Bioethical Issues in Health Care 2024 Lecture Notes PDF

Ethics of Science & Technology Bioethical issues in health care Chapter # 3 First Semester 2024-252024-25 Summer semester 2023-24  Bioethics Bioethics or biomedical ethics is the science that deals with the ethical of biological research and its appli...

Ethics of Science & Technology Bioethical issues in health care Chapter # 3 First Semester 2024-252024-25 Summer semester 2023-24  Bioethics Bioethics or biomedical ethics is the science that deals with the ethical of biological research and its applications, especially in medicine The number of bioethical issues surrounding the delivery of health care is growing because advancement of Biotechnology. The bioethical issues can be divided into: A.issues related to the beginning of life: focused on the process by which conception occurs, the products of conception, the beginning of life, including whether it should occur, family planning  Bioethics The bioethical issues can be divided into: B. issues related to the end of life& quality of life : It is an important area that may include: 1. Euthanasia & assisted death: Right-to-die, to refuse treatment, withholding and withdrawing treatment 2. Futile treatments: medicines, devices, or therapy that may has no benefits or may harm the patient (treatment for a respiratory infection in individual is dying of terminal cancer). Who decide? Accurate? Cost? 3. Organ transplantation: procurement (obtaining) of organs, availability of organs for minorities, allocation of organs, and the correctness of transplantations 4. Genome Project, gene therapy  Bioethics The bioethical issues can be divided into: C. access to healthcare and insurance for all D. management of healthcare, cost containment and quality of care E. Issues emerge by advancements in biomedical research such as: 1. Stem Cell Research - ‫أبحاث الخاليا الجذعية‬ 2. Cloning Research ‫ بحوث االستنساخ‬- 3. Genome Project Results ‫االبحاث الجينية‬- 4. Fertility Research ‫ابحاث الخصوبة‬-  Euthanasia ❖ Definitions :is the process of painlessly helping a terminally ill person to die. Based upon its Greek origin, euthanasia means a “good death”. ❖ Types: A. Based on the Consent for doing it:  Voluntary euthanasia  Non-voluntary euthanasia  Involuntary euthanasia B. Based on the way of doing it:  Passive euthanasia  Active euthanasia  Euthanasia Based on the Consent: 1. Voluntary euthanasia: Euthanasia made with the consent of the patient is called voluntary euthanasia. When the patient brings about his or her own death with the assistance of a physician, the term assisted suicide is often used instead. 2. Non-voluntary euthanasia: Euthanasia conducted when the patient is unconscious (where it is not possible to know the person’s wishes). 3. Involuntary euthanasia: carried out either against the person’s wishes, or without obtaining the competent person’s permission.  Euthanasia Based on the way of conducting it: 4. Passive euthanasia: entails the withholding of common treatments, such as antibiotics, necessary for the continuance of life or the patient refuses to take the treatment that could prevent him/her from dying “letting die”. 5. Active euthanasia: “killing” or actively bringing about death. It involves the use of lethal substances or forces to kill and is the most controversial means.  Euthanasia Pros of Euthanasia ❖ It provides a way to relieve extreme pain (Death with dignity) ❖ It provides a way of relief when a person's quality of life is low ❖ Frees up medical funds to help other people Cons of Euthanasia ❖ Euthanasia de-values humans’ life ❖ Physicians and other medical care people should be involved in directly causing death  Euthanasia Islamic view on Euthanasia ❖ Life is sacred and holy (‫)مقدس‬ ‫ان‬ َ ‫س‬ ِ ْ ‫) َو ُه َو الَّ ِذي أ َ ْحيَا ُك ْم ث ُ َّم يُ ِميت ُ ُك ْم ث ُ َّم يُ ْح ِيي ُك ْم ۗ ِإ َّن‬: ‫❖ قال تعالى‬ َ ‫اْل ْن‬ ﴾٦٦ ‫ )الحج‬.)‫لَ َكفُور‬ ❖ “The European council for Fatwa and Research stated “It is forbidden to end deliberately or to hasten the death of any person.” “Do not kill yourselves, for verily Allah has been to you most merciful.”  Euthanasia Islamic view on Euthanasia ❖ Everything that happens in life is a test ❖ “No one dies unless Allah permits it.” ❖ All forms of suicide are wrong ❖ The prophet Muhammad Tells of a story about a soldier with a wound who widened it to hasten his death and Allah said he did not permit him to enter paradise  Cloning Definition: ❖ Is the process by which we get identical copies from an organism, a cell or a molecule, already developed, in an asexual way. OR ❖ Is the production of a new being practically the same as the mother cell, through nonsexual/asexual genetic techniques.  Cloning Why Cloning is done (support)? Pros of Cloning ❖ Making copies of those that have deceased/died (produce people with desirable traits) ❖ A mean of curing diseases (combat genetic diseases) such as Diabetes, Parkinson's, and Cystic Fibrosis. ❖ Solution to infertility ❖ Provide children who need organ transplants to have a clone born to donate organs (cloned body parts can serve as backup systems for humans). ❖ Replicate animals for research purposes (Enable alterations of plants & animals).  Cloning Why Cloning should NOT be done (don’t support)? Cons of Cloning  Decline (weaken) in genetic diversity (same genetic material) & so the ability of adaptation  Bypass the natural reproduction.  Also, if a population of organisms has the same genetic information, then a disease would wipe out the entire population.  The moral rights of clones: not granted the birth of newness; we would not receive clones with such excitement as a child of a couple who conceived naturally.  Economic barriers: cost  Cloning Why Cloning should NOT be done (don’t support)? Cons of Cloning  The technique of nuclear transfer is also early in its developmental stages (errors are occurring, example, it took 277 trials to produce Dolly with abnormalities)).  Taking the work of God into our own hands (Human’s acting as God).  Mental and emotional problems that may result if a clone were to find out that he or she was cloned.  Production of undesirable traits  Invites malpractices into society  Undermining human life and devalue mankind  ‫‪Cloning‬‬ ‫‪Islamic view on cloning‬‬ ‫‪reproductive cloning is prohibited.‬‬ ‫توصيات المنظمة اْلسالمية للعلوم الطبية‪:‬‬ ‫‪‬‬ ‫أوال ‪ :‬تحريم كل الحاالت التي يقحم فيها طرف ثالث على‬ ‫العالقة الزوجية سواء أكان رحما أم بويضة أم حيوانا‬ ‫منويا أم خلية جسدية لالستنساخ‪.‬‬ ‫ثانيا ‪ :‬منع االستنساخ البشري العادي‪.‬‬  Abortion  Abortion is the termination of pregnancy before the viability of the fetus, that is, any time before the end of the 6th month (20-24 weeks) of gestation.  Abortion could be: 1. Spontaneous (miscarriage, result of natural causes) 2. Therapeutic (medical causes: to save the life of the pregnant woman; to prevent harm to the woman's physical or mental health) 3. Elective (personal causes, non-medical reasons)  Abortion Moral arguments regarding abortion ❑ Types of arguments regarding the morality of abortion have been identified as: Arguments about the moral status of the fetus (when the fetus should be considered a human being: the moment of conception? implantation of the ovum in the uterus? until the fetus is sufficiently developed biologically to sustain itself outside the uterus?); Arguments from potential; and Arguments from a woman’s right to reproductive autonomy (unwanted child, or a child born with a deformity or genetic defect) ❑ Abortion is a legal issue: it is illegal or unlawful action  Islamic view on abortion ‫سا‬ ً ‫علَى بَنِي ِإ ْس َرائِي َل أَنَّهُ َمن قَت َ َل نَ ْف‬ َ ‫ ) ِم ْن أ َ ْج ِل ذَ ِل َك َكت َ ْبنَا‬: ‫ قال تعالى‬ ‫اس َج ِميعًا َو َم ْن أ َ ْحيَا َها‬ َ َّ‫ض فَ َكأَنَّ َما قَت َ َل الن‬ ِ ‫سا ٍد فِي األ َ ْر‬ َ َ‫ِبغَي ِْر نَ ْف ٍس أ َ ْو ف‬ ِ ‫سلُنَا ِبالبَ ِينَا‬ ‫ت ث ُ َّم ِإ َّن َك ِثيرا ً ِم ْن ُهم‬ ُ ‫اس َج ِميعًا َولَقَ ْد َجاءتْ ُه ْم ُر‬ َ َّ‫فَ َكأَنَّ َما أ َ ْحيَا الن‬.32 ‫ون ) المائدة اآلية‬ َ ُ‫ض لَ ُم ْس ِرف‬ ِ ‫بَ ْعدَ ذَ ِل َك فِي األ َ ْر‬ Muslims regard abortion as wrong and haram (forbidden), but many accept that it may be permitted in certain cases. Abortion is permitted if continuing the pregnancy would put the mother's life in real danger. This is the only reason accepted for abortion after 120 days of the pregnancy (when the soul is embedded into the fetus). Some schools of Muslim permit abortion in the first 16 weeks of pregnancy, while others only permit it in the first 7 weeks  Organ transplantation  Definition: is the process by which a tissue or organ is removed and replaced by a corresponding part.  Types: Autograft: tissues from one’s own body. Homograft/ allograft :a tissue graft obtained/taken from an organism & implanted on an organism of the same species as the recipient Xenotransplantation: Transplanting organs or tissues of animal (e.g. pigs) into human beings Artificial organs (artificial joints, heart valves, and heart) transplantation. Short-term Issues with Organ Transplantation 1) Demand exceeding (is more than) supply 2) Obtaining organs without consent Stealing organs There may be killing to obtain organs 3) Providers interested in profit may screen donors poorly and this could lead to the spread of infection.  Issues with Organ Transplantation 4) Buying and selling of organs: Exploitation of people who are poor (poverty and debt may mean that some people sell their organs), when: They may not be fully informed, or Their financial predicament is a mean of ‘coercion’ or unjust/unfair inducement Make money from a personal ‘commodity’ The inability of some people to pay for organs could be a form of injustice 5) Rejection: a major problem 6) Cost/resource allocation and Re-transplantation  Issues with Organ Transplant 7) Use of animal organs: this has the potential to overcome the demand-supply problem (experimentation stage). In addition, there is also opposition to the use of animals for humans’ purposes (rejection, infection, religious factors,…). 8) Side-effects of immunosuppressive (cyclosporine) drugs such as Nephrotoxicity, acceleration of atherosclerosis, and hypertension 9) Getting organs of brain-dead persons and anencephalic infants (born with only enough brain to support such vital functions as heartbeat and respiration. If born alive, only about 5% will live longer than 3 days).  ‫‪Islamic view on organ donation‬‬ ‫‪‬‬ ‫‪The majority of Islamic religious leaders accept organ‬‬ ‫‪donation during life (provided it does not harm the‬‬ ‫‪donor) and after death in order to save life.‬‬ ‫‪ ‬قرر مجلس مجمع الفقه اْلسالمي باْلجماع جواز نقل عضو أو جزئه من‬ ‫إنسان حي مسلم أو ذمي إلى نفسه إذا دعت الحاجة إليه وأمن الخطر في‬ ‫نزعه وغلب على الظن نجاح زرعه كما قرر باألكثرية ما يلي‪:‬‬ ‫‪ ‬جواز نقل عضو أو جزئه من إنسان ميت إلى مسلم إذا اضطر إلى‬ ‫ذلك وأمنت الفتنة في نزعة ممن أخذ منه وغلب الظن نجاح زرعه‬ ‫فيمن سيزرع فيه‪.‬‬ ‫‪ ‬جواز تبرع اْلنسان الحي بنقل عضو منه أو جزئه إلى مسلم مضطر‬ ‫إلى ذلك‪.‬‬  Sperm banks  It is an aspect of artificial insemination  It has been established in USA for many reasons: Men who want to have vasectomy. Men who are exposed to high levels of radiation or other harmful substances that might result in mutation of genes or sterility.  Is it ethical? Yes, but with limitations.Do we have it in Jordan? Yes  Should be used for the same person but not to be sold or donated  Number of donation in a specific community  Sterilization  Sterilization :a technique that intentionally leaves a person unable to reproduce  Types: o Surgical sterilization (ligation or removal of reproductive organs such as in Cancer, could be voluntary: personal health status, familial genetic disorders, or simply not wishing to parent) o Chemical sterilization (drugs to decrease libido, sperm production, and sexual ability) used with people with repeated rape/treating sex offenders. ▪ Issues: Full and informed consent is required + obtain assent from the spouse? should laws forbid it for contraceptive purposes?  Eugenics  Eugenics the study of methods to improve inherited human 1. Positive eugenics encouraged the increase of desirable traits in the population by urging “worthy” parents. “Superior” couples were encouraged to have more children. 2. Negative eugenics: marriage restriction, sterilization, & permanent custody. ❑ Connected with genetic counseling and genetic research  Surrogate mothers  Surrogate mother is a woman who agrees to bear a child conceived through artificial insemination and to give up the baby at birth to others for rearing.  The majority of problems have occurred in situations in which a woman has been paid to serve as a surrogate mother.  A formal, contractual relationship is usually established as it is illegal to sell a child.  Issues: 1)What happens if the child is born with an anomaly and the family refuses to take the child?, 2)What if the surrogate becomes attached to the child and refuses to give up custody?, 3)What if the parents divorce before the child is born and wish to nullify the contract?  Single parents  More single women are trying to adopt children, and some see in artificial insemination as a logical solution by using a donor sperm, the child then may be raised as in the lesbian relationship  Providing a parenting option to lesbians is totally unacceptable to many people because traditional family composed of man and woman is in the best interest of all children.  In vitro fertilization (IVF) In vitro fertilization is a process that includes monitoring and stimulating a woman's ovulatory process then the ovum (plural, ova) is fertilized by the sperm outside the body (in the lab) then implemented in the uterus. Usually 3 to 5 fertilized ova implanted in the uterus in the hope that at least one will survive the procedure (a process that has resulted in some multiple births). Delivery usually done by cesarean section.  In vitro fertilization Despite the objections raised against IVF, it is now recognized (at least as far as natural parenting is concerned). Done in cases such as: blockage in the mother’s fallopian tubes or male infertility issues In vitro fertilization differs from Internal (In Vivo) fertilization (Artificial Insemination: the fusion of sperm with egg occurs within the body of a female).  In vitro fertilization (IVF) The sex of human embryos could be identified after about 3 days of conception. Is it ethical? This could allow us to implant only female embryos and could be used to prevent the birth of boys in situations where the mother was at risk of passing on a severe genetic disease that occurs only in males.  Artificial Insemination  It involves the planting of sperm in the woman’s body to facilitate conception.  There are two different kinds of artificial insemination: o Homologous, in which the husband’s sperm is used (the most common and creates the fewest problems legally, ethically, and morally) o Heterologous, in which a donor’s sperm is used. ❑ Issues: 1) knowledge and consent of the partner? 2) Anonymous donors?, 3) children’s right to know their biological parental and family background?, 4) anonymous donor has been used for insemination many times in one community  Prenatal Testing The tests that can be done to check the health of the fetus or to assess the risk for having conditions such as chromosomal anomaly or a neural tube defect. muscular dystrophy, cystic fibrosis, thalassemia, hemophilia, and sickle cell anemia, as well as congenital and genetic defects.  Techniques for Prenatal Testing 1) Chorionic villi sampling (from the placenta, 10th or 11th week of pregnancy) 2) Amniocentesis (14-20th week after the last period) 3) Fetoscopy (endoscopic procedure to allow surgical access to the fetus, the amniotic cavity, the umbilical cord, and the placenta) 4) Maternal blood serum sampling 5) Ultrasound (sonogram) 6) Isolation of fetal cells in maternal blood 7) Embryo biopsy or preimplantation diagnosis  Issues ✓ Invasive fetal sampling is labor intensive so the cost is high (not all people can do it) ✓ Chorionic villi sampling (CVS) or amniocentesis are associated with a 1-2 percent risk of miscarriage after the sampling due to the procedure. principle of do no harm ✓ Nature of the diagnosis: Which one to use the Invasive VS Non-invasive one ✓ Outcomes and its related decisions: abortion ✓ The distress and the health risk to the mother  Issues ✓ The timing issue is the risk to the mother or fetus of the invasive techniques (stage of Pregnancy: There are different stages at which fetuses can be screened for genetic disease or abnormalities) ✓ Encourage genetic screening: lead to 1. Identify gender 2. determine whether persons are predisposed to certain diseases or a couple might have the possibility of giving birth to a genetically impaired child 3. stress it places on a couple and because of the guilt placed on the partner carrying the defective gene (when that can be determined).  Stem Cell Research Stem cells are the body's raw materials or the cells from which all other cells with specialized functions are generated. A stem cell is a cell with the unique ability to develop into (differentiate into)specialized cell types in the body. The developments in genetic technology may remove the current demand: supply imbalance for organs or tissues (example: in humans there are stem cells from the liver in the bone marrow and so potentially could be used as a source of cells for liver transplants).  Stem Cell Research Sources of stem cells: 1. Embryonic (blastocyst) stem cells (are 3-5 days old and has about 150 cells): called pluripotent (‫ )متعدد القدرات‬stem cells which means they can divide into more stem cells or can become any type of cell in the body. Embryonic stem (ES) cells are considered to "have the potential to change into any number of human tissues“ so that ES cells appear not to carry the risk of rejection as the person's own DNA is used to create the cells Embryo must be destroyed  Stem Cell Research Sources of stem cells: 2. Adult stem cells: found in small numbers in most adult tissues, such as bone marrow or fat, have limited ability to give rise to various cells of the body (however, new evidence suggests that adult stem cells may be able to create various types of cells such as bone marrow stem cells may create bone or heart muscle cells).  Stem Cell Research Sources of stem cells: 3. Adult cells altered to have properties of embryonic stem cells (induced pluripotent stem cells) done using genetic reprogramming: reprogram the cells to act similarly to embryonic stem cells. This may cause adverse effects in humans. 4. Perinatal stem cells: Researchers have discovered stem cells in amniotic fluid as well as umbilical cord blood. These stem cells also have the ability to change into specialized cells and could be given to family members.  Stem Cell Research Importance of stem cell 1. Increase understanding of how diseases occur. 2. Generate healthy cells to replace diseased cells (regenerative medicine): spinal cord injuries, type-I diabetes, Parkinson's disease, amyotrophic lateral sclerosis, Alzheimer's disease, heart disease, stroke, burns, cancer and osteoarthritis. 3. Test new drugs for safety and effectiveness: researchers can use some types of stem cells to test the drugs for safety and quality.  Stem Cell Research Some ethical issues: 1. Creation of embryos specifically for research purposes and Destruction of human embryos 2. Informed and voluntary consent 3. Risks and benefits of experimental intervention  The human genome project and Gene therapy Genome an organism’s complete set of the DNA (contains the genetic instructions needed to develop and direct the activities of every organism) The Human Genome Project was first proposed by Noble prize-winning virologist Renato Dulbecco in 1986, started 1990, finished in April 2003. Aims: developing a detailed maps of the human genome (genetic makeup) to develop highly effective diagnostic tools, prevention, and to design highly effective treatments for disease as 4000 disease genes are thought to reside with the human genome  The human genome project and Gene therapy Identification and isolation of the defective gene and replacing it with a functional gene (gene therapy) could result in elimination of disease that have overwhelmed societies for years. Gene therapy is an experimental technique that uses genes to treat or prevent disease Genetic engineering: an experimental technique for introduction of a new gene from one organism into another organism (often across species) Understudy diseases: Hemophilia, Parkinson's disease, Cystic fibrosis, adult polycystic kidney disease.  The human genome project and Gene therapy Gene therapy can be divided into two categories. A. Alteration in germ cells (sperm or ova) that results in a permanent genetic change for the whole organism and subsequent generations. For ethical reasons this is not currently being considered for human being. B. Somatic cell gene therapy: treatment of cancers and blood disorders Gene therapy include: 1. Replacing a mutated gene that causes disease with a healthy copy of the gene 2. Inactivating (knocking out) the mutated gene 3. Introducing a new gene into the body (fight a disease)  Issues of the genome project and gene therapy Current gene therapy is experimental (on animals) and has not proven very successful in clinical trials. The Food and Drug Administration (FDA) has not yet approved any human gene therapy product for sale. Critics express several concerns about using of humans genetic info or project funding. Also, the ability to diagnose a genetic disorder before any treatment is available does more harm than good because it creates anxiety and frustration. The lack of a definitive sequence creates uncertainty about the appropriate definition of "normal“ How to insert the new gene into the body? multigene disorders? high cost  Brain death The traditional definition of death: “cessation of circulatory and respiratory function” A dead person is an individual who has sustained either 1. irreversible cessation of circulatory and respiratory functions, or 2. irreversible cessation of all functions of the entire brain, including the brainstem, is dead. 3. flat electroencephalographic tracings are obtained over a given period, often 48 hours Using of lifesaving procedures and mechanical devices Organs donation.  Brain death Persistent Vegetative State (PVS) Irreversible coma Irreversible brain damage What about these conditions?  Brain death criteria When we want to say brain death: 1. No suspicion that this is due to depressant drugs. 2. Primary hypothermia as a cause of coma should have been excluded. 3. Metabolic and endocrine disturbances which can be responsible for, or can contribute to, coma should be excluded. 4. Relaxants (neuromuscular blocking agents) and other drugs should have been excluded as a cause of respiratory inadequacy or failure. Diagnostic tests for brain death Typically seven clinical tests are performed: 1. Pupil reaction to light (death=fixed dilated). 2. Corneal reflex. 3. Facial nerve response to pain 4. Gag or cough reflex. 5. Doll’s eye test: head is moved from side to side - eye balls remain fixed in brain dead person; or drift from straight ahead position, then return when reflex is present.  Doll’s Eyes A: Normal (positive) A B: Abnormal B C: Absent C (negative) Diagnostic tests for brain death 6. Cold caloric test: Syringe ears with iced water to elicit a similar response. That is, no movement of eyes in brain dead person, or drift (e.g., towards syringed ear) or flicker in those who are not brain dead. Thirty seconds is allowed for any movement. 7. Absence of spontaneous respiration. Oxygen given while person is disconnected from the ventilator. Cold caloric test A: Normal (positive) A B: Abnormal B C: Absent (negative) C  ‫‪Islamic view on brain death‬‬ ‫أن مجلس مجمع الفقه اْلسالمي بعد تداوله في سائر النواحي التي‬ ‫أثيرت حول موضوع" أجهزة اْلنعاش "قرر ما يلي ‪:‬‬ ‫يعتبر شرعا ً أن الشخص قد مات وتترتب جميع األحكام المقررة شرعا ً‬ ‫للوفاة عند ذلك إذا تبينت فيه إحدى العالمتين التاليتين‪:‬‬ ‫‪.1‬إذا توقف قلبه وتنفسه توقفا ً تاما ً وحكم األطباء بأن هذا التوقف ال‬ ‫رجعة فيه‪.‬‬ ‫‪.2‬إذا تعطلت جميع وظائف دماغه تعطال نهائيا‪ ،‬وحكم األطباء‬ ‫االختصاصيون الخبراء بأن هذا التعطيل ال رجعة فيه‪ ،‬وأخذ دماغه‬ ‫في التحليل‪.‬‬ ‫وفي هذه الحالة يسوغ رفع أجهزة اإلنعاش المركبة على الشخص‬ ‫وإن كان بعض األعضاء كالقلب مثالً ال يزال يعمل آليا ً بفعل‬ ‫األجهزة المركبة‪.‬‬  Autopsy  Autopsy is the examination of a cadaver after death performed in order to provide greater medical knowledge concerning the cause of death.  Benefits of autopsy: 1. To provide knowledge about a rare or unknown diseases: it increases medical knowledge and make a good thing for the community (improve the care of the living individuals). 2. Teaching: teaching hospitals or universities.  Autopsy ❑ Benefits of autopsy: 3. Autopsy is required by law such as in cases of violent death or unattended death, no matter what wishes were expressed by the next of kin.  Issues: 1. When to do it? Permission or required by law 2. Respect the human body such as privacy 3. No organ should be removed from a corpse/ cadaver nor should the body be dismembered in any way except if there is a sufficient reason.