Download The History Of BioMedical Ethics

A Brief History and Overview
Of
Biomedical Ethics
Dr. Ruth Pilkington
7th October 2009
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What is Biomedical Ethics?
BIOMEDICAL ETHICS
APPLIED ETHICS
MORAL PHILOSOPHY
PHILOSOPHY
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Medical Ethics
Ethics expresses the ways in which we examine, explore
and attempt to understand the moral life.
What are the moral obligations of health professionals in
a world of advancing technology and promise.
Allows us to reflect on the relationship between the
professional and the patient.
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Medical Ethics
Ethics : a generic term for the various ways of
understanding and examining the moral life
Moral Choices:
what values, what reasons and what language
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Medical Ethics
Applied Ethics : a practical discipline
Investigates ethical issues which arise in medicine and
healthcare by applying the principles and methods
of moral philosophy to these problems
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Medical Ethics
The doctor patient relationship
What makes a good doctor / professional?
What choices, values and traits
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How Should One Live?
(Socrates)
How doctors should treat patients rests on general moral
principles about how a person should treat another person
Thus
Biomedical ethics grounded firmly in the study of moral
philosophy
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What is Biomedical Ethics?
Species of practical normative ethics
Norms = standards of right and wrong action &
behaviour
Normative ethics = is concerned with how people
ought to act, what sort of person one ought to
be or what sort of policies ought tot be
implemented.
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What is Biomedical Ethics?
Species of practical normative ethics
What one is obligated or permitted to do, or
prohibited from doing, in different contexts of
biotechnology, medical practice and research.
So we employ principles and theories of normative
ethics to motivate and justify actions and policies
in biomedicine.
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What is Biomedical Ethics?
Species of practical normative ethics
1.
Objectivity
2.
Impartiality
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What is Biomedical Ethics?
Descriptive ethics
Descriptive ethics is concerned with how people
actually behave, not how they ought to behave.
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What is Biomedical Ethics?
Metaethics
Metaethics is focussed on the nature of morality;
concerned with the point of ethics, i.e. what do
the terms ‘good’, ‘bad’, ‘wrong’, right mean..
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Contemporary Medical Ethics
‘...the student begins with the patient, continues with
the patient, and ends his studies with the patient,
using books and lectures as tools...’
Sir William Osler, Canadian Physician(1906)
As quoted in Singer, P, Viens, AM, Cambridge Textbook of Bioethics (2008)
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Ethical Reasoning
Clinical Ethics is learnt in the same way as clinical medicine
is learnt, ‘at the coalface’, through meeting patients and
their families, being involved in their cases. It is a
practical discipline.
The doctor must learn to recognise the ethical aspects of
his/her clinical (and scientific research work), and to
make reasoned decisions about this work within the
framework of the law and medical council guidelines.
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Contemporary Medical Ethics
‘Society allows doctors a degree of personal freedom in making
decisions and in their interactions with patients. But in giving
doctors that freedom society expects them to be able to defend their
decisions and actions with reasons...Doctors must be able to show
how their decisions and actions relate to the law and to the
relevant guidelines.’1
1Hope,
Savulescu, Hendrik, Medical Ethics and Law (2008)
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Ethical Reasoning
Learning to Reason
Scientific Reasoning
The skill of evaluating the
scientific evidence available and
applying it, using clinical judgement
to the clinical scenario at hand.
This is a fundamental part of your
medical education and later
practice.
Ethical Reasoning
In the same way, ethical
reasoning is a skill required to allow
you to identify and negotiate
ethical problems, using an
organized framework of ethical
methods or tools in the clinical
setting.
Ethical reasoning must stand up to scrutiny, (in court if necessary) in the
same way as the scientific aspects of decision-making.
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Traditional Medical Ethics
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2500 Years of Medical Ethics
A brief history
Timeline
460 BC
2009 AD
Hippocrates
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The School of Hippocrates
5th century BC
Hippocrates – ‘The Father of Medicine’
Medical School (Greek Island of Cos)
460 – 377 BC
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The Hippocratic Oath
c.1595
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Hippocratic Oath I
I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and
I take to witness all the gods, all the goddesses, to keep according
to my ability and my judgment, the following Oath and
agreement:
To consider dear to me, as my parents, him who taught me this art;
to live in common with him and, if necessary, to share my goods
with him;
To look upon his children as my own brothers, to teach them this
art.
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Hippocratic Oath II
I will prescribe regimens for the good of my patients according to my
ability and my judgment and never do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I
advise such a plan; and similarly I will not give a woman a
pessary to cause an abortion
But I will preserve the purity of my life and my arts.
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Hippocratic Oath III
I will not cut for stone, even for patients in whom the disease is
manifest; I will leave this operation to be performed by
practitioners, specialists in this art.
In every house where I come I will enter only for the good of my
patients, keeping myself far from all intentional ill-doing and all
seduction and especially from the pleasures of love with women or
with men, be they free or slaves.
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Hippocratic Oath IV
All that may come to my knowledge in the exercise of my profession
or in daily commerce with men, which ought not to be spread
abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my
art, respected by all men and in all times; but if I swerve from it
or violate it, may the reverse be my lot.
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Beneficence and Nonmaleficence
1.
2.
