Chapter 14. Medical Ethics and Bioethics

Transcription

1 152 Chapter 14 Medical Ethics and Bioethics Dr. John T. Giordano The Rod of Asclepius, A symbol of healing associated with the medical profession. The snake is often considered to be a symbol of life and renewal because it sheds its skin.

2 153 Life and Healing The meaning and significance of Life is traditionally defined Religion. Each religious tradition creates rules for the way human beings and other living things should be treated. In early hunting and gathering cultures, animals were killed for food, but their spirits had to be appeased. Religious scripture also creates rules for the treatment of others. Buddhist Dharma focuses on compassion, the Judeo-Christian tradition focuses upon commandments and love of one s neighbor. Islam also focuses upon charity and the obeying of revealed Law. As modern medicine began to develop beginning with the Greeks, the religious morality began to be replaced with a more rational ethics. The Greek physician Hippocrates of Kos developed a school of medicine and is credited with formulating the Hippocratic oath. This oath is the first instance of the development of an ethics concerning medicine. The Hippocratic Oath (Greek Version) I swear by Apollo The Healer, by Asclepius, by Hygieia, by Panacea, and by all the Gods and Goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture. To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician s oath, but to nobody else. I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein. Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

3 154 Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me. The Hippocratic Oath (Modern Version) I swear to fulfill, to the best of my ability and judgment, this covenant:... I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. (Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.) You can see the difference in the two versions. The first one draws from traditional knowledge and religious principles. The second one is secularized. We can also relate this to the difference between morality and ethics. Whereas morality would refer to the communal, traditional or religious beliefs which guide our actions, ethics would refer to the more individual and rational understanding of the values and norms that guide our actions. Ethics becomes a problem of philosophy.

4 155 The idea of medical ethics has been developed in history by such thinkers as the Islamic philosopher Avicenna, the Jewish philosopher Maimonides, and the Christian philosophers Paracelcus and St. Thomas Aquinas. As it developed, medical ethics became based upon such concepts as autonomy, beneficence, and non-maleficence. Autonomy is the ability of an individual to make their own decisions concerning their welfare. Beneficence is the promotion of well-being (the best interests of the patient). Non-maleficence is not doing harm. We can say that Medical Ethics in the present day has also developed in relation to medical law. This involves the idea of malpractice. Medical decisions are now judged based upon the avoidance of harm in the form of negligence and penalties measured in damages. Bioethics Medical Ethics gradually began to be replaced by Bioethics as the scope broadened to include both human and non-human issues. We might say that bioethics is born when our religious moral traditions no longer can answer the very complex questions which result from our medical technologies and bioengineering. Abortion In the case of abortion, the issue is often a definition of when life begins. This is a philosophical issue, a religious issue, and a scientific one. A religious person might say that life begins at conception, but a scientific explanation would be that conception or fertilization is merely a biological process, and that life would be something which slowly emerges with the continuation of that process; that is, the dividing and differentiation of cells, and the development of the nervous system. The following passage is by the famous utilitarian ethical philosopher Peter Singer. Those who defend women's rights to abortion often refer to themselves as 'pro-choice' rather than as 'pro-abortion'. In this way they seek to bypass the issue of the moral status of the foetus, and instead make the right to abortion a question of individual liberty. But it cannot simply be assumed that a woman's right to have an abortion is a question of individual liberty, for it must first be established that the aborted foetus is not a being worthy of protection. If the foetus is worthy of protection, then laws against abortion do not create 'victimless crimes' as laws against homosexual relations between consenting adults do. So the question of the moral status of the foetus cannot be avoided. The central argument against abortion may be put like this: It is wrong to kill an innocent human being. A human foetus is an innocent human being. Therefore it is wrong to kill a human foetus.

