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Biomedical Ethics 1 2 Introduction to Philosophy “Philos” = Love “Sophia” = Wisdom “Philosophy” = Love of Wisdom 3 A Formal Definition of Philosophy: • The rational, critical investigation of the fundamental questions of life that resist solutions by empirical science 4 Ethics • The Study of Right or Correct Behavior 5 Divine Command Theories 6 Ethics Chart 7 Ethics Objectivism Absolutism Contextual Absolutism Relativism Conventionalism Subjectivism 8 Objectivism • There are universally valid moral principles 9 Relativism • There are no universally valid moral principles 10 Absolutism • There is one universally valid moral principle • Immanuel Kant 11 Contextual Absolutism • There are several universally valid moral principles and context decides which one to follow • The Ten Commandments • Aristotle 12 Conventionalism • Society decides moral principles • Ruth Benedict 13 Subjectivism • The individual decides moral principles • Jean Paul Sartre • Friedrich Nietzsche 14 Meta-Ethics • The study of • Concepts • Methods of Justification • and Knowledge • of Ethics 15 Normative Ethics • The study of rational guidelines for behavior • How people “ought” to act 16 Descriptive Ethics • The study of how people do act • Describes how people do act 17 Naturalistic Fallacy • Confusing what “is” • With what “ought” to be • Confusing how people do act • With how they “ought” to act • “Ought” does not equal “is” 18 Normative Ethics • Biomedical ethics is a branch of normative ethics • Business ethics • Sports ethics • Etc. 19 Biomedical Ethics • Ethical issues associated with the practice of medicine • Advance reasoned analysis to clarify and resolve ethical issues • Practice of medicine in most inclusive way 20 Criteria for Ethical Theories • 1. Clear, well-defined concepts • 2. Consistent statement – No Contradictions 21 • 3. Should tell us how to act in all situations – Abortion – Euthanasia – Death Penalty – Sex and Love 22 • 4. The Simpler the better – Occam’s Razor – Less likely to make mistake – Easier to follow 23 • 5. Should be based upon the most complete evidence available – Many decisions lead to wrong action because of incorrect information 24 Consequentialist Theories • Moral theories that judge right / correct behavior based upon the consequences of the actions 25 Utilitarianism • John Stuart Mill • The right action in any situation is that action which creates the greatest amount of happiness 26 Cost-Benefit Analysis • A form of Utilitarianism Actions are evaluated based upon their corresponding cost and the anticipated benefits of the action 27 John Stuart Mill’s Moral Theory John Stuart Mill (1806-1873) English Member of Parliament Wrote on many subjects Utilitarianism The Greatest Happiness Principle Jeremy Bentham Act to create the Greatest amount of happiness For the greatest number of people As per a disinterested spectator Greatest Number of People • Everybody that your action will effect Disinterested Spectator • Your happiness cannot be more important than anyone else’s Happiness defined Pleasure Absence of Pain Hedonism • The goal is to experience as much pleasure as possible • Usually physical pleasure Epicureanism • The goal is to experience as much pleasure as possible without experiencing any pain • Only the best wine, food • No hangovers Different Kinds of Pleasure Quality Quantity Mental and Physical Quality of Pleasure • How many McDonald’s hamburgers equals a Filet Mignon? • None because the quality is different! • Some pleasures are simply better than others Quantity of Pleasure • Whatever you enjoy, isn’t more of it better? Point of Diminishing Returns • But we reach a point in our pleasure where more is not better but actually painful • How many pieces of candy do you like? • 5,10,15,? • How about a 1,000? Paradox of Hedonism • The more pleasure you derive from something, the more you need of it next time to receive the same amount of pleasure • Drugs and Alcohol Mental v. Physical Which is Superior? Mental Why? Based upon empirical evidence Ask those who have experienced both They agree that mental is superior Why is Mental Superior? 1. Greater Permanence 2. Safer 3. Less Expensive Act Utilitarianism An action is right if it produces more total happiness than any other alternative action available at the time Me My Mom My Dad My Aunt My Friends Total Visit Aunt -10 +8 +6 +10 0 +14 Go to Beach +10 -8 -6 -10 0 -14 Rule Utilitarianism After many acts, we develop a principle that if general followed would create the greatest amount of happiness for all people involved Criticisms 1. Requires too much 2. Focuses too exclusively on the future 3. Can lead to injustice Deontological Ethics • Greek: “Deon” = “Duty” • Moral theories that judge right / correct behavior based upon the intrinsic value of human beings 49 Kant’s Moral Theory 50 Immanuel Kant 1724-1804 German Wrote on many subjects Critique of Pure Reason 51 Requirements for Morality Free Will Rationality Moral Autonomy 52 Happiness? We are not here to be Happy But To be Worthy of Happiness 53 If happiness were the goal of human life Then we would be controlled by our instincts not reason The more you