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Conceptual Foundations of Bioethics

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Conceptual Foundations of Bioethics Monica (wife): We need to think about David’s wishes. He was CONCEPTUAL FOUNDATIONS OF always in control of his life, always a part of every medical decision. His advance directive is very clear. He does not want BIOETHICS: OVERVIEW his life to be artificially extended. We need to tell Dr. Alderfer to Although bioethics has been around for more than four turn off the respirator. decades, the field of neuroethics is in its infancy. Philosophers Amy (sister #2): Just pull the plug? Can Dr. Alderfer do that? I have developed several conceptual frameworks that contain can’t believe that someone can be killed just because the right valuable insights concerning the analysis of questions of right areas don’t light up on a brain scan. I want to hear about how other patients have been treated, why some are left on a respira- and wrong, good and bad. These ethical theories can help us tor while others are removed. There must be some guidelines as as we struggle with the moral dilemmas presented to us by to how to proceed in cases like this. advances in brain science. In the sections that follow, a variety Ben (brother): I think we need to meet with Dr. Alderfer. Amy’s of theories and methods will be explained with reference to point is well taken. We haven’t been in this situation before; we the hypothetical scenario described below.. need some guidance. Before the meeting, however, I want us all to think about what the Cleavers have stood for, we want our actions to reflect the kind of people we are. We must come The Case of David Cleaver: through this with our respect for one another intact. We need to Mr. David Cleaver, age 58, suffered a massive heart attack be open, honest, caring, and considerate of each other’s views. while shoveling snow. Medical emergency personnel arrived at the scene within minutes and resuscitated the stricken night watchman. During those minutes, however, his brain ACTIVITIES: was starved of oxygen, resulting in permanent brain damage. 1. Class Discussion: Two days later several of Mr. Cleaver’s family members met to a. Which family member(s) has/have identified the key discuss his treatment and future in the lounge outside the moral issue facing the Cleaver family? ICU in Thales General Hospital: b. Do you think that the Cleavers will be able to reach a consensus about whether or not to turn off the Bill (son #1): Dad’s heart is beating; he is still alive! We have no respirator? right to approve any action that could result in his death. 2. Role Playing: Jake (son #2): Bill, the doctor said that Dad has no chance of Choose a student to take the point of view of each of recovery. The fMRI showed no activity in critical areas of his the family members. brain. Without the respirator his heart would stop. There is NOTE: It may be instructive to repeat activities 1 and more to be considered here than simply keeping Dad’s heart 2 after students have studied the remainder of this beating. chapter. This may help students to recognize and come Bill: Like what? What could possibly compare to Dad’s life? to appreciate the increased sophistication of discourse We’re talking about life, about the sixth commandment: “Thou shalt not kill.” possible with the precise vocabulary and powerful conceptes and distinctions they have learned. Jake: There are dozens of lives involved. Right now, you are not in your store, I cancelled appointments with four clients, Sandy 3. Research: (Bill’s wife) is sitting by the phone popping Valium tablets, and Research one of the following topics and report your the medical bills keep piling up. findings to your class. Bill: You're just afraid of losing a little money! a. The effects of anoxia on the brain. b. Compromised brain states such as PVS, coma, and brain Jessica (sister #1): That’s not fair Bill. It’s not just money. We are all members of a family. Jake missed Michael’s hockey game death. last night and you haven’t seen your kids for days. We are all c. Recent developments in brain imaging and their use grieving. We need to support each other. We need to help each in the diagnosis of the brain states mentioned above. other through this. Copyright © 2010. Center for Bioethics - University of Pennsylvania Page 1 of 9 Finally, it is easy to construct situations in which utilitar- CONSEQUENTIALISM/UTILITARIANISM ian reasoning leads to conclusions that conflict with our moral intuitions. Consider, for example, a transplant center in Bill thinks that the act of disconnecting his father’s respi- a major city hospital. At any given time there is likely to be a rator is wrong because it is an example of a forbidden act – waiting list for people in need of kidneys, hearts, lungs, and the killing