5 156 Defenders of abortion usually deny the second premiss of this argument. The dispute about abortion then becomes a dispute about whether a foetus is a human being, or, in other words, when a human life begins. Opponents of abortion challenge others to point to any stage in the gradual process of human development that marks a morally significant dividing-line. Unless there is such a line, they say, we must either upgrade the status of the earliest embryo to that of the child, or downgrade the status of the child to that of the foetus; and no one advocates the latter course. The most commonly suggested dividing-lines between the fertilized egg and the child are birth and viability. Both are open to objection. A prematurely born infant may well be less developed in these respects than a foetus nearing the end of its normal term, and it seems peculiar to hold that we may not kill the premature infant, but may kill the more developed foetus. The point of viability varies according to the state of medical technology, and, again, it is odd to hold that a foetus has a right to life if the pregnant woman lives in London, but not if she lives in New Guinea. Those who wish to deny the foetus a right to life may be on stronger ground if they challenge the first, rather than the second, premiss of the argument set out above. To describe a being as 'human' is to use a term that straddles two distinct notions: membership of the species Homo sapiens, and being a person, in the sense of a rational or self-conscious being. If 'human' is taken as equivalent to 'person', the second premiss of the argument, which asserts that the foetus is a human being, is clearly false; for one cannot plausibly argue that a foetus is either rational or selfconscious. If, on the other hand, 'human' is taken to mean no more than 'member of the species Homo sapiens', then it needs to be shown why mere membership of a given biological species should be a sufficient basis for a right to life. Rather, the defender of abortion may wish to argue, we should look at the foetus for what it is - the actual characteristics it possesses - and value its life accordingly. ( Peter Singer s ideas have become quite controversial recently as some believe that his argument can also defend infanticide (the killing of an infant). But the very structure of the debate can be seen in the above passage. The question in its simplest form is whether we value the life of the developing embryo or foetus, or whether we value the freedom of the mother to terminate the pregnancy if desired? The abortion debate involves many ethical questions. Should we allow abortion? Should we restrict it to the first trimester of a pregnancy? Should we allow it when the mother s life is in danger (killing the fetus to save the mother, killing one life to save another)? Should we allow it in the case of rape? Should we allow it simply based on the discretion of the mother? This is the traditional debate around abortion. But with the development of our technologies things become even more complex. We can now know much about the embryo before it is born. So now we are faced with decisions concerning whether we should abort a foetus who we know to have birth defects? Other ethical issues concerning the beginning of life are artificial insemination, surrogate pregnancies and the choosing of children based upon genetic traits.

6 157 We can see that this debate can never be completely resolved since religion and science sees life in two different ways. But philosophers, religious writers, doctors, politicians and rights groups constantly look for balance and compromise. In the end, the debate involves the balance between the rights of the foetus and the rights of the mother. Euthanasia While abortion is concerned with the beginnings of life, euthanasia deals with the end of life. Should a person have the right to terminate their own life if they are suffering from an terminal disease? If a person is aided by a physician, this is called Physician-Assisted Suicide. Should the physician be able to terminate the life of a terminally ill patient with that patient s consent? As we saw in the Hippocratic Oath, the doctor is prohibited from harming a patient. So even if the patient wants to be helped to end their life because of terminal illness, the physician is prevented from doing so because of their oath. But doctors must make such decisions every day. So what kind of argument can be made for the right of a patient to choose death. This is what Peter Singer refers to as the freedom to choose argument. The nineteenth-century philosopher John Stuart Mill argued that individuals are, ultimately, the best judges and guardians of their own interests. So in a famous example, he said that if you see people about to cross a bridge you know to be unsafe, you may forcibly stop them in order to inform them of the risk that the bridge may collapse under them, but, if they decide to continue, you must stand aside and let them cross, for only they know the importance to them of crossing and only they know how to balance that against the possible loss of their lives. Mill's example presupposes, of course, that we are dealing with beings who are capable of taking in information, reflecting, and choosing. So, here is the first point on which intellectual abilities are relevant. If beings are capable of making choices, we should, other things being equal, allow them to decide whether or not their lives are worth living. If they are not capable of making such choices, then someone else must make the decision for them, if that question should arise. There was a very famous case that occurred in the United States between 1990 and 2005 involving a woman named Terry Schiavo who, as the result of a cardiac arrest, fell into what is called a persistent vegetative state. Her husband declared that she would not want to stay alive under such conditions, and that her feeding tube should be removed and she should be left to die. But her family fought to maintain her life support. Even the US president George W. Bush sided with the family. Finally, her husband won the court case and life support was stopped. Singer uses this case to continue his argument. Because I want to focus on voluntary euthanasia and physician-assisted suicide, I shall not now go into details regarding life-and-death decisions for those who are not capable of exercising choice. But to those who urge that, in the absence of choice, the decision should always be "for life"- as those who wanted Schiavo kept alive appear to believe - it is worth asking if they really want to insist on the use of every possible

