Introduction to Biomedical Ethics and Ethical Theories PDF

INTRODUCTION TO BIOMEDICAL ETHICS AND ETHICAL THEORIES WEEK 1: AGENDA➤What is biomedical ethics?: An introduction ➤Ethical theories: The basics BIOMEDICAL ETHICS & ETHICAL THEORIES: AN INTRODUCTION WHAT IS BIOMEDICAL ETHICS?➤T wo Ways of Conceiving Biomedical Ethics ➤The first way is to think of B...

INTRODUCTION TO BIOMEDICAL ETHICS AND ETHICAL THEORIES WEEK 1: AGENDA➤What is biomedical ethics?: An introduction ➤Ethical theories: The basics BIOMEDICAL ETHICS & ETHICAL THEORIES: AN INTRODUCTION WHAT IS BIOMEDICAL ETHICS?➤T wo Ways of Conceiving Biomedical Ethics ➤The first way is to think of Biomedical issues as an occasion for the application of well-worked and complete ethical theories ➤Philosophers apply ethical theories to determine what practices are acceptable, and what practices are not acceptable ➤This view is TOP- DOWN CASE SENSITIVE ETHICS➤The second way is sometimes referred to as “Particularism" or “Case Sensitive Ethics” ➤We will learn about ethical theories, but we don’t just apply them in a straightforward way to deduce moral claims about cases ➤We will start by treating each case or topic in its own unique particularity ➤Ethical theories and concepts help us reach a better understanding of what is at stake in moral disagreement, and formulate arguments regarding what is right or wrong, good or bad, permissible or impermissible, etc. ➤Cases FIRST , ethical theories SECOND ➤This is a BOTTOM-UP approach THE CASE OF BABY JOSEPH➤Joseph Maraachli (22 January 2010 to 27 September 2011) ➤At about 4 months, he had a seizure, and was admitted to hospital ➤About half a year after that, he stopped breathing, and was admitted to hospital in Ingersoll ON ➤Later, he was moved to the London Health Sciences Centre in London ON, and placed on a ventilator ➤He was diagnosed with Leigh's disease (a.k.a. Juvenile Subacute Necrotizing Encephalomyelopathy), first described by British physician Archibald Denis Leigh in 1951 THE CASE OF BABY JOSEPH➤Joseph’s parents and his attending physicians disagreed on his treatment ➤His parents wanted him to remain on life support so they could spend more time with their son ➤They were under no illusions regarding his prospects, and that he was soon to die no matter the support systems on offer ➤His physicians wanted to withdraw life-support, as Joseph had no chance of recovery WHAT MAKES THIS A CASE OF MORAL DISAGREEMENT? PARENTAL CONSENT VS. EXPERT AGREEMENT AND BEST PRACTICES➤Everyone agrees about most of the relevant FACTS regarding Joseph’s diagnosis and prospects ➤The different parties have competing VALUES ➤In fact, even most of their values are the same! ➤More precisely they are weighing values differently in coming to their decisions ➤Joseph's parents wanted more time with their son ➤Joseph's health care providers and hospital administrators wanted to live up to their fiduciary responsibility to not cause unnecessary harm to Joseph, or to engage in treatment regimes that were futile or went against professional best practices FACTS AND VALUES➤Separating facts and values ➤David Hume (1711-1776) ➤Hume argued that facts and values differed because one could not derive an evaluative judgment from a factual judgment—an "ought" from an "is" ➤In other words, have as many factual premises as you like, from whatever venerable science, and you can still not derive an ought from an is ➤So… ARE VALUES EVEN REAL?➤In some sense, the answer must be “yes”… ➤People have values, and psychologists and sociologists talk about them; they are thus objects of scientific inquiry ➤However, that isn't what we mean ➤When philosophers ask this question, they want to know if values are beholden to the world in any way. If having certain values, or weighing them differently, can be justified based on the way the world is (not merely described or explained as sociological phenomena) MORAL REALISM➤Realism about Moral Properties and Values: values pick out moral properties that are real -- i.e. they are part of the furniture of the universe, like other things, though we surely do not perceive these properties like we perceive tables and chairs, etc. ➤Any analysis of the ultimate constituents of the world will include moral properties, and our values in some sense refer to those properties ➤The man pictured is G.E. Moore (1873-1958), who published a famous defence of moral realism in 1904 in his book, Principia Ethica ANTI-REALISM➤Anti-Realism about Moral Properties and Values: the view that moral properties are not real, or at the very least we have no way of knowing them or whether or not they are real. ➤Extreme versions of this view hold that value judgments and moral claims are not truth-evaluable (like factual claims), and are therefore “non-cognitive”— they lack a sense, and are probably just an expression of an attitude we have toward this or that state of affairs ➤Pictured is Rudolf Carnap, a German born philosopher who lived from 1891-1970, though he moved to the US in 1935 to escape the spread of fascism in Europe ➤He was part of a school called Logical Empiricism; they argued that only scientific claims had meaning (“cognitive significance”) LET’S SEE IF THERE ISN’T A MORAL RULE WE CAN MOSTLY AGREE ON LET’S SEE IF THERE ISN’T A MORAL RULE WE CAN MOSTLY AGREE ONDO YOU THINK KILLING INNOCENT PEOPLE IS WRONG, AND SHOULD BE PROHIBITED? MAYBE ETHICS REALLY IS JUST SUBJECTIVE… LET’S LOOK AT AN ABSTRACT CASE TROLLEY ETHICS➤English moral philosopher Phillipa Foot (1920-2010, pictured) came up with a set of decision problems ➤Philosophers and moral psychologists ever since have focussed on “the trolley problem” ➤It is actually a set of problems based on a common scenario, with some changes introduced when necessary TROLLEY ETHICS➤It is what philosophers call a “thought experiment”—a contrived vignette to test our moral intuitions ➤Judith Jarvis Thomson (b. 1929, pictured) did a lot of work on trolley problems, and we will read a paper by her in a couple of weeks where she tests our intuitions about the permissibility of abortion using thought-experiments ➤But what IS the trolley problem? CLASSIC TROLLEY PROBLEM➤There are many variants, but the classical trolley problem is called “Bystander and Switch”, or sometimes just “Switch” ➤Imagine you are standing beside a switch, near train tracks ➤After the switch, the tracks diverge from one another ➤One one set of tracks is a single person, tied to the tracks and unable to move ➤On the other set of track are five people, also tied and unable to move ➤You didn’t put these people there, you are just a bystander who happens on the scene ➤All 6 people have the same standing in the community, are roughly the same age and in the same health, and aren’t being punished for any wrong-doing ➤The train is heading for the five, but you can flip a switch that will divert the train to the single person on the other track ➤You have two choices: 1. Do nothing, and let the train kill five people (the single person survives). 2. Flip the switch, killing the single person and saving the five What do you do? What is the right thing to do? CLASSICAL ETHICAL THEORIES… AND THE CHALLENGE OF ETHICAL THINKING! DEFENDING AN ETHICAL POSITION➤No straightforward formula or test exists to identify an ethical issue ➤Ethical thinking requires what Aristotle called phronesis — moral judgment or wisdom ➤Experience in moral matters, not just the application of some rule ➤But usually, there is some general consensus regarding what issues are moral (or have some moral dimension to them) WHAT ROLE DO ETHICAL THEORIES PLAY? ➤Systematizing ethical concepts & principles ➤Adjudicate between competing demands ➤Craft principled moral arguments, justifying our decisions (or maybe just our beliefs) ➤Guidance on life and action ➤Help us understand moral phenomena ETHICAL THEORIES THE UTILITY OF ETHICAL THEORIES➤Why even learn about ethical theories, if we’re doing “case sensitive” biomedical ethics? ➤Why not just proceed without reference to theories? ➤A sharper awareness of ethical issues and considerations ➤Conceptual tools necessary to navigate moral controversy ConsequentialismVirtue EthicsDeontology CONSEQUENTIALISM CONSEQUENTIALISM➤A family of views that determine the morality of decisions, actions, or events based on their consequences ➤What makes an act right or wrong is the extent to which it promotes the good (happiness; well-being; beauty; etc.) ➤There is no cleavage between what is right and what is good KINDS OF CONSEQUENTIALISM ➤Consequentialists agree that what matters morally are consequences of action ➤But, what consequences? ➤What values do we prioritize UTILITARIAN CONSEQUENTIALISM➤This view was developed by Jeremy Bentham (1748- 1832, pictured top), and a son of one of Bentham’s colleagues James Mill, namely John Stuart Mill (1806-1873, pictured bottom) ➤For utilitarians, the right thing to do is to promote the good, which they identify with psychological states of pleasure or happiness UTILITARIAN CONSEQUENTIALISM➤Originally intended to be central to social reform ➤Maximizing hedonic values is the most efficient and most moral way of organizing a society ➤Both Bentham and Mill were social reformers and politicians HEDONISM — THE PURSUIT OF PLEASURE➤While utilitarianism is a truly 19th century moral theory, it takes from classical moral theory going all the way back to ancient Greece ➤In the ancient world, debates we would normally think of as ethical were mostly about value theory — what sorts of things are valuable, and what sorts of things are most basic in our system of value ➤Hedonists (precursors to utilitarians) all agreed that pleasure was the only intrinsic value ➤We might like wealth, or health, or beauty, or other things, but only in so far as they can bring us pleasure ANCIENT HEDONISMCYRENAICISM (after Aristippus of Cyrene, 435-356 BCE) EPICUREANISM (after Epicurus, 341-270 BCE) HEDONISM — THE PURSUIT OF PLEASURE➤Ancient hedonists disagreed on what kind of pleasure was most valuable ➤Aristippus of Cyrene (435-356 BCE) developed a hedonism that made basic pleasures its central feature: drink, food, sex ➤Momentary sensations are better than those of anticipation or memory ➤Epicurus (341-270 BCE) disagreed ➤He prioritized some pleasures over others: basic pleasures are good, but they tend to bring problems in the long run ➤What we really ought to value is “higher pleasures” EPICURUS➤Epicurus thought a life that had its basic material needs met (food, shelter, clothing, security) was better than a life of material excess ➤But this is only true if one uses this material security to reach a state of ataraxia (or deep tranquility) through acts of contemplation UTILITARIAN CONSEQUENTIALISM➤Bentham and Mill had a similar disagreement ➤Bentham: All pleasures are of a kind — only to be distinguished by their intensity ➤Mill: Pleasures come in different kinds — higher and lower “It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied. And if the fool, or the pig, is of a different opinion, it is only because they only know their own side of the question.