medical ethics theories

medical ethics
Dr. Rami Abo Ali

1. Medical Ethics and Legal medicine Dr. Rami Abo Ali Medical Ethics - Dr. Rami Abo Ali 1

2. Medical Ethics Theories Dr. Rami Abo Ali Medical Ethics - Dr. Rami Abo Ali 2

3. Globalization and medicine Globalization The world is a big market Starts at the end of last century . Decreased morals Materialistic target > moral target Cause a lot of fights and wars between people Change the term (patient ) to (costumer / client ) When moral side is influenced by materialistics , there will be a lot of ethical problems 3 Medical Ethics - Dr. Rami Abo Ali

4. Difference between morals & ethics Morals : Latin word, means : custom To do what is right , and to leave what is wrong Related to cultures and religions Not related to place, job, time ( honesty , goodness ) It is inside issue , relationship between a person and his beliefs . It is not measurable . If it didn’t cause harm , no legal punishment , maybe social punishment (liar ,..) 4 Medical Ethics - Dr. Rami Abo Ali

5. Difference between morals & ethics Ethics : Greek word , means character There is rules and guidelines . Changes upon time , place and developments of science Influenced by developments in human rights. Morals are different from doctor to other , but ethics is the same . Non-ethical behavior have legal punishment even if didn’t cause physical damage . (psychological harm ) 5 Medical Ethics - Dr. Rami Abo Ali

6. INTRODUCTION Several philosophers have given different theories of ethics . The ethical theories provides an ordered set of moral standards to be used in assessing what is morally right and what is morally wrong regarding human action in general. A moral theory is a mechanism for assessing whether a particular action or rule is ethically justified. More precisely, a moral theory can help us to sharpen our moral vision, it helps us determine whether an action or a rule is ethically right , wrong, or permissible. These theories help us in getting better understanding of ethics and guide us in making ethical decision. 6 Medical Ethics - Dr. Rami Abo Ali

7. Ethical Theories : We will talk about three of these ethical theories : Consequence-based \ Utilitarian Theory Virtue Theory Deontology Theory 7 Medical Ethics - Dr. Rami Abo Ali

8. Consequence-based Utilitarian Theory An individual act (X) is morally permissible if the consequences that result from (X) produces the greatest amount of good for the greatest number of persons affected by the act . It primarily refers to moral views or theories which base their evaluations of acts solely on consequences Opposite of deontology theory . Patient’s benefit is the most important thing regardless the way to achieve that . The most common, but not the only, form of consequentialism is utilitarianism ( The End J ustifies T he Means ) 8 Medical Ethics - Dr. Rami Abo Ali

9. Utilitarianism Utilitarianism is a moral theory that advocates actions that promote overall happiness or pleasure and rejects actions that cause unhappiness or harm. A utilitarian philosophy, when directed to making social, economic, or political decisions, aims for the betterment of society. According to the “classical” version, what makes a consequence good or bad is its effect on people’s happiness . Roughly, a consequence is bad if it reduces happiness, good if it increases happiness. Happiness, in turn, is understood to mean: an increase in pleasure and/or decrease in pain. Because of the emphasis on happiness, Utilitarianism is sometimes called “ the greatest happiness principle ”. 9 Medical Ethics - Dr. Rami Abo Ali

10. Utilitarianism cont. 10 Medical Ethics - Dr. Rami Abo Ali "The greatest amount of good for the greatest number of people" is a maxim of utilitarianism. The major philosophers who developed the utilitarian approach were Jermy Bentham (1748-1832) and John Stuart Mill (1806-1873 ) , British philosophers .

11. Utilitarianism cont. Utilitarianism appears to be a simple theory because it consists of only one evaluative principle : Do what produces the best consequences. In fact, however, the theory is complex because we cannot understand that single principle unless we know (at least) three things: What things are good and bad; Whose good (i.e. which individuals or groups) we should aim to maximize ; Whether actions, policies, etc. are made right or wrong by their actual consequences (the results that our actions actually produce) or by their foreseeable consequences (the results that we predict will occur based on the evidence that we have). 11 Medical Ethics - Dr. Rami Abo Ali

12. Strengths of Utilitarianism It is believed that actions are right if they are useful to a majority of people . It is most commonly applied ethical theory In this theory, the worth of each action is judged primarily on its own merits . Gives a clear answer to the question ( what should I do ? ) Human in this theory is neutral . ( as an object ) 12 Medical Ethics - Dr. Rami Abo Ali