7 158 means of life support to draw out existence to the last possible minute. Very few people really want this, either for themselves or for those they love. The Roman Catholic Church does not insist on it, allowing for the withdrawal of what are sometimes called "extraordinary means." Yet, by allowing life to end earlier than it might, these proponents of "pro-life" attitudes are effectively deciding for those who are not capable of making such decisions, and they are deciding against life, not for it. Anyone who values individual liberty should agree with Mill that the person whose life it is should be the one to decide if that life is worth continuing. If a person with unimpaired capacities for judgment comes to the conclusion that his or her future is so clouded that it would be better to die than to continue to live, the usual reason against killing-that it deprives the being killed of the goods that life will bring-is turned into its opposite, a reason for acceding to that person's request. ( That is, according to Singer, the respect for life is also the respect for the freedom of the person to choose how or when to die. With the developing technologies for prolonging life, this question is now more important than ever. A very sick patient can be maintained indefinitely in a vegetative state with a low quality of life and with great expense to their family. Under such conditions of pain and expense do they have a legitimate claim to have assistance to end their life? Genetic Modification Genetic modification concerns the technological modification of life itself. Now that the genetic information of most species of life has been mapped, it is now able to be manipulated. Various genes within the DNA sequence are responsible for various traits. We always have had modified plants developed through the selection of genetic traits through breeding. However, now we can manipulate the genetic material of plants directly. This leads to the development of genetically modified food. But the genetic modification of food comes at the expense of natural diversity. This is called the loss of biodiversity. So our natural varieties of plants are disappearing and being replaced by genetically modified species which are usually more vulnerable to disease and pests.

8 159 Svalbard Seed Vault ( Recently there has been an attempt to collect and store the seeds from our natural food plants. One such facility in Svalbard, Norway is called the Global Seed Vault, or sometimes the Doomsday Seed Vault. The croptrust.org website describes its mission as follows: WHAT IS THE SVALBARD GLOBAL SEED VAULT (SGSV)? The purpose of the Svalbard Global Seed Vault is to provide insurance against both incremental and catastrophic loss of crop diversity held in traditional seed banks around the world. The Seed Vault offers fail-safe protection for one of the most important natural resources on earth. ( Another ethical and political problem involves commercial seeds which have be genetically modified to contain a terminator gene. This is called Genetic Use Restriction Technology. This terminator gene restricts the use of the seed for one growing season. Farmers cannot store seeds, they have to purchase a new supply from seed companies every season. Genetic modification is also used to cure disease. This would seem to be a valuable technology. But there are also critics who claim that genetic modification as a solution to cure disease ignores the environmental factors of disease. Nevertheless, there are other criticisms of the use of GM animals, as the watchdog group GeneWatch has pointed out. Its director Helen Wallace says the rise in the use of GM animals reveals a disturbing trend: the "genetification" of biology. "There are

9 160 undoubtedly some legitimate uses of GM animals but this blanket rise is worrying and bears little relation to reality," she says. Wallace points to the widespread creation of animals mice in particular that have been genetically altered so they succumb to human conditions such as obesity and cancer. These mutants are then used to test drugs that could counter these ailments in humans. "The trouble with this approach is that it stresses the use of medical intervention for ailments that also have clear environmental causes," says Wallace. "Too much food and exposure to pollutants are also clear causes of cancer and obesity, but these are being ignored because of our obsession with genetics. In fact, in many conditions, genes have only a small role to play in the causation of the disease, yet we have become fixated on trying to tackle them, to the detriment of other, more fruitful approaches." ( This critique sees genetic modification as a departure from a deeper respect for nature. The human being is not merely an organism isolated from nature, but an organism deeply entwined with its environment. But the pharmaceutical industry depends upon this false isolation of the human being from environmental factors. For the pharmaceutical industry, every mental problem becomes a mere chemical imbalance to be treated with drugs and not addressed through changes in environment and life-style. The other critique of the use of genetic modification to treat disease involves the stem-cell research used to develop such technologies. The stem cells used in research and cures, come from developing fetuses and therefore are condemned by the anti-abortion advocates. Animals The genetic modification of food animals also creates ethical issues. We are creating food animals which are basically mutants. These are animals who are kept in the dark for their entire life, who cannot walk or fly because their muscles are overdeveloped for the purpose of being eaten.