- John Stuart Mill MILL’S PRINCIPLE OF UTILITY➤“ Actions are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse of happiness” (Mill, Utilitarianism) ➤Happiness is a subjective quality, but one that we can measure across subjects ➤Acts are right when they promote the good overall, i.e. for all sentient beings ➤Only the hedonic value of consequences matters ➤What motivates action only matters if it makes a difference to the consequences BENTHAM’S HEDONIC CALCULUS➤Bentham proposed a hedonic calculus ➤This calculus requires giving utilities raw values ➤The consequences of some action are aggregated to come to a conclusion about whether a particular act is morally right or wrong ➤While Bentham thought one might actually be able to do these calculations, Mill argued that one must internalize the principle of utility ➤We can’t actually do a calculus, but we can guide our action in such a way that we try to produce the greatest overall happiness ➤This is true of legislators, and of individual moral actors DEONTOLOGY DEONTOLOGY➤A family of ethical theories that determine the rightness or wrongness of an action based on how it conforms to a moral law ➤The right thing to do can differ from the action that produces the most overall good ➤If an act is objectively wrong, it cannot be pursued, even if it promotes the good ➤Duty demands that we act in accordance with a universal moral law KANTIAN DEONTOLOGY➤Based on the ethical writings of Immauel Kant (1724-1804) ➤Distinguishing the right and the good ➤Doing the right thing ➤Morality and autonomy ➤We are moral because we are "legislators in the kingdom of ends" KANTIAN DEONTOLOGY➤If you have reason, you are a full moral agent Reason gives you: ➤Autonomy ➤Dignity ➤Duties/obligations THE GOOD WILL➤Kant is an anti-hedonist ➤This means that while there are lots of good things that exist (e.g. pleasure) the only thing that has intrinsic value is the Good Will. ➤His ethics is not based on bringing about pleasure instead of pain; rather, it’s about exercising one’s good will—i.e. acting out of a sense of duty or obligation, rather than by inclination THE GOOD WILL➤Why not base ethics on pleasure and pain like the utilitarians? ➤Well, we can derive pleasure from things that are both moral and immoral ➤I could get pleasure out of rescuing animals, helping the elderly, or bringing medical care to children in under- developed countries, but I could also get pleasure out of torturing or killing innocent people ➤This means that pleasure would need to be qualified—it needs to be measured against consequences ➤Pursuit of pleasure is only of value when properly motivated ➤Kant wants to base his ethical system on a good that doesn’t need qualification—having the will to act morally is the only unqualified good—the only thing with intrinsic value ➤Though bad consequences may follow from acting according to one’s duty, or good consequences from acting against it, the good will is good in-so-far as an action pursued from a sense of duty (a motivation to act rightly) never makes an action worse OBJECTIVE MORAL LAW?➤Kant thinks there is one overarching moral law, and that you can discern it by reason alone ➤He calls it the "categorical imperative” ➤CATEGORICAL vs. HYPOTHETICAL imperatives ➤“If you want to go to the concert, then finish your essay” ➤This is a hypothetical imperative ➤Your duty is bound by whether or not you want to go to the concert ➤Kant wants a rule that is binding that isn’t bound by a hypothetical condition—its binding nature is “categorical” because it is not conditional ➤What would such a moral rule or law look like? THE CATEGORICAL IMPERATIVE (3 FORMULATIONS)1.Act only according to that maxim [rule for action] whereby you can at the same time will that it can become a universal law without contradiction 2.Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end. 3.Act as if you are through your maxim [rule for action] always a legislating member in the universal kingdom of ends. THE CATEGORICAL IMPERATIVE (3 FORMULATIONS)➤The categorical imperative (in any of its formulations) holds universally for all moral agents and is dictated by reason ➤Any agent (if you have reason, you are an agent) is bound by the categorical imperative ➤We are free to do what we want because we are agents, but our freedom also creates a self- imposition—we are obligated to follow the moral law once we discern it by light of reason ➤(It shouldn’t be a surprise that Kant was writing at the height of the Enlightenment in Europe, with his focus on reason as the sole source of a morality based on a universal moral law and a sense of duty that binds us to the law) THE CASE OF LYING WHY IS LYING IMMORAL FOR KANT? LYING➤Lies, like any other kind of bad action, can’t be made right by the good consequences they produce; i.e. lying is wrong no matter the consequences in Kantian deontology ➤They also can’t be judged as wrong because of their consequences, so how does Kant determine their wrongness? ➤Lies only work against a backdrop of truth-telling. You are willing (attempting to bring into the world) two contradictory things at once: (1) that your lie be efficacious, which presupposes that the institution of truth-telling is in tact, and (2) that the institution of truth-telling be damaged by your action (your lie) ➤Lying is immoral because you have a contradictory will, not a good will ➤You are debasing your rationality by willing a logical contradiction LYING➤Say you are a doctor and you want to lie to your patient about their condition ➤You act in accordance with the maxim that it is okay for you to do this because it is beneficial for you. ➤But this is to will a contradiction of sorts: it is irrational and immoral ➤This is because you simultaneously will that your lie be efficacious while the institution of truth telling remains efficacious ➤Lying is immoral because it cannot be universalized without contradiction ➤You are treating yourself as an exception to a moral law that reason tells you is universally applicable VIRTUE ETHICS VIRTUE ETHICS➤Focuses on moral development, and the creation of virtuous agents through proper education and inspiration WHAT VIRTUE ETHICS STUDIES:➤The virtues themselves ➤Motives ➤Moral Character ➤Moral Education ➤Moral Wisdom or Judgment or Discernment ➤Friendship and Family Relationships ➤Deep Concept of Happiness (eudaimonia) ➤The role of emotions in morality ➤Fundamental questions about what sort of person you should be, and what sort of communal life we should pursue to be the best people we can be EUDAIMONISTIC VIRTUE THEORY➤Centres around the idea that there’s an ultimate good ➤Human happiness and moral excellence intimately bound ➤Perfecting the self or promoting human flourishing ➤Being moral is not about following a set of prescribed rules ➤Does this seem strange to us? ➤How does this framework for ethics differ from what we encountered with utilitarianism and deontology? ACTION AND THE GOOD➤Every action is directed at some good (even if it falls short of realizing this good) ➤Ultimately, action is directed at an ultimate good ➤For Aristotle (and many other virtue ethicists) this goal is happiness ➤But not the happiness of the simple hedonist (not pleasure) ➤Aristotle uses the term eudaemonia ➤This is a deep happiness, attached to our nature as social beings and rational agents ➤It is human flourishing—and its measure is therefore probably biological, or at least sociological/political ➤Healthy individuals living in healthy societies, organized by reason60 ARISTOTLE ON “THE GOOD”—WHAT ALL THINGS ARE AIMING AT➤This is how Aristotle defines the “good” ➤However we act, we’re pursuing some good ➤Examples?➤Getting an education ➤Going to the gym ➤Getting marriedWhat’s the problem with this list of goods? THE GOOD LIFE➤Some goods are sought out for the sake of something else ➤All actions directed at something greater ➤We need to know what this target is ➤If we fall short, that’s probably okay ➤But what if we are shooting at the wrong target? ➤What if, instead of flourishing, we are just trying to accumulate material things, without the cultivation of the self? ➤In short: NO! ➤Once we know what our target is, then we just need a science to help us pursue it ➤It doesn’t have to be a precise science like physics ➤If happiness is the highest good, and the aim of action is directed at happiness, then we just have to aim at happiness RELATIVISM? What’s the problem here? ➤Are we all likely to define happiness differently? ➤How would you define happiness?IT’S NOT RELATIVISM?! REALLY?! Answering this question for Aristotle is going to require that we have an idea of what is right and just HAPPINESS AS THE HIGHEST GOOD➤In order to illustrate that happiness really is the highest good Aristotle looks at what a good person is ➤Q1: What is a good X? ➤Q2: What is the characteristic function of an X? ➤Before we can answer Q1 we have to answer Q2 ➤This requires a function argument ➤Just as the eye, the ear, the foot…. each has its proper function, human beings also must have a proper function THE PROPER FUNCTION OF HUMAN BEINGS➤Is it simply living? ➤No ➤Is it sense perception? ➤No ➤What do we do that no other thing does?Reason A LIFE OF REASON AND CONTEMPLATION➤In order to be happy… ➤One must act in conformity with one’s essence (i.e. in conformity with reason) ➤One has to act rightly and to the right degree (i.e. disposed to choose the mean) ➤One has to exercise practical wisdom ➤One must possess excellences (aka “the virtues”) VIRTUES OR EXCELLENCES➤The virtues go back to the ancients, and their use in VE goes back to Plato (427-347 BCE) and Aristotle (384-322 BCE) ➤The virtues are deep character traits, or dispositions for action in many situations ➤They are, for Aristotle, the "golden mean" of action in certain spheres of action BEING VIRTUOUS➤Requires both intellectual and practical expertise ➤2 types of virtue ➤Intellectual ➤Perfected through education and contemplation ➤Moral ➤Perfected through practice and habit VIRTUE AND THE MEAN➤Practice doesn’t always make perfect ➤We’re not born virtuous people ➤Acting is what makes us just or unjust ➤Characteristics develop from corresponding activities ➤The mean: The midpoint between excess and deficiency ➤It is relative to each person, and their capabilities, and is context sensitive (e.g. courage is different for the sniper and the medic in war, and different in war than in sports or social activism, etc.) ➤How to act is contingent on both the agent and the situation at hand ACTING APPROPRIATELY➤No specific formulas dictating absolute rules for action ➤It is difficult to see how there could be, since most moral situations are in some way novel — never encountered before, or covered by a well-known rule ➤We have to know how to act rightly and to the right degree HONESTY… AGAIN!