13. Criticism of Utilitarianism Cannot predict the outcome of actions in advance , thus it is impossible to set the standers of one’s moral action on the basis of the act itself The notion of utility is very vague. It is very difficult to determine what the maximal utility would be for all affected by a situation. There is doubt regarding what is the “majority”. Sometimes its action may benefit the majority at the cost of exploitation of the minority It may sometimes result in unethical and immoral choices as it judges morality by the results only, and not by the means It is very much difficult to foresee the consequences with accuracy . 13 Medical Ethics - Dr. Rami Abo Ali

14. Examples of utilitarianism Headache : you can find the causes and treat it upon its cause , or u can give painkiller ( cetacodiene ) and patient will be happy . You get great result of exam even if you cheated ( the result is the most important , not the way or method ) . You gave placebo medicines to treat warts . The patient believes that it is the best medicine , he might be cured of warts . The result is the most important thing . 14 Medical Ethics - Dr. Rami Abo Ali

15. Virtue Theory This philosophy stems from Aristotle ( 384-322 BC. ) and is based on the virtues of the person making a decision . The virtue ethical theory judges a person by his/her character rather than by an action that may deviate from his/her normal behavior The consideration in virtue ethics is essentially “ what makes a good person ,” or, for the purpose of this discussion, “ what makes a good public relations professional ?” Virtue ethics require the decision-maker to understand what virtues are good for public relations and then decisions are made in light of those particular virtues. 15 Medical Ethics - Dr. Rami Abo Ali

16. Virtue cont. Examples : If the virtue of honesty is the of utmost importance to a good public relations professional, then all decisions should be made ethically to ensure honesty is preserved. Honesty is good and should be done in all situation even it hurts some times ( doctor and cancer patient ) Abortion : Killing the human being is a crime , the embryo is a human being , so , according to virtue theory , abortion is considered a crime and shouldn’t be done even if it is life threatening in some medical conditions .. But , what if we consider the embryo is not a human being yet ?! 16 Medical Ethics - Dr. Rami Abo Ali

17. Virtue cont. Strength : Depends on appearance of morals more than morals itself ( embryo is a human being ? ) Multiple and differs from person to another Important in medical practicing and for medical students and doctors ( best character ) Criticism : It does not take into consideration a person’s change in moral character Difficult to analyze , selfish , and character depending . Dangerous if it is extreme . No middle choice between good and bad 17 Medical Ethics - Dr. Rami Abo Ali

18. Deontology Theory Deontological ethics or deontology from Greek word deon , “ that which is binding ” or refers to “ obligation , duty ” which is the normative ethical position that judges the morality of an action based on rules . It is sometimes described as “ duty ” or “ obligation” or “ rule” based ethics , because rules “ bind you to your duty” . Duties are action that should be done or avoided regardless of consequences 18 Medical Ethics - Dr. Rami Abo Ali

19. Deontological (duty-based) ethics are concerned with what people do, not with the consequences of their actions. Do the right thing. Do it because it's the right thing to do. Don't do wrong things. Avoid them because they are wrong. Someone who follows Duty-based ethics should do the right thing, even if that produces more harm (or less good) than doing the wrong thing: People have a duty to do the right thing, even if it produces a bad result Maybe it will not achieve the best results , but the result will be morally good and accepted . ( What is built on wrong will be wrong ). Opposite of utilitarianism theory 19 Medical Ethics - Dr. Rami Abo Ali

20. Medical Deontology Defined as a Set of : Ethical standards and principles of behavior of medical practitioners while executing their professional duties Professional ethics of medical workers Principles of behavior of medical personnel , directed towards maximum benefit of treatment of the patient! 20 Medical Ethics - Dr. Rami Abo Ali

21. Strength of duty-based ( deontology ) ethics Emphasizes the value of every human being , and tend to focus on giving equal respect to all human beings. Says some acts are always wrong Provides 'certainty‘ Deals with intentions and motives 21 Medical Ethics - Dr. Rami Abo Ali

22. Criticism of duty-based ( deontology ) ethics Absolutist : sets absolute rules. The only way of dealing with cases that don't seem to fit is to build a list of exceptions to the rule. Allows acts that make the world a less good place Because duty-based ethics is not interested in the results it can lead to courses of action that produce a reduction in the overall happiness of the world. Hard to reconcile conflicting duties , and it doesn't deal well with the cases where duties are in conflict. 22 Medical Ethics - Dr. Rami Abo Ali

