CHAPTER 14 – BIOETHICS – ETHICAL ISSUES IN MEDICINE
General Overview
This chapter engages a range of issues that revolve around the rights and
obligations of those involved in health care either as patient, a member of the
patient’s family, or health care professional and associates. The topics of
truth, confidentiality, informed consent, research, and experimentation are
broad – but here explored specifically in the context of medicine – and apply
to many areas of professional concern including education, law, and other
fields.
Class Suggestions
You might start by sketching out broad lines of possible responses to some
of the issues in terms of the consequentialist and nonconsequentialist
approaches or perhaps rights and consequences. Once these are on the board
you can tackle some of the more specific issues. Some students might be
encouraged to share some of their hospital experiences with you. Homework
projects might include questioning someone in their family about the
doctor-patient relationships that they have experienced or heard about. The
cases here could be used to spark discussion or for group or pair
presentations.
The recently passed Affordable Care Act will generate ethical issues
concerning wealth and resource distribution, the nature of the doctor-patient
relationship, confidentiality and choice, sustainability and health care costs,
privacy rights, quality of care and medical research. The law is not fully
implemented and there are already numerous court cases pending
concerning areas of this legislation. This emerging change in healthcare
offers real-time practice for students to examine the above ethical issues and
see the various relationships that exist with ethical issues. Attention to the
above issues should generate good classroom discussion and also be a
valuable way to help students separate ethical issues from legal issues and
political policy.
Chapter Summary
Bio-ethics – life ethics or relations between sick and dying, health and
medical professionals.
Health Care Professionals and Patients and Their Families – Rights and
Obligations
Paternalism
Relation between doctors and patients is like parent and child.
Engineering Model:
“Value-free” or purely technical approach to patients.
Priestly Model:
Opposite of engineering model – doctor-priest does what is considered best
by avoiding harm.
Radical Individualism
Patients have absolute rights over their bodies.
Reciprocal View
Patients, families, and health workers make decisions together as part of a
team approach. This can develop into two models:
1. Collegial model – patient and doctor as colleagues
2. Contractual model – covenant between doctor and patient
Truth Telling and Informed Consent
Two issues:
1. To what extent should patients be told the truth?
2. Informed consent as formalized procedure for patient to accede to
treatment.
Paternalistic View of Truth Telling
Patients have a right to know the truth about their condition even if it will
affect them adversely.
Moderate Position
In between telling patients what they want to know when they want to know
it. Requires careful judgments about patients and their capacity to deal with
the truth.
Informed Consent
Now necessary because of complexity of medical procedures. In order to
fully and intelligently “consent” to such procedures the patients must be
thoroughly “informed” about the details, effects, complications, etc.?
Doctors’ Reactions to Truth Telling and Informed Consent
1. Patient doesn’t need to be fully informed
2. Patients often don’t want to hear complicated explanations
3. Risks shouldn’t frighten patients
4. Risk may deter patients from agreeing to necessary procedures
5. Psychosomatic risks
Patients’ and Families’ Reactions to Truth Telling
Patients may deny existence of their conditions but may want to know the
truth. Patients and families should be kept as fully informed as possible,
especially when it is clear they do want to know.
Confidentiality
Confidentiality problematic in relation to STD’s.
Positive HIV tests and AIDS
Spouses and Partners:
Should spouses or partners of HIV positive patients be told if the patient is
unwilling to tell them? HIV positive patients are protected by confidentiality
procedures.
Health Caregivers with HIV/AIDS:
Should caregivers have the same protection/confidentiality, etc. as patients?
Guilt and Innocence in Treating Patients
Do judgments regarding the extent to which patients are responsible for their
condition affect the quality of care they receive? Should this be the case?
Ethical Issues in Medicine
Ethics and Behavior Control
Should behaviors considered “socially unacceptable” be controlled by
medical technologies?
Problems with Behavior Control:
What is “normal” behavior? Who decides and on what basis?
Human Experimentation
In Favor:
1. Justified if it advances human knowledge
2. Prisoners or mentally ill who are capable of consent
Against:
1. Human beings shouldn’t be treated as means to end (e.g., Guatemalan
syphilis experiment)
2. Should not be performed on mentally incompetent or those not free to
consent
Genetics and Stem Cell Research
Arguments for Experimentation:
Scientific knowledge should proceed without hindrance.
Arguments against Experimentation:
Experimenting with God’s or nature’s plan, especially artificially creating
life, should not be allowed.