10 161 Illustration from ( But this ethical issue goes far beyond the genetic modification of food animals to the rights of animals themselves. Animal rights includes such topics as animal testing, genetic engineering, keeping wild animals in zoos, hunting, and the destruction of animal habitat. It is easy to speak about human rights which respect the dignity and the autonomy of the human being. This dignity is often connected to the idea that human beings are rational conscious creatures who have feelings. Animals have traditionally been considered as lesser beings that do not possess such qualities. But these assumptions are now being called into question. We recognize that animals can think, feel empathy and possess many of the qualities that human beings pride themselves on possessing. Therefore, animals should also be accorded rights and some degree of equality. Peter Singer writes: The argument for extending the principle of equality beyond our own species is simple, so simple that it amounts to no more than a clear understanding of the nature of the principle of equal consideration of interests. We have seen that this principle implies that our concern for others ought not to depend on what they are like, or what abilities they possess (although precisely what this concern requires us to do may vary according to the characteristics of those affected by what we do). It is on this basis that we are able to say that the fact that some people are not members of our race does not entitle us to exploit them, and similarly the fact that some people are less intelligent than others does not mean that their interests may be disregarded. But the principle also implies that the fact that beings are not members of our species does not entitle us to exploit them, and similarly the fact that other animals are less intelligent than we are does not mean that their interests may be disregarded. (

11 162 This brings up problems concerning the balance between the interests of human communities and animal communities. For example, is it permissible to kill animals which pose harm to people, destroy crops, or spread disease? How far do we extend the rights of animals at the expense of local communities? Importance of Bioethics We can suggest here that Bioethics is often concerned with what is natural as opposed to what is artificial. We want to somehow preserve what is natural in the world around us and within ourselves. Some critics would suggest that this involves a flawed argument that something is good simply because it is natural and bad because it is unnatural. This is called the naturalistic fallacy. Other problems concern the status of our theories themselves for making decisions. They tend to be too ideal and not practical. The Stanford Encyclopedia of Philosophy in its article on Bioethics describes this problem as follows: In confronting questions bearing on health inequalities and inequities, bioethics will naturally seek guidance in various contemporary theories of justice, including Rawlsian contractarianism, utilitarian cost-benefit analysis, and libertarian theories of natural rights. In order to present us with a picture of a completely just society, the theorist must make several idealizing assumptions that tend to distance that picture from social reality as we know it. ( The alternative to such ideal theories is a movement called anti-theory which focuses on the diversity of cultures, religions and situations. At the other extreme, bioethics has witnessed the emergence of several interesting varieties of anti-theory, including various strains or combinations of casuistry, narrative ethics, feminism, and pragmatism. Although each of these alternative methodological approaches features more moderate variants that reserve a legitimate place for moral principles and even for some kinds of theory, their stronger antitheory incarnations unite in rejecting any justificatory role either for high moral theory or mid-level moral principles. Whereas theorists tend to favor top-down, deductivist modes of thinking, the anti-theorists embrace bottom-up (but not too far up) modalities of thought, such as common law jurisprudence in which the factual particularities of the case take center stage (Arras 1990). Whereas theorists tend to emphasize the capacity of our ordinary moral experience to be neatly ordered and systematized, the anti-theorists emphasize the cultural embeddedness, particularities, and ineradicable untidiness of our moral lives (Elliott 1999). And whereas theorists aspire to construct symmetrical cathedrals of normative thought, the anti-theorists tend to conceive of the moral life as Wittgenstein conceived of language itself, i.e., as a haphazardly evolving city consisting of a maze of ever-expanding little streets, alleyways and squares. ( Is there a balance between theory and practice? These are some of the issues that Bioethical philosophers are struggling with. But for all of us, no matter what career or profession we pursue, these questions are very important. We do need to pay close attention to these issues because by virtue of our technologies, we are changing our environment and ourselves in

12 ways which we don t completely understand. Our religious and moral values developed over long periods of cultural history and have allowed us to live in communities and make decisions based upon what is considered right or wrong. But now the pace of change in society has become so great and so fast that our traditional values have struggled to adapt. We do not have a solid place to stand. Bioethics attempts to allow our values to catch up with our technological innovations. 163