23. Examples of Deontology Hopeless cancer patient asked you is there any hope to live ? You shouldn’t say “ yes you will die after 3 months” You should say “ your situation is not so bad , we are doing our best , you should be calm , nobody knows when to die” In this case we are not lairs , but we didn’t tell the whole truth , we just do our duties toward the patient to make him calm and comfort . Patient need kidney transplantation , I cant do the operation if I know that this kidney is stolen or they buy it . ( opposite of utilitarianism ) Diabetic patient come to clinic and afraid of this disease Tell him it is simple issue and half of people have this problem , happiness ( utilitarianism ) Tell him he should take the medicine and do pay attention for diet and medical recommendations to prevent later complications of this disease . ( deontology ) 23 Medical Ethics - Dr. Rami Abo Ali

24. Kant’s Duty-based Ethics Immanuel Kant (1724-1804) (Kaliningrad , Russia) Represent deontological ethics Kant thought that it was possible to develop a consistent moral system by using reason. If people were to think about this seriously and in a philosophically rigorous manner, Kant taught, they would realize that there were some moral laws that all rational beings had to obey simply because they were rational beings, and this would apply to any rational beings in any universe that might ever exist 24 Medical Ethics - Dr. Rami Abo Ali

25. Kant’s Concepts 25 Medical Ethics - Dr. Rami Abo Ali

26. Kant’s Duty-based Ethics Good Will What is good? Although Kantian ethics are usually spoken of in terms of duty and doing the right thing, Kant himself thought that what was good was an essential part of ethics. Kant asked if there was anything that everybody could rationally agree was always good. The only thing that he thought satisfied this test was a good will: . 26 Medical Ethics - Dr. Rami Abo Ali

27. Kant’s Duty-based Ethics The Notion of Duty Distinction between “I want” and “I ought”. Moral actions are not spontaneous, if I see someone in need of help, I may be inclined to look the other way, but I will recognize that my duty is to help. Considering only those actions that are seemingly good according to Kant are actions that seem good by duty, that are good to my common sense of duty and for that they are right 27 Medical Ethics - Dr. Rami Abo Ali

28. Kant’s Duty-based Ethics The Nature of Imperatives Imperatives are commands For kant there exist 2: Hypothetical Imperatives Categorical Imperatives Hypothetical Imperatives If you want you ought. The ought or the duty is conditioned by your desires, wants and goals . Our goals are grounded in self-interest . Example : you should study to succeed the exam ( maybe you will not succeed in first time , then you change your methods and study harder to achieve the result ) 28 Medical Ethics - Dr. Rami Abo Ali

29. Categorical Imperative The general from of Do. (Unconditioned) For Kant there is only one imperative command and it is the Moral Law . Example : do emergency treatment to the patient even he is your enemy . Divided in 2 formulations First Formulation “Always act in such a way that you would be willing for it to become a general law that everyone else should do the same in the same situation..” Second Formulation “Act so that you treat humanity, whether in your own person or that of another, always as an end and never as a mean .” See if your actions are using others or affecting others, in the meaning of never using them as a mean to achieve but always as an end 29 Medical Ethics - Dr. Rami Abo Ali

30. Confliction of duties Lying or not telling the truth is morally unacceptable , but , what if a soldier was captured by enemy , he will have two choices : to tell the truth and betray his country , or to lie . He is here in front of tow duties , what will he chose ? Lying and betraying are both immoral , but in this case to lie is better than to betray . The rule here is to follow the least damage . Another example , breast cancer 2 nd stage no lymph nodes metastases , chemotherapy , radiotherapy , surgery with total resection , or partial resection . ?? Deontology theory and the religions both have the rule of ( Necessities allow Prohibitions ) 30 Medical Ethics - Dr. Rami Abo Ali

31. New deontology theories Rossian duty-based ethics Rawls’s theory of justice 31 Medical Ethics - Dr. Rami Abo Ali

32. Rossian duty-based ethics The 20th Century philosopher W. D. Ross [Sir David Ross] ( 1877-1971) . Attempts to incorporate aspects of utilitarianism and aspects of Kantianism Rejected the utilitarian notion that an action is made right by its consequences alone, but he was also troubled by Kant’s view, if a rule passed the categorical imperative (and became a duty to follow), it could have no exceptions, it was absolute. He saw not only that such rules fail to show sensitivity to the complexities of actual situations, but also that they sometimes conflict with one another . 32 Medical Ethics - Dr. Rami Abo Ali