➤Being honest cannot be, as it was for Kant, about not telling lies ➤Aristotle thought that being honest was a kind of mean between tactlessness and being overly discreet; between saying all of the truth all of the time, and never speaking the truth ➤Telling the truth because the consequences would be good or because it follows a rule misses the mark ➤One is honest because that is what an honest person would do PHRONESIS➤Practical wisdom ➤Knowledge gained from experience, life, and contemplation ➤Good intentions aren't all that matters ➤Mature moral agents are also properly informed and have knowledge about how the (moral) world works THE PERSON OF PRACTICAL WISDOM➤Our moral educator ➤Our moral template/exemplar ➤A person known for wise and sober moral decision making and action ➤A person who uses experience to sharpen intentions ➤Person will also likely be intelligent, graceful, blessed with political acumen, humorous, affable, etc. ➤Here are three exemplars for me: feminist philosopher and social activist bell hooks, the novelist Kurt Vonnegut, and the labour activist and trans-rights advocate Leslie Feinberg ➤Vonnegut is a moral exemplar because of his unbreakable humanism and honesty ➤bell hooks and Leslie Feinberg because they have spent their lives fighting for those who don’t have a voice, when the easy thing is to just look out for oneself EMBRYOS, EMBRYONIC STEM CELL RESEARCH, AND MORAL STANDING MORAL STANDING MORAL STANDING (OR MORAL STATUS)➤An entity has moral standing (or moral status… the two terms are interchangeable) when it has interests ➤Some people might propose further criteria, so this might only be a necessary (though perhaps not sufficient) condition for moral standing ➤If an entity has moral standing, then we cannot act toward it however we want; we must take into account its interests as we act ➤Think of it this way: The entity can be caused harm or wronged in some way MORAL STANDING➤Inanimate objects (e.g. artifacts or natural objects) do not have moral standing ➤They might be valuable/valued by entities that have interests, but they themselves have no moral standing ➤Autonomous adult human beings do. Why? ➤What other entities have moral standing? STANDING VS. AGENCY➤We normally think that there are more entities that have moral standing than there are moral agents ➤Though Kant would disagree; he thinks the only entities with moral standing are moral agents ➤A moral agent is an agent capable of deliberation and action (based on that deliberation)—agents have reason, dignity, and rights/obligations relative to other agents ➤Normally, agency is taken to presuppose rationality ➤Rationality, however, is a very high standard, isn’t it? AN ASIDE: KANT ON ANIMALS AN ASIDE: KANT ON ANIMALS➤Kant argues that merely sentient beings have no moral standing ➤You have to have rationality to have moral standing ➤Only beings in the “kingdom of ends”—those rational agents who can curtail their actions to others based on a conception of the other as a fellow agent ➤Must be able to make and understand rights claims ➤Thoughts? WHAT/WHO WOULD GO ON A LIST OF MORAL BEINGS? CRITERIA FOR MORAL STANDING? EMBRYONIC STEM CELL RESEARCH➤“ A Stem Cell Story” ➤https://www.youtube.com/watch?v=2-3J6JGN-_Y ➤If this link won’t work, the video has been posted on LEARN under Content and Links to Films and Videos DO EMBRYOS HAVE MORAL STANDING? WHY OR WHY NOT? THE DESTRUCTION OF EMBRYOS FOR SCIENTIFIC RESEARCH The Moral Status of Stem Cells Against Stem Cell Research, SOREN HOLM REDUCTIO AGAINST THE VIEW THAT EMBRYOS HAVE MORAL STANDING➤Some argue that embryos have moral standing worthy of us curbing (or even stopping entirely) the development of IVF technologies and disease research using embryos ➤But what criteria or criterion of moral standing do embryos satisfy? ➤Not rational; not sentient ➤Is it their potential for sentience or sapience? REDUCTIO AGAINST THE VIEW THAT EMBRYOS HAVE MORAL STANDING➤The potentiality argument: human embryos should be granted full moral status because they have the potential to become human beings with uncontested moral status ➤This argument uses an interesting strategy that allows us to ignore any “grey” ares that might exist when it comes to thinking about moral standing ➤How so? REDUCTIO AGAINST THE VIEW THAT EMBRYOS HAVE MORAL STANDING➤Embryos have the potential to be like beings with uncontested moral status ➤They have a nucleus with genes needed for development ➤If the environmental factors are just right, then we could have an adult human with uncontested moral status ➤Therefore, embryos shouldn’t be destroyed ➤Singer and Sagan want to argue against this line of reasoning THINKING THINGS THROUGH… ➤Why should we grant moral status based on potential? ➤What consequences come along with adopting this criterion for moral status? THINKING THINGS THROUGH…➤A lot of things we don’t normally think of as having moral status also have the potential to be like us ➤Skin cells ➤Non-embryonic stem cells ➤Etc. THINKING THINGS THROUGH…➤This means that the argument we just rehearsed on the previous slides entails that each skin cell has uncontested, full moral status, which seems absurd ➤Scratching an itch now becomes a serious moral wrong—indeed, a crime ➤Getting a facial scrub would constitute premeditated murder ➤You are knowingly killing entities that have the potential to become persons REDUCTIO AD ABSURDUM➤This is a very powerful argumentative technique ➤It assumes the truth of your interlocutor’s position ➤Using an agreed upon logic standard, we derive a contradiction, absurdity, or just something the interlocutor thinks is false from the interlocutor’s own position ➤The interlocutor cannot (a) say that you are just speaking past him or her, or (b) not giving his or her position a fair shake ➤YOU ARE ASSUMING IT IS TRUE, after all REDUCTIO AD ABSURDUM➤This mode of argument is one of the reasons why ethical debates, when argued properly, are not subjective ➤A reductio assumes the truth of an alternative position, and then shows that it leads to what the interlocutor will find an unpalatable logical consequence ➤Either the interlocutor has to change their position (so that it does not entail an absurdity), or bite the bullet (and accept that their belief does not rationally cohere with other beliefs they hold dear) ➤They cannot keep their belief system the same and claim to be rational AN OBJECTION BY LEE AND GEORGE➤Embryos have moral standing ➤This isn’t as a logical consequence of potentiality; it’s a consequence of biological fact, since they are human beings ➤Some beings have intrinsic value and basic rights and others do not ➤Moral difference tracks fundamental ontological difference ➤(“Ontology” is just a fancy philosophy word for the study of fundamental things) AN OBJECTION BY LEE AND GEORGE➤Embryos are essentially human persons, and only accidentally at a particular stage of development ➤Embryos are intrinsically valuable agents with a rational nature (even if they can’t exercise it at the moment) ➤For example, you are a rational agent; however, when you get drunk at a party, you momentarily lose your capacity for rationality ➤However, that doesn’t mean you lose your moral status AN OBJECTION BY LEE AND GEORGE➤When Lee and George use “accidental/ly”, they use the term to mean that you satisfy a property that is not part of your essential self ➤In other words, if I considerably changed your DNA, or if you were born to different parents, you would be a different person ➤However, the fact that you are wearing a green shirt today is just an accidental truth about you; you would still be you if you changed the shirt from green to red ➤Being an embryo is like this; it is a momentary state of a rational being in which it cannot exercise its rational nature HOW WOULD YOU RESPOND IF YOU WERE SAGAN AND SINGER? SØREN HOLM➤Chair in bioethics at the Centre for Social Ethics and Policy, part of the School of Law at the University of Manchester in Great Britain and the University of Oslo ➤Argues against the destruction of embryos, but not because embryos have the same moral status as fully developed, adult human persons SØREN HOLM—AGAINST THE LIBERAL ARGUMENT➤The Liberal Argument is a family of similar arguments (of which Sagan and Singer's argument is a member) ➤Holm is arguing against it ➤According to the Liberal Argument, embryos are not persons (i.e. not rational agents) ➤They do not deserve to be accorded "lower" moral status on other grounds, e.g. sentience, since they are not sentient ➤But there is a problem here ➤Time for another reductio… SØREN HOLM—AGAINST THE LIBERAL ARGUMENT➤The Liberal Argument justifies the (non-painful) killing of pre-personal human entities of all sorts - including fetuses, and even newborns ➤Such killing is justified based on net benefits to others ➤Even if the benefits are slight (creating a really effective anti-aging cream, for example), the embryo has no interests in its pre-personal state, and therefore no moral status, and therefore we ought to be able to use it for our benefit ➤Replace “embryo” with “newborn” in the previous bullet-point; do you find this acceptable? ➤Newborns aren’t yet rational persons, but most of us think we can’t just harm or kill a newborn for our own benefit! SINGER THINKS INFANTICIDE IS SOMETIMES ACCEPTABLE➤Interview with William Crawley ➤https://www.youtube.com/watch?v=3bi81JcddWc SINGER THINKS INFANTICIDE IS SOMETIMES ACCEPTABLE➤Interview with William Crawley ➤https://www.youtube.com/watch?v=3bi81JcddWc ➤If the link doesn’t work, find the video on LEARN under Content and Links to Films and Videos ➤In this video Singer talks a little bit about why he thinks infanticide is sometimes okay, but he also talks about animal rights and other issues that we’ll talk about later ➤Singer is a consistent thinker— it’s not a reductio ad absurdum if someone is willing to accept the consequences which in this case is sometimes infanticide ➤He gets around the argument by Holm by saying that newborn babies are sentient, so the reductio from holm goes ➤If it’s okay to use pre- personal entities, then why can’t we use fetuses or newborns for whatever we want ➤Singer says they’re sentient so we could never use them for whatever we want, but that it is sometimes okay to kill them in cases where they have severe disabilities (he is