of innocent persons. Jake, on the other hand, is other organs and tissues. Suppose that a young accident more interested in the consequences of the action than in its victim is brought into the emergency department with a form or kind. He wants to consider how all involved would severe fracture of his femur. Routine surgery and some time be affected by (1) disconnecting the respirator and (2) leaving in traction should result in a full recovery. It turns out, it connected. Jake advocates taking the action with the best however, that the man with the broken leg is a good match for outcome for everyone involved. Jake is a consequentialist. several transplant patients whose life can only be saved with replacement organs. Should the man’s organ’s be “recovered” Consequentialist ethical theories determine the so that three or four others can live? It would seem that the rightness or wrongness of an action by its consequences utilitarian decision machinery could require an affirmative rather than by the type of action it is. They define the right in answer. The focus of utilitarianism on the aggregate is incon- terms of the good. The right action is the one that produces sistent with individual rights --such as the right to life -- many the most good. This begs the question, “What is good?” The think are inviolable. most widely supported version of consequentialism is called utilitarianism. Utilitarians consider happiness (pleasure or An attempt has been made to devise a procedure that well-being) to be the only thing that is good in and of itself – preserves the fundamental insight of utilitarianism – the the only thing that has intrinsic value. Utilitarians strive to importance of promoting the common good, without produc- follow the greatest happiness principle: act so as to produce ing moral judgments that are inconsistent with our ideas the greatest overall happiness. about rights, duties, and justice. Rather than applying the utilitarian calculus to each action (Act Utilitarianism), Rule For the Cleavers to determine the right thing to do, Utilitarians attempt to identify a set of rules, which if followed, according to this principle, they must perform the following would maximize happiness. Perhaps, “do not kill innocent utilitarian calculus: persons,” is such a rule. But what if the common good would be better served if the rule were modified to say, “do not kill 1. Identify the feasable courses of action. innocent persons except those in persistent vegetative states 2. Calculate the sum of "utility" (pleasure and who have written advance directives indicating that they do pain) associated with each action for everyone not wish to be kept alive under such circumstances.” Rules affected. with exceptions may produce more overall happiness. But as exceptions multiply, rule utilitarianism can become indistin- 3. Choose the action that will result in the greatest guishable from act utilitarianism. amount of utility - the greatest hapiness, everyone considered. In spite of its theoretical problems, utilitarianism has an important influence on medical ethics. Public health practices, There are problems with this practice. for example, operate under utilitarian guidelines. Quarantines First, in order to calculate the sum of pleasures and pains that violate individual freedoms are justified by utilitarian resulting from a given action, interpersonal comparisons must appeals to the common good. be made. Many consider this to be impossible. ACTIVITIES: Second, how is the moral agent to predict the conse- 1. Class Discussion: quences of her action? How far in the future should she look? a. Jerry is a fourth-grade student who has difficulty Predicting the future is an uncertain business. concentrating on a task for more than a few minutes. He often becomes fidgety, initiates conversations with Third, utilitarianism sets an unreasonably high standard other students, calls out before being recognized, and for behavior. Using utilitarian assumptions, a middle class must be repeatedly reprimanded by his teacher. His American father, for example, should not buy an ice cream behavior has a negative effect on everyone in the class. cone for his daughter. Surely, the two dollars for the ice For several weeks, while Jerry was taking the prescri- cream could be put to better use if donated to Oxfam. It tion drug Ritalin, the climate in the classroom became could pay for a vaccination – perhaps save a life. The provision much more conducive to learning. He stopped talking of basic health care is likely to produce more utility than an the drug because of negative side effects. Was it wrong ice cream treat for Jerry to stop taking Ritalin? How should the answer to this question be determined? Copyright © 2010. Center for Bioethics - University of Pennsylvania Page 2 of 9 b.
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