33. Rossian duty-based ethics cont. Kantian ethics seems pretty uncompromising and not really suited to the disordered of many moral choices that people have to make. He suggested that it would be helpful to look at two kinds of duty: Prima facie duties (Legal term indicating that something is obvious enough to be considered true until proven false) Actual duties 33 Medical Ethics - Dr. Rami Abo Ali

34. Prima facie duties Are self-evident and obvious duties ( prima facie is a Latin expression meaning 'on first appearances' or 'by first instance') Can be known to be correct if a person thinks about them and understands them: Should be promoted, "all things considered“ Can be outweighed by other prima facie duties. { when we have reached sufficient mental maturity and have given sufficient attention to the proposition it is evident without any need of proof, or of evidence beyond itself } W D Ross, The Right and the Good, 1930 34 Medical Ethics - Dr. Rami Abo Ali

35. Ross listed The Seven Kinds of Prima Facie Duties: Fidelity Reparation Gratitude Justice Beneficence Self-improvement Non- maleficence (avoiding actions that do harm) Calling these 'duties' may be a bit misleading, as they are not so much duties as "features that give us real (not only obvious) moral reason to do certain actions". Ross later described prima facie duties as "responsibilities to ourselves and to others" and he went on to say that "what we should do (our duty proper [our actual duty]) is determined by the balance of these responsibilities." 35 Medical Ethics - Dr. Rami Abo Ali

36. Actual duties This is the duty people are left with after they have weighed up all the conflicting prima facie duties that apply in a particular case . the ground of the actual rightness of the act is that, of all acts possible in the circumstances, it is that whose prima facie rightness in the respects in which it is prima facie right most outweighs its prima facie wrongness in any respects in which it is prima facie wrong . W D Ross, The Right and The Good, 1930 36 Medical Ethics - Dr. Rami Abo Ali

37. Examples of Applying the Prima Facie Duties If you are carrying a heavy load into a building and a passer by holds the door open for you, you can  see  immediately that an expression of gratitude is in order. (You are directly applying the relevant prima facie duty where it is applicable and discovering your  actual duty  in the circumstances.) If you are an able-bodied passer-by not carrying anything yourself and you notice someone trying to carry a heavy load into a building, you might  see  immediately that you ought to hold the door open for him or her. (You would be directly applying the prima facie duty of beneficence.) 37 Medical Ethics - Dr. Rami Abo Ali

38. Problems with the Rossian approach Ross's idea still leaves some problems: How can we tell which prima facie duties are involved in a particular case? How can we compare and rank them in order to arrive at a balance which will guide us as to our actual duty? Ross thought that people could solve those problems by relying on their intuitions. 38 Medical Ethics - Dr. Rami Abo Ali

39. Rawls’s theory of justice The theory of justice formulated by Harvard philosophy professor John Rawls (1921–2002) can be understood as attempting to combine the strengths of utilitarianism and deontology while avoiding the weaknesses of each view. For Rawls, the central task of government is to preserve and promote the liberty and welfare of individuals. Thus, principles of justice are needed to serve as standards for designing and evaluating social institutions and practices. 39 Medical Ethics - Dr. Rami Abo Ali

40. Principles of justice Rawls’ position has direct relevance to such bioethical issues as who should have access to health care, how donated organs should be distributed, and who should pay for society’s medical costs. Rawls argues that there are two essential principles of justice: Each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all. Social and economic inequalities are to be arranged so that they are both To the greatest benefit of the least advantaged Attached to offices and positions open to all under conditions of fair equality of opportunity. 40 Medical Ethics - Dr. Rami Abo Ali

41. For Rawls, these two principles are taken to govern the distribution of all social goods: liberty, property, wealth, and social privilege. The first principle has priority. It guarantees a system of equal liberty for all. The second principle governs the distribution of social goods other than liberty. Though Rawls’ overall position has relevance to individual medical decisions, it’s most important application is to the social institutions and practices of medical care and research . 41 Medical Ethics - Dr. Rami Abo Ali

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