realizing that there is no real difference between killing a fetus with severe disabilities and killing a newborn with severe disabilities). They’re both sentient but pre-personal entities. If it’s okay to kill a fetus with, say, a neural tube defect then it should be permissible to kill a newborn with that same disability ➤Infanticide is only okay when the medical professionals and parents agree that the child has no prospects for a good life. It’s basically a mercy killing. It’s recognizing the entity has interests and determining that it’s best for the infant to not live. PROBLEM WITH A DIRECT CONSEQUENTIALIST ARGUMENT➤Killing an embryo might produce bad effects ➤Nevertheless, the medical benefits might be so great as to outweigh the destruction of the embryo ➤It is justified to sacrifice some for the benefit of others (especially if the some are embryos, and the others are full-fledged human persons) ➤But doesn't this kind of argument also prove too much? ➤Why not sacrifice adult humans for the benefit of other adult humans? ➤This is another reductio—showing that a moral principle which allows for sacrifice of an embryo extends to permissible sacrifices of adult human persons (even against their will) HOLM’S ALTERNATIVE: STANDARD RESTRICTIVE ARGUMENTS➤Family of arguments that say: it’s wrong to kill a human life regardless of its stage of development ➤Lee and George put forth such an argument against the position Singer endorses ➤Comes in strong and weak forms ➤Strong restriction vs weak restriction ➤Holm proposes a GRADUALIST ANALYSIS ➤Destructive use of embryos is pro tanto wrong, but less wrong than the killing of a fetus, a newborn, or an adult CONSISTENCY?➤We quite often engage in action that leads to the destruction of embryos ➤Even just trying to conceive may lead (statistically) to 3-5 embryos that do not implant or spontaneously abort ➤Ought we stop engaging in reproduction because of the harm we are doing to these embryos? ➤Aren't the goals of curing disease just as laudable if not more laudable than reproduction? IS CONSISTENCY EVERYTHING??➤Society contains "spheres of justice" ➤The application of principles of justice from one sphere to another is not always warranted ➤Different social goods are different for a reason ➤Different practices of producing these goods is different ➤We have to take account of these differences ➤Research is different from facilitating reproduction, and the practices associated with producing the goods of each are different too ➤Reproductive liberty does not translate into research liberty EMBRYOS AND HOSTS: INALIENABILITY OF REPRODUCTIVE TISSUE? FEMINIST CRITIQUE OF A COMMON ASSUMPTION➤All of our talk thus far has spoken about embryos as if they are distinct entities ➤These entities may or may not have interests and rights that may or may not be trumped by the benefits to be gained from their destruction in certain research contexts ➤But what if we view the egg (fertilized or not) as part of the woman, like other tissues (e.g. organs)? ➤Now, we ought not commodify eggs, but not because the embryo has some particular moral standing ➤This is a typical Marxist feminist view ALIENATION AND COMMODIFICATION➤Feminists use Marx to argue that reproductive tissues are inalienable ➤Marx argued that one’s body and one’s labour belong to the person ➤We harm the person when we treat their bodies as things to be bought and sold ➤And it isn’t just Marx ➤At the time of the American Civil War, Republicans compared wage-labour to slavery! ALIENATION AND COMMODIFICATION➤Commodification: turning something into a commodity (a thing for sale) based on market value (what Marx calls “exchange value”) ➤When we commodify the body or a person’s labour, we are turning them into a thing rather than treating them as a person (think here of Kant) ➤We should not be alienated from ourselves or our labour in this way—these are all parts of a whole ➤Marxist feminists argue against the commodification of embryos in this way FEMINIST CRITIQUE OF A COMMON ASSUMPTION➤McLeod and Baylis are arguing that this Marxist theory is not developed well enough ➤It isn’t clear why oocytes are like, say, organs ➤Oocytes don’t seem to be required for autonomy ➤If a woman wants to commodify her eggs, what harm is done to her? ➤We don’t let people sell their organs because, while they “own” them in some sense, they are not like property ➤Selling them will do great harm to the individual’s health and wellbeing ➤That isn’t the case for oocytes. They seem more like male sperm—not integral to embodied person WHO DO YOU AGREE WITH? FEMINISTS LIKE MCLEOD AND BAYLIS, OR TRADITIONAL MARXIST FEMINISTS? ARE OOCYTES INALIENABLE? CONSEQUENCES OF THE MARXIST VIEW➤The Marxist view also leads to some consequences that feminists usually find problematic ➤To make the egg more important, Marxist feminists tie them to reproductive ability ➤But this means the view is… A.Pronatalist (reproduction is an essential good for women) B.Poses a threat to women’s reproductive autonomy (since abortion might be seen as a kind of alienation) C.Doesn’t respect different views women can take to their reproductive cells (some women just don’t care about their eggs this way) D.Reinforces biological reductionism (reducing women’s autonomy to their reproductive function)—some women, e.g. trans women or cisgender women who have undergone the removal of their ovaries, are incapable of making eggs THE ETHICS OF ABORTION NICHOLAS RAY PUBLIC DEBATES➤Philosophers have argued for the permissibility or impermissibility of abortion since practical ethics became popular in the 1970s ➤All philosophers agree that the state of public discourse regarding abortion is troubling ➤These “debates” are usually just opportunities to shout at, and speak past, one another ➤Philosophers try to (a) discover the fundamental principles at play in pro-life and pro-choice positions, (b) sharpen those principles so they do not admit of counter-example, and (c) use those principles to ground better arguments for both pro-life and pro-choice positions LEONARD WAYNE SUMNER➤Usually just called Wayne Sumner ➤Canadian philosopher (working out of the U of T) who focusses on practical ethics and philosophy of law ➤Arguing from a consequentialist perspective for a “Third Way” ➤Abortion is permissible in some (most) cases, and perhaps impermissible in others LEONARD WAYNE SUMNER➤Just like Singer and Sagan from last week, Sumner argues that the morally relevant property is sentience ➤Abortion is permissible up to the point where we have good evidence the fetus can feel pleasure and pain ➤This is usually at some point in the second trimester of pregnancy ➤After this point, decisions to abort must take into account the interests of the fetus LEONARD WAYNE SUMNER➤Abortion may still be permissible, but deliberations about the morality of abortion (and perhaps the legality of abortion) have to take into account the relevant interests of the fetus ➤But what if we don’t agree with Sumner or Singer (or other consequentialists) that the morally salient property is sentience? ➤What if moral status hinges on some other property/properties? DON MARQUIS—STATE OF DEBATE➤All sides involved in debate have to be clear about the principles that motivate their positions ➤This is not true of most public debates about abortion DON MARQUIS—STATE OF DEBATE➤Most pro-lifers rest their arguments on the principle "It is always prima facie wrong to take human life" ➤This principle is too broad—it is clear there are some justified cases of killing ➤Pro-choicers want a narrow principle: "It is prima facie seriously wrong to kill only persons" ➤This is too narrow ➤We need better principles! DON MARQUIS—STATE OF DEBATE➤Marquis is proposing a new theory of moral status ➤The deprivation account of the badness of death and the wrongness of killing (often just called the Deprivation Account) ➤Except perhaps in very rare cases, killing (including abortion) is a prime facie serious moral wrong ➤Agreement on this moral fact has been hampered by flaws in the dialogue regarding the ethics of abortion MORAL PRINCIPLES AND MORAL THEORY➤Both pro-life and pro-choice principles are nearly right ➤They cover all but the most tricky cases ➤But they are accidental, not necessary/essential generalizations ➤We need a more theoretical account of the wrongness of killing, which can’t rely on our pre-theoretical (or "pre-analytic") thinking THINKING THINGS THROUGH….➤Killing primarily wrong because of its effects on the victim ➤Loss of life is perhaps the greatest loss one can suffer ➤BUT WHY? ➤After all, “loss” here is an odd term ➤A dead person is no longer a person, and so therefore death cannot harm the dead person ➤But Marquis argues that “loss” does not equate to “harm” ➤Why? DEATH➤The hedonist philosopher Epicurus (341-270 BCE) argued that death is not a bad for the person who dies ➤Wherever death is, I am not; wherever I am, death is not ➤It is irrational to fear death, therefore—such a fear can only be a phobia DEATH➤Death cannot be bad for the person who dies, because the only bad things are harms, and harms have to have a patient ➤Dead persons cannot be patients of harms ➤Marquis is arguing against this position re: the badness of death DEPRIVATION ACCOUNT OF THE BADNESS OF DEATH➤Death is not a bad in and of itself ➤The change in biological state is not relevant to ethics or value theory ➤What makes death bad (and killing wrong!) is that it deprives us of activities, projects, experiences, and enjoyments ➤Killing brings about an unjustified loss of a future ➤"A future like ours” theory of moral status DEPRIVATION ACCOUNT➤Moral status hinges on having a future like ours ➤It might be less morally wrong to kill entities that have very different futures from our own ➤It might be less wrong to kill a pig, let’s say, since pigs can be deprived of a future with certain experiences, but not because they have a future like ours ➤A pig can’t hope to finish its first novel, or grow a social movement, or see its piglets graduate university, etc. DEPRIVATION VS. SANCTITY OF LIFE➤How is this view different than the religious "Sanctity of Life" account of the wrongness of killing? ➤On this view, it is wrong to kill because all life is sacred, and killing is prohibited by divine decree DEPRIVATION VS. SANCTITY OF LIFE➤Unlike the Sanctity of Life account, this theory tells you what natural properties subvene moral status (i.e. it is not just some supernatural quality) ➤Doesn’t rely on religious authority, or some detached moral properties that have nothing to do with the world ➤An entity has moral status once it is likely that the entity will, in the normal run of things, have the cognitive and social abilities to support a future filled with experiences (good and bad), life goals to be pursued, projects to be planned and executed, relationships to be entered into, etc. ➤Marquis thinks this is true of human life, not from the moment of conception, but from the moment where the embryo is viable in early pregnancy DEPRIVATION VS. POTENTIALITY ARGUMENTS➤It is better than a potentiality argument because it is not saying that we should respect embryos or fetuses because they have the potential to be rational ➤Marquis is arguing that the embryos or fetus possesses a future like ours—of which it can be deprived ➤The viable embryo/fetus has this property RIGHT NOW ➤This doesn’t require a bizarre Aristotelian metaphysics about what is essential to its nature ➤Marquis isn’t saying the embryo or the fetus has a rational nature (it probably doesn’t… and what does “nature” even mean) ➤Marquis is saying that the embryo or fetus has a future like ours—a future where it can pursue its own conception of the good REVISITING THE PARAMETERS OF MARQUIS’ ACCOUNT➤What about instances where the “future like ours” doesn’t look like ours (or at least we have good reason to believe that it won’t be like ours)? ➤What if the child is born with greatly diminished prospects, perhaps due to severe cognitive impairment? ➤What about cases where ensuring that a fetus is able to have a “future like ours” at the expense of the host’s health? HEALTH OF THE HOST➤Remember that Marquis is arguing that a fetus has moral standing similar to an adult human person ➤This means it is a prima facie serious wrong to kill the fetus ➤But aborting a fetus to save the host might not even count as “killing”, or it may count as a justified killing ➤We must think of the doctrine of double-effect DOCTRINE OF DOUBLE EFFECT➤Intentionally doing X (where X is permissible) even though you know it will lead to some bad consequence Y is not the same as intentionally doing Y ➤Let us assume that intending to Y is impermissible ➤Another way of putting it: acting in a moral way may end up unintentionally (but knowingly) causing harms it would otherwise be impermissible to intend ➤We generally regard being the cause of death of an innocent person as morally permissible in cases of self-defence, and this might be such a case ➤Knowingly causing the death of an innocent isn’t always the same as killing, and even if it counts as a killing it may be permissible JUDITH JARVIS THOMSON➤Deontologist who argues that abortion is permissible in most, if not all, cases ➤“ A Defense of Abortion” (1971) was written before Roe v. Wade (1973) ➤She is writing in a context in which legal rights of bodily autonomy are not extended to include abortion ➤Since the overturning of Roe, many states have since greatly restricted access to abortion, making this paper timely again A NEW DIALECTIC FOR ABORTION DEBATES➤Thomson denies that abortion debates are settled by a determination of humanity or even stronger notions like personhood ➤We can grant that the fetus is a person (though she doesn't think this is the case) ➤Still, abortion is morally permissible, even under such a strong assumption A NEW DIALECTIC FOR ABORTION DEBATES➤We never have an obligation (i.e. duty) to sustain the life of another human being ➤Doing so is a supererogatory act (an act that goes above and beyond the call of duty to promote the good) ➤Why this legal (and moral) asymmetry? ➤On what grounds can pro-life proponents demand of the pregnant they use their body in this way? THE SICK VIOLINIST…AND THE NEFARIOUS ACTIVITIES OF MUSIC LOVERS THOMSON’S ARGUMENT➤Thomson structures her paper around several analogies ➤An analogy is a cognitive process that transfers meaning from a base case to a target case, usually to change our beliefs about the target case ➤Thomson gives us some very interesting thought experiments to help us think things through ➤She is trying to show you that you, generally speaking, have the intuition that person bodily sacrifice is never expected to save the life of another, except in cases of abortion (legal asymmetry) SICK VIOLINIST THOUGHT EXPERIMENT➤She asks us to imagine that we wake up in a hospital bed back to back with a famous violinist. Turns out this violinist has a fatal kidney ailment and you are the only one who can help. You were knocked out, kidnapped, and plugged into his circulatory system so that your kidneys can extract waste from his blood ➤If unplugged, the violinist will die. Don’t worry, though, this will only take 9 months. At this point he will be okay and can be safely unplugged from you The violinist doesn’t pose any specific health threats, though you are likely to gain a considerable amount of weight, and the whole arrangement can often be uncomfortable and painful. ➤What do you do? ➤It’s nice if you wait it out ➤Is it demanded of you, though? THOMSON’S ARGUMENT➤What if the hospital administrator says that you have to stay in bed because all persons have a right to life; violinists are persons? Yes, you have a right to say what happens to your body, but a person’s right to life trumps that ➤This is the “Extreme View” ➤JJT’s claim: no existing law would require you to stay hooked up to the violinist, and morality does not demand you to stay hooked up ➤If you stay hooked up, you are doing a good thing, but you are under no obligation to ensure another person lives ➤The right to life of the violinist means you cannot kill the violinist; it does not entail that you have an obligation to prevent him from dying (or save his life) WEAKENING THE CASES➤Having established that in cases of rape there is no obligation to save the life of a fetus, Thomson begins to weaken the cases ➤The following analogies cover cases where the host’s life is at risk, but also cases where they are just being asked to use their body to sustain the life of another ➤Thomson wants to see what you think about the vignettes, and whether your response to the vignettes is incongruous with your views on abortion BUT IT'S NOT THE BABY'S FAULT... WHAT IF IT'S FAT? (ALSO, WHY DO PHILOSOPHERS WRITE LIKE THIS, ALWAYS ABOUT FAT PEOPLE?) STUCK IN A HOUSE WITH A BABY AND THE BABY KEEPS GROWING AND EVENTUALLY IT’S PUSHING YOU UP AGAINST THE WALLS OF THE HOUSE, BUT YOU HAVE A KNIFE ARE YOU JUSTIFIED IN KILLING THE BABY? BUT THE BABY NEEDS THE HOST’S WOMB TO LIVE! BUT THE BABY NEEDS THE HOST’S WOMB TO LIVE!➤Smith and Jones find themselves outside on a cold day ➤Jones is freezing to death because he does not have a coat ➤Smith has two coats ➤Jones takes Smith’s extra coat (Smith does not offer it) ➤Is Smith permitted to take it back, even though it will lead to Jones death? ➤Smith has a property right, and this is stronger that Jones’ right to life ARE PROPERTY RIGHTS REALLY STRONGER THAN A RIGHT TO LIFE? STRONGER? PROPERTY OR LIFE➤Generally speaking, a right to life is a very weak right ➤It is a negative right we each possess, and it curtails the action of others against us ➤You must have a very strong justification for killing me if I possess a right to life ➤But it is NOT , generally speaking, thought of as a positive right ➤A positive right places demands for certain kinds of pro-action toward me STRONGER? PROPERTY OR LIFE➤In other words, it is almost always impermissible to kill a person (because they have a right to life) ➤It is almost always permissible to let others die, even when we can save them ➤Only certain role responsibilities are caveats to the permissibility of letting others die, e.g. parents and guardians, doctors and emergency responders, and the like ➤Each one of you lets thousands of people die every day even though you have the power to save them, yet we don’t think there is a moral demand on you to save a life ➤It is a good thing, if you do it; Smith would’ve been nice to share his coat ➤But it is not demanded of you that you use your property to save the life of another USING ANOTHER’S BODY USING ANOTHER’S BODY➤Henry Fonda (1905-1982), American actor ➤JJT thinks he’s handsome ➤She imagines being in a hospital, sick with some nondescript illness ➤The only thing that will save her is if he comes and gives her a kiss ➤Is he obliged to do this? NO! ➤(Here, Thomson isn’t even saying that the effort is all that big a deal. Even if he is already in the room, he would not be obliged to give her a kiss. He is not obliged to use his body in any way based on the needs of others. If he kisses her, he is doing something good; but it is not obliged.) ➤We generally do not force people to use their bodies in intimate ways with others. In fact, we usually set up the law to prevent forced intimacy! ➤(More on this soon) PEOPLE SEEDS, OPEN WINDOWS PEOPLE SEEDS, OPEN WINDOWS➤Imagine there are “people seeds” floating around. These are basically viable embryos that can lodge into soft surfaces (upholstered furniture, rugs and carpets, etc.) ➤You really like to enjoy a nice breeze ➤You know that even good window screens can’t keep all of the people seeds out ➤If one gets into your house, and lodges in your sofa, are you obliged to keep it there as it develops? ➤Are you even obliged to use screens? (Assume you really like fresh air and breezes; you really do not like screens!) PEOPLE SEEDS, OPEN WINDOWS➤Thomson thinks you have no obligation to (a) ensure that persons do not attempt to use your body/property, and (b) allow them to continue to use your body/property once they start ➤You are not required to give of your body or your property to sustain the life of another ➤The right to life (in law and morality) is not a right to the body or property of another RISKY BEHAVIOUR➤Some will argue that those who end up pregnant hand over their rights to bodily autonomy when they engage in risky behaviour ➤They know they can get pregnant ➤It is like inviting someone into your home ➤If they didn’t want to live with the consequences of their actions, they should have taken the proper precautions ➤But this line of criticism is itself susceptible to criticism WHAT ABOUT RISKY BEHAVIOUR? RISKY BEHAVIOUR➤First, it is unclear why having sex (even unprotected sex) is like “inviting” a fetus ➤If I open all of the doors and windows in my house, even removing the screens (contraception) because I like fresh air, and you innocently walk into my house, I am not obliged to let you stay in my house, eating my food, using my property, etc. ➤I am only obliged when I actually (intentionally and explicitly!) invite you into my house—when we contract via a rent agreement, for example RISKY BEHAVIOUR➤Also, this criticism implies that those who don’t want to risk pregnancy either have to abstain from sex altogether, or make absolutely sure they can’t get pregnant ➤But this would mean more than just using contraception ➤This would mean getting voluntary hysterectomies (since no other form of contraception or surgical birth control is 100% effective) ➤This is an extreme demand, and it jeopardizes bodily autonomy LEGAL (AND MORAL) ASYMMETRY➤Nowhere in the law do we expect people to be Good Samaritans ➤We expect people to be “Minimally Decent Samaritans” ➤The law and folk morality demand that we be non-maleficent ➤The law doesn’t demand that we be beneficent ➤Again: abortion laws seem to be the only exception to this general rule A QUESTION OF METHOD➤Neither pro-life nor pro-choice positions address the fact that gestation happens inside a body ➤Results in thinking of fetuses as atomistically situated ➤Margaret Little wants to change this discussion A QUESTION OF METHOD➤But fetuses are situated within a womb ➤Relationship is best modelled as an intimate relationship ➤This may seem like it grants a lot to the pro-life WHAT PRO-LIFE CONSEQUENCES FOLLOW FROM INTIMACY? WHAT PRO-CHOICE CONSEQUENCES FOLLOW FROM INTIMACY? IS THERE A DUTY TO GESTATE? DUTY TO GESTATE?➤It might seem at first that the intimacy of gestation grounds a pro-life argument ➤The fetus isn’t something detached from the host ➤Thomson’s analogies might not be as strong because of this! ➤The fetus isn’t like a person who comes into your home, or someone who needs your coat in a storm ➤Not some stranger DUTY TO GESTATE?➤But Little still agrees with Thomson ➤There is no duty to gestate ➤And, in fact, Thomson didn’t go far enough in her arguments ➤Having a duty to gestate fails to respect bodily autonomy; but it’s worse than that, in fact DUTY TO GESTATE?➤Intimacy could be a personal reason for someone to willingly gestate ➤Feelings of love associated with the intimacy are quite often described by parents as a great joy ➤But harm is caused when this intimacy is forced through law ➤Forced intimacy isn’t accepted in any other relationships DUTY TO GESTATE?➤Little is arguing that anti-abortion laws would force intimacy ➤If we create pro-life laws, how do we prevent them from entailing a nasty consequence—that some bodies can be used in the most intimate ways without their consent ➤Here you can see Little extending Thomson’s argument PROCREATION AND PROCREATIVE BENEFICENCE PROCREATIVE BENEFICENCE➤General consensus that parents ought to do whatever is in their power to have the "best" children ➤Those trying to conceive… A.spend lots of money on supplements, even months before they plan on getting pregnant B.abstain (during conception, pregnancy, and even during breast-feeding) from drugs, alcohol, their favourite foods (like sushi) and a number of other regular activities in order to have the "best" babies C.Do regular exercise D.Visit various specialists regarding their health and the health of the fetus ETC. BENEFICENCE V. NON-MALEFICENCE➤Key conceptual distinction ➤Beneficence is helping others ➤Here, we would be helping children be the best they can be ➤Non- Maleficence is simply doing no harm ➤We often confuse the two concepts, but we should be careful not to WE HAVE DUTIES NOT TO HARM CHILDREN, BUT DO WE HAVE DUTIES TO BENEFIT THEM? BENEFICENCE➤Normally, we don’t think we have duties to be beneficent to others ➤For example, in our unit on abortion, Judith Jarvis Thomson argued that the law and morality usually only demand of us that we be “minimally decent Samaritans”, i.e. that we be non- maleficent ➤However, we don't need to argue whether or not parents have a duty to help ➤Almost all of them already accept that they have this duty—the freely adopt it, most of them before conception of their children ➤The philosophical questions regarding procreation come downstream from typical questions about whether or not our duties are beneficent or merely non-maleficent THE PRINCIPLE OF PROCREATIVE BENEFICENCE➤A principle proposed by Julian Savulescu ➤Procreators must weigh this principle when making decisions, but it has a prima facie status in mature decisions about procreating ➤We have a prima facie duty to produce the best possible off-spring THE PRINCIPLE OF PROCREATIVE BENEFICENCE“Couples (or single producers) should select the child, of the possible children they could have, who is expected to have the best life, or at least as good a life as the others, based on the relevant, available information.” WHAT MIGHT BE CONTENTIOUS ABOUT ADHERING TO THE PRINCIPLE OF PROCREATIVE BENEFICENCE? BENEFICENCE AND TECHNOLOGY➤We now have the ability to test for diseased traits ➤Soon, we may be able to test for non-disease gene subtypes (alleles) that determine intelligence, physical constitution, attitude, etc. ➤Coupled with in vitro fertilization (IVF), pre-implantation genetic diagnosis (PGD), and pre-natal testing/screening/diagnosis (PND) give us the tools to select the best children BENEFICENCE AND TECHNOLOGY➤We are also able to engage in genetic editing using technologies like CRISPR-Cas9 ➤With further extension of this technology, using CRISPR aligned with different enzymes or proteins, We could conceivably design children to have specific traits, including disease resistance ➤But we could also design children with certain non-disease traits associated with intelligence, athleticism, appearance, etc. CONSEQUENCES OF PPL OF PB➤The Principle of Procreative Beneficence captures a duty we have to our unborn children ➤This duty might require us to engage in embryo selection (if using IVF), selective abortion, or, if technologies develop, genetic manipulation of embryos ➤A principle which seemed quite intuitive will inform procreative decision-making in contentious ways ARGUMENTS AGAINST PROCREATIVE BENEFICENCE SIMPLE ARGUMENT➤“You might kill Mozart!” ➤Well, you would be selecting embryos, and that is probably different from killing (even if embryos are persons) ➤Setting this aside, you might not choose to implant Mozart; but you mightn’t implant Hitler ➤This is really just a silly way of thinking about the issue INEQUALITY ARGUMENTS1.Procreative Beneficence will maintain or increase inequality 2.Disability Discrimination Claim: even selecting based on disease traits perpetuates views of those diseases/disabilities INEQUALITY ARGUMENTS➤Some of these worries come out in the film for this week ➤Gattaca (1997) ➤In a world where most people are genetically enhanced, how will just “normal” (non-genetically modified) people, or people with diseases, be viewed? GATTACA➤Vincent Freeman (Ethan Hawke) lives in a society where babies are no longer born “naturally” ➤As one of the last naturally born people, he is thus viewed as genetically inferior to most others ➤He hasn’t been bred for greatness ➤Others in this society excel because they have been created—designed really—to fulfill particular roles ➤Natural children are relegated to second-class status within the society GATTACA➤Vincent has always wanted to travel into outer space, but because of his genetic makeup he can’t to that ➤He works as a janitor for a space exploration corporation, but that is about as close as he can get ➤So he finds a genetically modified person who sells him a new identity ➤Jerome Morrow (Jude Law) is a laboratory- engineered “valid” ➤Jerome had been in an accident that left him paralyzed (this is the only way disability exists in this society) ➤Vincent assumes Jerome's DNA identity and joins the Gattaca space program HARM ARGUMENTS AGAINST PROCREATIVE BENEFICENCE1.Excessive and Overbearing Parental Expectations 2.Using the child as a means, not treating the child as an ends 3.Closing off possible future options based on current (imperfect) information HABERMAS: PERSONS VS. THINGS➤Putting forth a Neo-Kantian argument ➤Our conception of persons in ethics and law relies on the notion of autonomy ➤ Genetic technologies call into question the very framework of autonomy ➤And they call into question ethics and the law HABERMAS AND HUMAN NATURE➤Genetic technologies allow us to select people and their traits ➤Can we design persons? ➤We normally think of designing things—not persons ➤Persons are supposed to be (more or less) a product of chance, not design intention ➤If another person is choosing your traits in accordance with their conception of the good, can you really be autonomous—can you ever see yourself as working towards your conception of the good, if you’ve been designed for a specific purpose? COMPLEX CASE➤Deaf lesbian couple from Washington DC have deliberately conceived a deaf child, their son Gauvin ➤Sharon Duchesneau and Candy McCullough used their own sperm donor: a friend with five generations of deafness in his family ➤Like others in the deaf community, Duchesneau and McCullough don't see deafness as a disability ➤They see being deaf as defining their cultural identity and see signing as a sophisticated, unique form of communication WHAT DO YOU THINK OF DUCHESNAU AND MCCULLOUGH’S DECISION TO TRY PRODUCE A DEAF CHILD? PROCREATIVE BENEFICENCE VS. PROCREATIVE AUTONOMY➤What happens when one's commitment to equality and personal interests conflict with Procreative Beneficence? ➤Should individuals have rights to Procreative Autonomy? ➤Savulescu says we should— we ought to favour reproductive liberty in liberal democracies ➤Procreative Beneficence must be balanced amongst other principles (such as the Principle of Procreative Autonomy), but it is a normative principle that ought to guide our reproductive decision- making—it must be properly weighed ➤Savulescu thinks we can justifiably criticize procreators for not properly weighing Procreative Beneficence WHAT DO WE MEAN BY “BEST” OR “HEALTHY”➤Selection or design of “healthy” embryos can be problematic ➤“Best” is an evaluative, not a descriptive, term ➤Even “healthy” isn’t a purely descriptive term—it is loaded with assumptions about value ➤How we talk about what is “healthy” and “unhealthy” can indicate which evaluative assumptions we adopt ELISABETH GEDGE➤Professor of Philosophy, McMaster University ➤Arguing against a trend she sees in discussions about genetic medicine ➤Wants to do a discourse analysis of the way we talk about the prospects of selecting based on genetic traits (or designing those traits) ELISABETH GEDGE AND GENOHYPE➤Concerned with “genohype” ➤The “excessive preoccupation with genetic medicine, the exaggerated claims made on its behalf, and various associated dangers" ➤Testing for "healthy" human embryos inadvertently stigmatizes those with a disability as "deviant"/ "abnormal" ➤Implies that these people do not have a life worth living—or at least a greatly diminished life EXPRESSIVISM➤Language can assert a particular content and express an underlying attitude ➤For example, I can assert that I am fine, but do so in such a way that I express annoyance at being asked how I am doing ➤Sometimes, we express unintentionally! ➤For example… EXPRESSIVISM➤Our assertions about “curing” or “eliminating” certain disorders unintentionally cause symbolic harm to disability communities ➤Practices that seek to prevent the birth of persons with disabilities express an underlying evaluative attitude about disabilities and disabled persons ➤Is perpetuated by the push for PND and PGD ➤Assertions are often about health, but the unintentional attitude expressed is that people with a disability have a diminished life, or even a life not worth living CONSEQUENTIAL VS. SYMBOLIC HARMS➤PND and PGD might present consequentialist harm, e.g. threat of unwanted intervention, increased discrimination, or reduced social services ➤But it also presents a symbolic harm ➤The message expressed devalues persons with disabilities by (1) depicting them in a way inconsistent with their moral status; and (2) unjustly positioning them as abnormal/subordinate/inferior PROPER VS. DE FACTO MORAL STATUS➤Distinction owed to Welsh-Canadian philosopher Jean Harvey (1947-2014), formerly of the University of Guelph ➤Proper moral status is the status we carry as human persons; should elicit "recognition respect" (following Kant) ➤De facto moral status reflects the recognition we actually receive and the degree of empowerment we enjoy as moral agents living in socio-political context ➤Genohype constructs "hyperseparated" and hierarchical binaries ➤"Unhealthy" or "abnormal" individuals defined relative to assumptions about normality and health ➤Identity construction often leads to devaluation of persons DISABILITY DISCOURSE AND OTHERING➤Differentiation of this sort makes repression and domination seem natural ➤We cluster together traits of inferior groups ➤Women, racial minorities, persons with disabilities, LGBTQ folk, the poor, the very young and the very old, are all defined by the way the depart from the straight, white, middle-aged male norm ➤Background assumptions are at work in discourse of "racial tolerance" and "disabled accommodation” ➤Tolerance assumes separation and difference ➤Accommodation assumes those whom are separated need special help to be brought back to “normal” THE MEDICAL NORM—THE IDEAL PATIENT➤Male medical norm ➤Leonardo’s Vitruvian Man ➤Male, white, slim build, properly proportioned, etc. ➤Since the beginning of the scientific picture of man this has been our conception of the ideal human being ➤Anyone who deviates from this mythical norm will be abnormal ➤As we’ll see later in the term: even just being a woman, or being young or old, or being fat or thin, is enough to deviate from this norm ➤Even if being overweight is (or soon becomes) a statistical norm, it won’t be a functional norm ➤Medicine bases assumptions about health on functional norms as well as statistical norms DISABILITY DISCOURSE AND OTHERING➤"Inferior" peoples and cultures of domination are products of several sequential practices that follow a "dualistic logic" like the one used to generate the ability/disability binary: (1) backgrounding (2) hyperseparation, (3) incorporation, (4) instrumentalism, and (5) stereotyping DISABILITY DISCOURSE AND OTHERING➤We can better understand if we compare disability to other axes of marginalization ➤We have empirical evidence that people of colour as a class of persons and women as a class of persons have diminished opportunities ➤Many find it shocking when these markers of identity are grounds for abortion, or if we were to choose to have children of one race over another (if such technologies exist) ➤Concerns about segregation and eugenics WHAT IS A DISABILITY? LAURIER’S LIBRARY➤This is the library at WLU ➤It has an accessibility ramp ➤It ensures that anyone with mobility issues is able to enter the building ➤Isn’t it odd though that we talk about it like this? ➤The WLU Library, like Waterloo’s Dana Porter Library, has front doors a good 10 feet off the ground ➤Unless any of us can fly, or jump like a super-hero, we all need help getting up to the front doors ➤Yet, we don’t talk about stairs in the same way: as “disability accommodation” LAURIER’S LIBRARY➤Can you come up with examples of things that if they were done to help disabled people they would be called “accommodation”, but that are just set up for persons without disabilities? ➤Sidewalks ➤Busses ➤Stairs ➤etc. SOCIAL ACCOUNT OF DISABILITY➤Disability can be defined socially ➤Strong Version: disability just is a lack of social supports for certain people ➤Weaker Version: Disability isn’t only the physical or cognitive features of an entity, but how those features lack support in social context ➤To talk about disability you have to talk about the environment within which the person is abled or disabled ➤So, what makes deafness a disability isn’t really the neurophysiological disorder, it’s the design of institutions, practices, and spaces by people who aren’t considering what it means to be deaf ➤So, we design places to be places we can use, but if we don’t think of everyone when we design them then those spaces will be disabling DISABILITY AND THE DESIGN OF SPACE Gaulaudet University, Washington DC https://www.youtube.com/watch?v=FNGp1aviGvE Video also posted on LEARN under Content MARTHA NUSSBAUM: CAPABILITIES, JUSTICE, DIGNITY ➤Philosopher who works out of the University of Chicago ➤Concerned with questions of justice and political organization ➤Argues against traditional liberal conceptions of political and social organization based on a contract between equals for mutual benefit MARTHA NUSSBAUM: CAPABILITIES, JUSTICE, DIGNITY ➤Problems arise when we try to think of the individual rights bearer as abstract because that means we don’t adequately perceive difference ➤If we don’t perceive difference, how can we account for all persons? ➤Nussbaum points this out. ➤She also points out that we all find ourselves disabled at some point in our lives. For example, the very young and very old that don’t have full bodily or cognitive functioning get left out of our politics MARTHA NUSSBAUM: CAPABILITIES, JUSTICE, DIGNITY ➤We are not equal in bodily or cognitive ability ➤All of us have already been disabled (as small children), and will be disabled again (if we are lucky enough to grow old) ➤We ought to set up our societies to ensure everyone has an opportunity to live a life commensurate with the dignity of the person ➤https://www.youtube.com/watch?v=cbcGbflpFzI ➤Video is also available one Learn under Content CAPABILITIES➤What does it look like if we set up society based on the needs of the individual rather than equality of individuals? ➤Do the Prevalence of PND and PDG tell us something about disability, or about our society’s poor record dealing with disability? ➤Would procreating individuals or couples make different procreative decisions if they knew their society would support them and their offspring if those offspring are born with disabilities? INFORMED CONSENT AND COMPETENCENicholas Ray Biomedical Ethics WHAT IS INFORMED CONSENT? THE BASICS➤Health care system based on a respect for autonomy (from the Greek auto = self; nomos = law) ➤This is usually manifest in the concept of self-determination: autonomous agents have the right to determine what will and will not be done to them, consistent with their own values (i.el their conception of the good) ➤Self-determination is the basis of the doctrine of informed consent ➤Physician must discuss treatment options with patient, informing her of the relevant probabilistic outcomes, and then the patient consents to treatment ➤Which treatment is BEST is not a medico-scientific matter; it is determined by the patient in accordance with her values INFORMED CONSENT: SOLUTION TO TWO PROBLEMS➤In therapeutic medicine, there are two decision problems; we’ll talk about them in a second, but here is some background to those problems ➤The patient’s values must factor into her decisions ➤But patients are almost never well-informed about the relevant science ➤Competent patient decisions are a factor of (a) the patient’s values, and (b) the relevant facts ➤The patient has access to her values but not the relevant knowledge (diagnostic; therapeutic; long- term outcome) PROBLEM #1: BRACKETING PHYSICIAN VALUES➤Health professionals must inform the patient, but this means sticking to the facts ➤Health professionals must never assume they know the patient’s values ➤They must also never force their values and interests upon the patient—no colonizing the patient’s conception of the good ➤They have a fiduciary responsibility (responsibilities based on a special trust-based relationship) ➤Colonizing the patient’s values breaks this trust ➤They also have professional responsibilities ➤What they think the patient should value is irrelevant PROBLEM #2: INFORMING THE PATIENT➤Making sure the patient has the relevant information ➤But, since patients are not experts, this means giving them the relevant information tailored for the patient ➤Do not assume the patient understands facts about their body, what treatments are available, or the likely outcomes of pursuing one kind of treatment over another ➤Do not assume the patient knows statistics, or how to interpret clinical trial data, etc. ➤(BTW: There is no algorithm for how physicians make these judgments) ANOTHER PROBLEM: PATIENT REASONING➤We’ll get back to these two problems in a second ➤But there is a third pesky problem, this one about how people tend to reason (even in non-medical contexts) ➤Even if healthcare providers could pass along all of their knowledge to the patient, properly tailored to the patient, there would STILL be a problem ➤Does the patient have the ability to reason from the facts in accordance with their values? ANOTHER PROBLEM: PATIENT REASONING➤Perfect information and perfect access to one’s values is insufficient for decision-making ➤This is because people must reason using probabilities, and we are (on the whole) pretty bad at doing this, especially when we try to do it without taking time to do the calculations ➤Most of us don’t even know how to do the calculations! THINKING ABOUT PROBABILITIES➤Philosophers and mathematicians have worked out a lot of formal, mathematical devices to help us make decisions when we have only probabilistic information ➤All of the relevant factual information in medicine is probabilistic ➤There are no exceptionalness laws in the life sciences or medicine as there are in physics ➤Even in physics, lots of laws turn out to be probabilistic! THINKING ABOUT PROBABILITIES➤We have the mathematics ➤But few of us know how to use it ➤Probability theory is the science of decision-making under imperfect information ➤We usually don’t use the tools of this science ➤Most people do not know the math, and maybe don’t even know that math can help us out! THE MONTY HALL PROBLEM➤Named after Canadian TV game show host, Monty Hall ➤Probability problem loosely