Stem Cell Research
Stem cells are capable of developing into many different kinds of cells.
The Moral Issue:
Stem cells can be developed into tissues which could potentially cure
diseases like Parkinson’s, Alzheimer’s diabetes, etc. Extracting stem cells
from 5 to 7 day old embryos kills them.
Government Limits:
To receive federal funds, George Bush decided that stem cell lines that were
derived:
1. With the consent of the donor
2. From excess embryos (created for reproductive purposes)
3. Without any financial inducement to the donors
No federal funds for:
1. Stem cell lines derived from newly destroyed embryos
2. The creation of human embryos for research
3. The cloning of human embryos
Could the use of adult stem cells resolve this dilemma?
KEY TERMS AND CONCEPTS
Bioethics Informed Consent
Rights Right to Know
Obligations Confidentiality
Paternalism Behavior Control
Radical individualism Experimentation
Reciprocal Model Genetics
Truth-Telling Stem Cell Research
ESSAY QUESTIONS
1. “Doctor knows best.” Evaluate this claim looking at its advantages and
disadvantages in terms of patient care.
2. Critically explore the rights and obligations involved in doctor-patient
confidentiality. Try to illustrate your answer with examples and/or
cases.
3. Examine the ethics of behavior control. What are the problems and
advantages of such an approach?
4. Are human experiments ever justified?
5. Should embryonic stem cells be used in research? Discuss in relation to
the dangers and potential benefits.
TRUE/FALSE
1. Bioethics means “life ethics.”
2. Paternalism, as the name suggests, is that position that argues that health
care professionals know only what they learn from patients.
3. Radical individualism is the view that some patients have very strong
and extreme political views.
4. Informed consent refers to a formalized procedure whereby patients
consent to treatment usually in writing.
5. If doctors kept patient information strictly confidential there would be
no moral issues.
6. Behavior control in bioethics refers to technologies that alter a person’s
behavior with or without their consent.
7. In some cities in the US hyper kinetic children have not been allowed to
go to school unless their parents agree to give them a drug that slows
down their activity levels.
8. Those strongly in favor of experiments on both humans and animals
argue that anything that advances scientific knowledge or aids humanity
is justifiable.
9. Sexually transmitted diseases do not have to be reported by law.
10. Stem cells have the potential to become any kind of body cell.
MULTIPLE CHOICE
11. Paternalism in medicine is best captured in the phrase
a) doctors know best.
b) patients know best.
c) nurses know best.
d) all of the above.
12. The engineering model of doctor-patient relations suggests that
a) the patient is the engineer of his illness.
b) the doctor is a qualified technician treating and improving the
body-machine.
c) the patient is valued above all else.
d) doctor and patient are part of a team.
13. That doctors should tell their patients what they want to know and when
they want to know it is referred to as the approach to truth telling.
a) paternalistic
b) patient’s rights
c) moderate
d) worst
14. If doctors all agree that patient related-information is private then why is
confidentiality an issue?
a) Doctors find it difficult to keep quiet.
b) Doctors get paid from the newspapers for releasing secret
information.
c) Doctors are known for breaking confidences.
d) Protecting the innocent.
15. The assumption behind informed consent is that
a) patients don’t understand their condition.
b) doctors might abuse their trust.
c) doctors and nurses often do things against a patient’s will.
d) in order to consent to a procedure a patient must be informed about
it.
16. A ___________ approach to human behavior control would insist that
we don’t know what the
standard for normal behavior is.
a) behaviorist
b) antibehaviorist
c) Kantian
d) Caring
17. So called ___________ is a technique used to deal with overeating,
drug, or alcohol abuse.
a) brain surgery
b) “hot wax” treatment
c) carrot ‘n’ stick
d) aversive conditioning
18. The main moral argument against the use of human beings in
experiments is that
a) humans do not make good subjects.
b) humans should not be used as a means to an end.
c) animals are less squeamish.
d) animals don’t think or reason.
19. The central view of those opposed to stem cell research is that
a) no good can come of it.
b) the slippery slope or Domino effect will make us like Nazis.
c) humans can’t “play God.”
d) the procedure kills the embryo.
20. How will the use of adult stem cells resolve some of the moral issues
involved here?
a) Because they’re older they can deal with it.
b) Because an embryo is not involved.
c) Because adult stem cells are more useful.
d) None of the above.
Answer Key to Chapter 14 Test Questions
True or False:
Multiple Choice: