Facts, Values, and Ethical Reasoning 2023

Facts, Values, and Ethical Reasoning Greg Moorlock– [email protected] 2023 Learning Outcomes Explain the distinction between facts and values and its importance in treatment and healthcare policy Describe key ethical theories and principles that are relevant to healthcare and begin to under...

Facts, Values, and Ethical Reasoning Greg Moorlock– [email protected] 2023 Learning Outcomes Explain the distinction between facts and values and its importance in treatment and healthcare policy Describe key ethical theories and principles that are relevant to healthcare and begin to understand how these can be applied to clinical situations Appreciate the role of contextual factors and differing values (e.g. those held by patients, doctors) in healthcare and ethical decision making Session Structure 1. What is ethics, and what is the distinction between facts and values? 2. Ethical theories 3. The role of contextual factors A note on style Philosophy is traditionally a very discursive subject. The Values, Law and Ethics theme reflects this. Disagreement is great and stimulates healthy debate. Feel free to challenge views and have your say. Just be prepared to defend yourself… What is ethics? How one ought to act This requires justification/reason/argument A big assumption about the nature of ethics… What is going on here? Is it morally acceptable? Key concepts Some variables: Role of person administering drug Type of person/thing receiving the drug (Un)known/(un)intended effects (harms/benefits) Maria Maria, aged 14, has heart failure secondary to cardiomyopathy. Her cardiomyopathy was caused by high-dose cancer drugs which she received to treat acute myeloid leukaemia. It was known that one day she may need a heart transplant. Maria collapsed at school and was admitted to a children’s high dependency unit. Doctors fitted her with a temporary pacemaker, but said that she needs a heart transplant. Without a heart transplant she will die. Maria says she does not want one. Despite doctors’ attempts to persuade her, she is insistent. She says she has been through a lot with the leukaemia and does not want to go through any more. She would rather live a short life with her own heart than a longer one with someone else’s; and she does not want to suffer any more. Her father supports her decision although her mother is unsure what is Facts and values The case includes factual claims and value claims. Facts are claims about the world that have been, or can in principle be, verified by empirical methods. Values are claims about, or expressions of, things like: – Preferences – Attitudes – Emotions Thick concepts Thick concepts are claims that have both factual and evaluative content: The doctor was intimidating The president is straight-talking Those plants are weeds How can we assess claims? Factual statements: Use empirical methods to determine their truth (consider statements like ‘if I let go of this pen it will fall to the floor’; ‘if I die there will be more resources available to help others’) How can we assess value claims? Consider: ‘It will be better for me to die’ ‘You should respect my wishes’ ‘Doctors are supposed to be kind and compassionate’ To assess these claims, we need to turn to moral theory. Moral Theories Within healthcare (and philosophy generally), three of the most popular moral theories are: – Consequentialism/utilitarianism – Deontology – Virtue ethics  Consequentialism A simple general definition: – Of all the things a person might do at any given moment, the morally right action is the one with the best overall consequences. The rightness or wrongness of a person’s actions depend only on the consequences. - This excludes a lot of what we may think is also important This definition leaves open: – What makes a consequence good or bad – What types of consequence are relevant – How different consequences should be weighed against each other. There are different types of consequentialism, which variously Consequentialism Moral theory is supposed to be normative – it tells us what we should do; To talk about ‘best consequences’ you need to evaluate possible alternative consequences and rank them; So you need to be clear about what makes one consequence better than another; This needs to be robustly defensible: e.g. “One consequence is better than another if it results in there being more people called Greg in the world.” – convincing? So what sort of thing might it be better to have more of in the  Utilitarianism Utilitarianism is one form of consequentialism: Of all the things a person might do at any given moment, the morally right action is the one which maximises utility. Utility is intrinsically good For the likes of Bentham and Mill (who were hedonistic utilitarians*), ‘Utility’ = (generally speaking) ‘Happiness’ The right thing to do at any given moment is that which maximises pleasure and minimises pain/suffering Often stated (a bit wrongly) as: “the greatest happiness for the greatest number.” *(Although there is some contention about Mill’s precise take on utilitarianism) Deontology “Deon” – duty Rules govern actions and we have a duty to abide by them regardless of cost Contrasted with emphasis on outcomes (as is the case with consequentialism) “The right is prior to the good” Deontology Often seeks to respect autonomy – Because it’s the only way of respecting an individual’s right to determine their own life Virtue ethics Focuses on the character of the person (the doctor/professional?), not their actions A right act is the action a virtuous person would do in the same circumstances. Not “what should I do?” but “what kind of person should I be?” Key concepts in virtue ethics A move away from universal principles Virtue “lies in a mean” – between excess and deficiency: Cowardice – Courage - Rashness Summary of moral theories ‘Suppose it is obvious that someone in need should be helped. A utilitarian will point to the fact that the consequences of doing so will maximize well-being, a deontologist to the fact that, in doing so the agent will be acting in accordance with a moral rule such as “Do unto others as you would be done by” and a virtue ethicist to the fact that helping the person would be charitable or benevolent’ - Rosalind Hursthouse Ethical reasoning in clinical practice Principles Particulars (context/facts of the case) Perspectives (of all those involved or affected by the case) A useful way of remembering what to consider when analysing an ethical question PPP in practice A 65 year old man is admitted with a history suggestive of tuberculous meningitis. He has recently arrived from another country and speaks no English. He is drowsy and mildly disorientated. A lumbar puncture (placing a needle in the spine to draw off some cerebrospinal fluid) is necessary for diagnostic purposes. The registrar who has admitted the patient suggests that the accompanying medical student carries out the lumbar puncture under her supervision. It will be good Principles Respect for autonomy – informed consent? Beneficence – acting in the patient’s best interests? Consequentialism – weighing patient’s interests against benefit of training the student? Particulars – capturing the situation It’s important to describe a situation accurately: – Moving one’s finger – Turning on a light – Disturbing someone’s sleep – Showing a visitor the way at night – Same situation, described differently. Different implications. Mumford, S. A Philosopher Looks at Sport (2021) Particulars Harms associated with this procedure – how much are they increased when done by medical student? How experienced is this particular student? How beneficial will it be for this student to have this learning opportunity? Are there other patients who the student could learn with, who represent a lower risk? Perspectives Patient – Expectation of care – Trust in doctors Family – Want the best care for their relative – May suspect discrimination – May trust doctor – May support student training Perspectives Medical student – Wants to improve skills – Wants to gain approval from seniors and peers – May be uncomfortable with consent situation Registrar – Wants to teach student / benefit future patients Other patients – Support teaching; vs. – Concern that they would be better off not being experimented on Learning Outcomes - Revisited Explain the distinction between facts and values and its importance in treatment and healthcare policy Describe key ethical theories and principles that are relevant to healthcare and begin to understand how these can be applied to clinical situations Appreciate the role of contextual factors and differing values (e.g. those held by patients, doctors) in healthcare and ethical decision making