know the more pain and suffering you experience 54 Good Will Only thing in the world that cannot be perverted Although we might not always be able to do the right thing We must always want to do the right thing 55 Categorical Imperative Absolute Command of Moral reason 56 Deontological Ethics Morality based upon duty It is our duty to follow the Categorical Imperative 57 Moral Worth of an Action Based Upon Our Intentions Not The Consequences of the Action 58 Why? 1. Because doing what is right has intrinsic value 2. Since we are not God, we cannot guarantee that what we intent to happen will actually happen 59 Therefore We are only responsible for what we have complete control over OUR INTENTIONS 60 Wallet Example 61 1st Formulation Act only on the maxim that you could will to be a universal law of nature (without contradiction) 62 What is a Maxim? An Intention Or Reason for doing something 63 What is a Universal Law of Nature? Something that must happen whether or not we want it to Example: Gravity 64 Without Contradiction? Every time we are going to act We are to think about why we want to take that action Then imagine how we might write out a statement expressing our reasons for action 65 If the action we are thinking about taking is morally wrong Then we will see a contradiction in the sentence stating our intentions 66 Example We want to borrow money from a bank But we have no intention of paying the money back to the bank What would a statement look like expressing this intention? 67 It is morally acceptable to sign a promissory note to pay back the money when I have no intention of keeping my promise to pay the money back 68 Contradiction? I make a promise with no intention of keeping the promise 69 70 2nd Formulation Always treat people as ends in themselves never as means to an end 71 Don’t use people Why? Because human beings have intrinsic value Rationality Free Will Moral Autonomy 72 We use objects not people Pornography? 73 Conscience? • We might think of the Categorical Imperative as our conscience • The sense of what is right or wrong in our behavior and motives 74 Deontological Medical Ethics • Ultimate worth of the Individual • Maximum Individual autonomy • Respect for the individual 75 Virtue Theories • Mainly concerned with what kind of a person we are • A virtuous person will act correctly in situations 76 Teleological Ethics • Greek: “teleos” = end / purpose • Moral theories that judge right / correct behavior based upon a particular goal or purpose or consequences of the action 77 Aristotle’s Moral Theory 384-322 BC Greek Philosopher Nicomachean Ethics Student of Plato Wrote on many subjects What do you want to be when you grow up? HAPPY!!!! Teleological Ethics of Aristotle The end or goal of man is to be happy Isn’t your ultimate desire to be Happy? All things aim toward happiness • Why do you want to be rich? • Why do you want a nice car? • Why do you want a nice spouse? • Intermediate Goals Isn’t your final goal TO BE HAPPY? Why do you want to be Happy? • Silly Question • Because Happiness is the Ultimate Goal in Life Eudiamonia Greek for Happiness Eudiamonia Defined To live well Well-being Human flourishing Self-sufficient Family Friends Fame Wealth But also: Luck Fortune Based upon TEMPORAL CIRCUMSTANCES Example Wonderful family tragically killed in accident Would you still be happy? Probably not! How do we understand happiness? By answering the question: What is the function of Man? The function of a thing will help us determine what a “good” thing really is Example What is the function of a knife? To cut Therefore a good knife cuts good and is therefore sharp The function of man is the exercise of his reason A Good Man Is a man who uses his reason The rational man What does it mean to be rational? To live in such a way that will enable you to satisfy your purpose Which is to be happy! How do we achieve this? By Developing Virtue Arete Virtue Excellence The virtuous man is the most excellent man What is Virtue? The Relative Mean between two extremes The middle point between two extremes The “Golden Mean” Relative v. Absolute Mean Absolute Mean is the exact mid-point between two extremes Aristotle is not talking about this! Relative Mean • This is what Aristotle is talking about 99 Based Upon? • The Individual’s • Physical • Intellectual • Genetic • Specific Circumstances For Example • How much should you drink? Considerations Weight? Physical Constitution? • How much food have you consumed? • What’s your mental and emotional state? These may change over time • Your Mean may change You need to know yourself • Possessing Virtue means that you also know yourself • Your Limits • Your Strengths • Your Weaknesses 4 Primary Virtues Wisdom Justice Courage Moderation Wisdom What are the two extremes that wisdom is the middle point of? Justice Courage Moderation Social Virtues Concerning Money • The Virtue is to be Generous Virtue Concerning Honor • Pride • (Appropriate Self-Respect) We should have Good Temper Virtue is not Natural • We are not born with virtue This is Good • If we had to be born with virtue and were not • That would be it • There would be nothing we could do about it How do we develop Virtue By