Was injected with a drug that helped him finish the race
‘Cure for the modern man’
Increasing urbanization, people working in factories - bad air quality, no breaks, no food/water
Birth rate dropped in population
Cure for the modern man - Hormone enhancement for men was made
Serge Vernoff used testsicles as a therapy
Who is Serge Vernoff and what did he do?
French surgeon
- gained fame for his practice of xenotransplantation of dog testicle tissues onto the testicles of men as anti-aging therapy
- happened b/w the 1920s and 1930s
German Olympians (1970s)
Were drugged without their knowledge
Some female athletes realized they were developing ‘masculine’ traits due to steroid use
Ex; growing more facial hair
Typical moral objections to enhancement
-cheating/unfairness
-harm to self, others, the institution
-intrinsic/extrinsic goods
- zero-sum vs non zero sum
Stuard Greens ‘4 elements’ of cheating
- The rule must be fair and fairly enforced
- Rule breaking must take place in a cooperative rule governed activity
- The rule breaker must intend to break the rules
- The rule breaker must intend to gain an advantage
Harm to self, others, the institution
Self – sliding scale (doping ≠ abuse)
The activity itself may not be healthy on its own
So why would enhancement be an issue?
Others
Coercion - if you can’t beat them, join them
Ex. if someone else in your class is taking Vyvanse do do better on exams, you feel coerced into taking them to so they do not take your spot in medical school
Institutions
Do they profit from high/enhanced performances?
Is this unjustified infringement on autonomy?
Intrinsic/ extrinsic goods
Intrinsic goods - benefits you gain from doing the activity that have value only to you
Extrinsic goods - the things of commercial value that we gain from high performance
ie. getting a high paying job
Allen Buchanan beliefs on drug
drugs don’t necessarily mean that one isnt ‘earning’ their success
They could be training harder and longer, and thereby actually developing more skill
Zero Sum vs Non Zero Sum
Zero sum - a winner and everyone who falls behind lost (gold medal is only real winner)
Non zero sum - not one single prize for one team/person to claim
Human Growth Hormone (HGH)
Form of enhancement
Biosynthetic human growth hormone (hGH) for their children who were projected to be of average or above ‐ average height even without it
Enhancement as Moral Boundary
Enhancement is contrasted with ‘medically indicated’ treatment
Ex; internist may have an obligation to offer to prescribe a beta blocker to a patient with heart disease, but not to an athlete, say an archer, who wants the drug in order to increase the interval between heartbeats and thus have a longer time to aim and release the arrow
Enhancement as moral signpost
- Warning that we are approaching unsettled moral territory
- Alerts us to ground our moral judgments in outcomes and principles
5 arguments FOR biomedical enhancement
- incoherency argument
- line drawing objection
- liberty argument
- resistance is futile
- people should shape themselves
Line drawing objection
Insists that drawing a line anywhere on that continuum is inevitably subjective and therefore can not be justified
Liberty objection.
People should be free to choose whatever ends they value and whatever means they want to reach those ends
Issues - often used as a persuasive or argumentative tactic to win a debate or discussion, (tends to be treated as a kind of rhetorical trump card)
Incoherency argument
Claim that there is no rational basis for distinguishing between acceptable and unacceptable means of enhancement
Says that all means of reaching a goal are equivalent – this is not true, ignores that means matter not only ends
Resistance is futile
- Boundaries were shattered in the past, therefore boundaries will fall in the future
- attempts to restrict access to enhancements will be unsuccessful because people will pursue them anyway
People should shape themselves
People should be free to shape themselves and make own decisions
issue - self harm/self destruction
Human nature view on enhancement
1) Human nature as raw material
2) Human nature is shaped by the conditions or circumstances that we are born into, rather than being predetermined.
(as contours of the given)
3) Human nature as a normative guide (serve as a guide for determining what is morally right or wrong)
4 Ethical concerns against enhancement
1) Undermining human nature
- People fear that biotechnologies may harm what defines and motivates human existence, while parents’ excessive control over their children’s traits is often countered by various techniques used to shape their development
2) Waste of resources
3) complicit with and reinforces unjust norms
4) Justice and unequal access
Readings belief
Enhancement = means of human flourishing