Hippocratic Oath:
Established the principles of Beneficence and
Non-maleficence
Prohibited poisons and potions for abortion
or euthanasia
3. Maintain confidentiality
4. Avoid exploitation
5. Pursue ‘best interests’ of patient
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The Hippocratic Oath
However no acknowledgement of the patient’s
rights (e.g. truth telling or consent)
Does not deal with welfare of society or of others
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The Hippocratic Oath
The Oath of ‘a closed, self-protecting guild’1 ;
an ‘old boy’s club’?
‘Tradition of altruistic doctors practising paternalistic
medicine...’?
1Harris,
J, Bioethics (2001) OUP
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Thomas Percival,
English Physician
Beginning of modern professional ethics
First used the term ‘Medical Ethics’ in his book on
the subject (1803)
Somewhat of a misnomer at this point; conflicts
between practitioners were endemic at this time
c.f. Manchester doctors dispute
Tripartite structure of medicine at the time:
Physicians, Surgeons and Apothecaries
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Thomas Percival
Expanded the Hippocratic focus on the doctor-patient
relationship to a broader social ethic of medicine
emphasizing the professional responsibility of the
physician.
Influenced the early ethical codes of AMA, BMA and the
WMA up until 1940’s
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Medico-ethical Assoc. 1800s
Manchester Medico-ethical Assoc.
BMA medico-ethical committee 1853
The attempt to produce codes of professional ethics to
deal with certain recurrent problems they faced
in the practice of their profession.
‘Colleague control’
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AMA Code of Medical Ethics 1849
Revised to AMA Principles of Medical Ethics
1903
Leading with revised editions to a code embodying
a set of principles that in the spirit of Percival,
emphasize not only nonmaleficence and beneficence
but also doctors’ responsibility to the medical
profession and to society at large.
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Medical Ethics
Foundations I
Traditional codes of ethics:
Doctors ‘as independent, self-sufficient
philanthropists, whose beneficence is analogous to
generous acts of giving.’
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Modern /Biomedical Ethics
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20th C : Nazi Germany and US
Experimentation on Humans
Without their consent
‘Perverse extension of the authoritarian nature of
paternalism’ (Glannon)
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Nuremberg Code (1947)
The judgment by the war crimes tribunal at
Nuremberg laid down 10 standards to which
physicians must conform when carrying out
experiments on human subjects.
1. ‘The voluntary consent of the human subject is
absolutely essential…’
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Nuremburg Code (1947)
Informed Consent enshrined in Medical Ethics Code
Patient oriented approach for the first time
Medical ethics ceased to be the sole domain of doctors; now
tested against the principles of society (Kennedy, 1981)
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Changing Society 1960s
Less deference to authority
Anti-war movements, Vietnam, Cuban Missile
crisis, CND, hippies, public demonstrations for
‘rights’, civil rights movements, feminism
Generally more assertive attitudes to individual
rights and self-determination
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Changing Medicine
Technology progressing to offer more expensive
treatments, life-prolonging, scarcity of resources
with increasing costs (Dialysis, Organ transplant,
Artificial ventilation)
Reproductive control with contraception and
abortion – concept of reproductive rights
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‘Bioethics’ (1971)
‘a new discipline that combines
biological knowledge with
knowledge of human value
systems’ (Potter, 1971)
Medicine
Ethics
The study of the ethical
dimensions of medicine and the
biological sciences
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*
Science
‘Bioethics’
A growth in Academic comment with a shift in Moral
philosophy increasingly from metaethics to applied ethics
Increasing ethical issues for society as a whole, prompted by
the new technologies (IVF, Genetics, Stem cell technologies,
etc.)
Non-medical commentary (philosopher, sociologist, ...) on
how medicine and science should be regulated and how doctors
and scientists should behave
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Modern Medical Ethics
Foundations II
Moral Philosophy
Contemporary Medical ethics:
1960s Moral problems of modern society
CND, Vietnam, ...
Personal and public responsibility for happens to the world
Patients have rights and entitlements
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Beneficence
and Nonmaleficence
Early interpretations
excessively paternalistic
Now tempered with the recognition of other
principles
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Autonomy
Gradual shift in decisional authority from doctor
to patient
Introduced the patient based principle of
AUTONOMY
To sit alongside and complement physician based
principles of beneficence and non-maleficence
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AUTONOMY
auto = ‘self ’
nomos = ‘law’
Moral Self Rule
Having the capacity and the right to selfdetermination; to formulate and follow a life plan
of one’s own making
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AUTONOMY
Respect for persons
as autonomous
ends-in-themselves
Capacity to Reason
Apply the moral law
unto ourselves
John Stuart
Mill’s
Principle
of Liberty
Kantian Ethics
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Sovereign
over own mind
and body
Individual freedom can be
restricted only if risk of
harm to others
Justice
In context of a changing society,
‘equality’ involves the concept of equal access to
society's ‘goods’,
i.e. scarce and expensive healthcare resources
How can these be justly allocated?
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Modern Biomedical Ethics
Modern bioethics reformulates the fundamental moral
problems as a problems for society, rather than merely
ones of professional self-regulation.
Takes the patient’s perspective as it’s starting point.1
1 Gillick,
M., NEJM 2000; 342 (19) 1458-59
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