Developing Character Qualities Through Practice Through Habits • Thru Experience • Thru a Good Teacher Virtue Ethics in Medical Ethics • Emphasizes Virtuous Character • Truthfulness • Compassion • Sincerity • Courage 118 Emphasizes who we are as opposed to the performing of actions In virtue ethics Agents performing the actions are the focus In action-based approaches to ethics The principle thing emphasis is the doing the right thing 119 For Example • Suppose someone does what is wrong (?) but has extraordinary compassion • (Lies to a patient) • Recovering from a serious car accident and does not tell of the death of a family member as passenger 120 • Suppose someone does what is right (?) but is mean and nasty • (Tells the patient the truth) • Recovering from a serious car accident and does not tell of the death of a family member as passenger 121 Prima Facie Duties • W.D. Ross • (1877-1971) • English Philosopher • The Right and Good • (1930) 122 Prima Facie Duties • “at first sight” • A prima facie duty is a conditional duty • There is no absolute prima facie duty • Any duty can be overridden depending upon the circumstances 123 Moral Relativism • Right or correct action is relative to • 1. The Situation • 2. Important Factors 124 Common sense tells us in some situations that an action (keeping a promise) is right, not because of its consequences, but because of what has happened in the past (we made the promise). 125 Conflicting Duties • Common sense also tells us in some situations that we have more than one duty and that one duty • (relieving distress) • may be "more of a duty" than another duty (fulfilling a promise). 126 Elements of Ross’ Moral Theory • A variety of relations among individuals are morally significant 127 • promiser-promisee, • creditor-debtor, • wife-husband, • child-parent, • friend-friend, • etc 128 • There are a few general "rules of thumb" to follow when prima facie duties conflict • For example: • Nonmaleficence is generally more important than beneficence. 129 • However, there is no ranking among the prima facie duties that applies to every situation. • Each situation must be judged separately. 130 Ross’ List of Prima Facie Duties • 131 1. Fidelity • Duty to fulfill (explicit and implicit) promises/agreements into which one has entered 132 2. Reparation • Duty to make up for wrongful acts previously done to others 133 3. Gratitude • Duty to repay others for past favors done for oneself 134 4. Justice • Duty to promote fairness 135 5. Beneficence • Duty to improve the conditions of others 136 6. Self-Improvement • Duty to improve one's own condition 137 7. Nonmaleficence • Duty not to injure others 138 Bottom Line • How do we make a decision when there are conflicting prima facie duties? • Ross says that the best we can do is make a • “Considered decision” 139 Important Concepts • Respect for Patient Autonomy • Principle of Nonmaleficence • Principle of Beneficence • Principle of Justice 140 The Ethics of Care and Feminist Ethics • Emphasizes • Empathy • Concern for the needs of others • Caring 141 Carol Gilligan • Women tend toward an • Ethics of Care • Men tend toward an • Ethics of Justice 142 • Relationships should be taken into account more when making a moral decision • Caring responsiveness to the needs of others is often morally preferable to detached dispassionate moral evaluation 143 • Must be more aware of oppression • Personal • Professional • Institutional 144 Casuistry • Case Study • Considering each situation as unique while trying to apply more general ethics principles 145 Practical Wisdom • Necessary for applying more general ethical principles to individual cases and situations 146 Practice over Theory • Casuistry asserts the priority of practice over theory • What has worked or produced the best results in the past 147 Reflective Equilibrium and Appeals to Coherence 148 John Rawls • No one level of ethical conviction deserves priority • General Moral principles • Prima Facie Duties • Casuistry 149 Considered Judgments • We use past experience to evaluate current situations • We can go from principle to case or • We can go from case to principle 150 • Moral reasoning is dynamic • It is never static • New situations demand new analysis 151 Conflict Resolution? We want coherency / consistency in our overall system of ethical convictions 152 Logical Consistency • Avoidance of outright contradiction 153 Argumentative Support • Must give good reasons for our ethical decisions 154 Liberty-Limiting Principles 155 The Harm Principle • To prevent harm to others 156 Principle of Paternalism • When someone acts like a “father” to someone else • Physician to patient • To prevent someone from harming themselves 157 Principle of Extreme Paternalism • To benefit the person 158 Principle of Legal Moralism • To prevent person from acting immorally 159 Social Welfare Principle • To benefit society 160 Logical Argumentation • Your final paper and presentation 161 Standard Form • • • • (1) Premise 1 (Reason 1) (2) Premise 2 (Reason 2) Therefore: (3) Conclusion (What you are trying to convince someone to accept) 162 Counter Examples • State the one major fact against your position • Respond to it 163