based on Monty Hall’s show Let’s Make a Deal MONTY HALL PROBLEM➤Imagine you have three doors, all equal in every relevant way ➤Behind one of the doors is a car ➤Behind the other two are goats ➤Monty asks you to choose a door; you pick #1 ➤Monty, who knows what is behind the doors, then opens door #3 to reveal a goat ➤He then asks you if you want to switch to door #2 DO YOU SWITCH FROM DOOR #1 TO DOOR #2 YOU SHOULD SWITCH➤The best strategy for winning is to switch ➤It might feel like the choice between Door #1 and Door #2 is an either/or, and therefore a 50/50, but this is exactly where our guts leads us to the wrong answer ➤We are confusing a logical fact with a probabilistic fact ➤There are two options, but they are not equally probable ➤Door #2: 66.6% chance (or a probability of 0.666…) ➤Door #1: 33.3% chance (or a probability of 0.333…) YOU SHOULD SWITCH➤Your initial choice (Door #1) has a probability of 1/3 ➤That NEVER changes throughout the Monty Hall problem ➤That means the probability of the car being behind the conjunction of Door #2 (1/3) and Door #3 (1/3) is 2/3 ➤That NEVER changes either ➤When Monty opens Door #3, showing you a goat, the probability space collapses ➤Door #3 is now probability 0 ➤But the conjunction of Door #2 and Door #3 is still 2/3 ➤That means Door #2 is 2/3 DON’T TRUST THE MATH? YOU COULD ALWAYS DO UNNECESSARY EXPERIMENTS!https://www.youtube.com/watch?v=M9wfxElkxMI This video is also posted under Contentn on LEARN WHY INFORMED CONSENT IS AN ETHICAL ISSUE➤T wo underlying values ground the doctrine of informed consent ➤The first is promotion of individual well-being ➤The second is self-determination ➤But depending on how we determine competence, these values could very well conflict! ➤We want to know how to proceed when there is a purported conflict TWO KINDS OF ERRORS1. Failing to prevent the harms caused by poor decisions when those decisions were made incompetently 2. Transgressing autonomy when a competent person is denied the right of self-determination PRESUPPOSITIONS OF INFORMED CONSENT➤Informed Consent predicated not only on autonomy, but on the preconditions for autonomy ➤Central amongst these is rationality ➤Physicians must respect the wishes of those who are able to reason about future outcomes ➤Others (children, some cognitively disabled persons, persons in extended unconscious states, and perhaps even persons with disabilities like severe depression) may not get to decide, at least about some matters PRESUPPOSITIONS OF INFORMED CONSENT➤So, informed consent requires that my autonomy be respected, but it also presupposes that I meet the requirements for exercising autonomy ➤I must be recognized to be rational and able to exercise rational competence ➤Physicians must respect those who are able to meet this condition… in other words those who are able to made decisions grounded in reason, those that are able to make decisions about future outcomes ➤Thus, not everyone may be in a position to get to decide about at least some matters related to their health—at least not on their own PRESUPPOSITIONS OF INFORMED CONSENT➤How are judgments about competency made? ➤There are two views regarding competent decision-making ➤Particularist Views ➤Generalist (or Principled) Views ➤We’ll start with generalist views, then talk about Brock and Buchanan’s particularism, and then come back to talk about generalism in more detail PRINCIPLED OR GENERALIST ACCOUNTS OF COMPETENCE➤We can discern competent from non-competent persons based on some principle, or through the application of a general rule for competency ➤Context does not usually matter ➤If a person has her rational faculties, then she is competent to make decisions (when properly informed) ➤If a person meets the threshold for competency, then we have to respect that person’s ability to make their own decisions PARTICULARIST ACCOUNTS OF COMPETENCY➤The type of account favoured by Allen Buchanan and Dan Brock in the first of our readings for this section ➤Competency is always relative to some task, or even to sub-tasks ➤Context always matters ➤Thus, competence in decision-making (capacity for decision-making) has to be settled on a case by case basis Allen Buchanan James B. Duje Professor at Duke University Oxford Uehiro Centre for Practical EthicsDan W. Brock Frances Glessner Lee Professor Emeritus of Medical Ethics in the Department of Global Health and Social Medicine at Harvard Medical School PARTICULARIST ACCOUNTS OF COMPETENCY➤Decision-making capacity is incomplete until we assessers of a concrete decision-making process fill in the relevant context ➤What is the choice, the conditions under which it is to be made, the quality of the information imparted by expert healthcare providers, etc. ? ➤Competence is decision- relative, not global/general, and not based on principles (where those principles are silent about contextual features) “A competency determination, then, is a determination of a particular person's capacity to perform a particular decision-making task at a particular time and under specified conditions.- Buchanan and Brock WHAT KIND OF DEFINITION IS THAT?! ➤What do you notice about Brock and Buchanan’s definition? ➤Almost everything is a variable! ➤That’s what Buchanan and Brock want you to see. It’s all a bunch of inter-related variables; you can’t make a determination until all of these variables are settled and understood."A competency determination, then, is a determination of a particular person's capacity to perform a particular decision-making task at a particular time and under specified conditions.” FACTORS ON DECISION-MAKING COMPETENCY➤Not all cognitive impairments are gradual and linear in their progression ➤Aged patients suffering from dementia can have moments of great lucidity that punctuate long stints of worsening confusion ➤Depressed patients can have good and bad days ➤How patients get information is also a contextual variable FACTORS ON DECISION-MAKING COMPETENCY➤Brock and Buchanan’s particularism wants to account for the fact that some persons may be competent to make decisions in one situation or on a particular day, and not competent in the next situation ➤The actual environment where the patient is getting the relevant information even could make an important difference. ➤A patient given information from a trusted source in a familiar setting (say her home) might be competent, but not competent while making a similar decision about treatment after being informed by a stranger, in a hospital, after waiting for many hours in sub-standard and stressful conditions ➤This is one of the reasons why lowering wait times and making hospital settings less stressful is so important CHERYL MISAK'S ICU PSYCHOSIS➤Professor of Philosophy, University of Toronto ➤Not an ethicist; she focusses mostly on the history of analytic philosophy, American Pragmatism, and philosophy of language ➤But she is writing about her own experiences as a patient in the ICU CHERYL MISAK'S ICU PSYCHOSIS➤Found herself hospitalized and intubated, suffering from septic shock, acute respiratory distress syndrome, and multiple organ failure ➤Suffered from “ICU Psychosis” CHERYL MISAK'S ICU PSYCHOSIS➤ICU psychosis is a disorder where patients who are in the ICU or a hospital setting similar in kind to an ICU suffer from things like extreme anxiety ➤They may get paranoid or hear voices, think things like the doctor is out to hurt or kill them ➤They can be very very confused and disoriented, get agitated and even become violent ➤It’s an “acute brain syndrome” and those who are suffering lose some cognitive function ICU PSYCHOSISFolks in ICUs often suffer from ➤lack of sleep; ➤strange and uncomfortable surroundings; ➤medication side-effects; ➤inability to effectively communicate; ➤desire to be extubated; ➤PTSD; ➤delusions of torture and harm at the hands of healthcare professionals ➤Etc. ➤Packed ICUs, as many hospitals have already experienced with COVID-19 patients, only make these problems worse—patients left long periods without contact, in worsening condition ICU PSYCHOSIS➤Misak argues that ICU stressors blur the line between sanity and insanity, and is certainly not ideal for competent decision-making ➤We may even want to drop the doctrine of informed consent in such settings ➤Unless we have evidence to the contrary, we should suppose people in such contexts are incompetent BACK TO BUCHANAN AND BROCK GENERALIZATIONS FROM PARTICULARS➤While Buchanan and Brock are particularists, they still think there are general underlying capacities that are necessary for any kind of competent decision-making ➤The first is the capacity for communication and understanding ➤The second is the capacity for reasoning and deliberation ➤The third is a the possession of a set of values and a conception of the good ➤What makes them different from generalists, then? GENERALIZATIONS FROM PARTICULARS➤Communication capacities, reasoning capacities, and a conception of the good are necessary, not sufficient capacities for competent decision-making ➤For Buchanan and Brock, there isn’t a single sufficient condition for competence that is context-invariant; there is no set of necessary conditions, no matter how robust, that together constitute sufficient conditions fr competence that are context invariant ➤In the same way that being unmarried is necessary, though on its own insufficient, for being a bachelor COMMUNICATIVE CAPACITIES➤Communication and Understanding ➤Take part in processes of becoming informed ➤Possession of linguistic, conceptual, and cognitive abilities ➤Understanding of particular information relevant for decisions ➤Appreciate the meaning of alternatives, e.g. what would it feel like to be in a state that can be caused by this or that treatment method? REASONING AND DELIBERATION➤Capacities to draw inferences about consequences of treatment options ➤Capacity to compare alternative options as they further one's conception of the good or promote one's ends ➤Some capacity for probabilistic reasoning ➤Capacity to think of future outcomes ➤Understand how values enter deliberation VALUES AND CONCEPTION OF THE GOOD➤Reasonably consistent and stable values and conception of the good, capable of being employed stably in extended deliberation ➤Ability to see particular outcomes as benefits or harms, goods or evils ➤Ability to assign weight or importance to alternative outcomes ➤Note: None of this requires a fully consistent set of goals (since nobody has such a maximally consistent set of goals), nor a full life plan RESULTSContext-sensitive Sensitive to riskNo single standard Varies with expected harms and benefitsCould be competent to accept but not refuse Value-choice, not scientific factBalance between self-determination + ind. well-being RESULTS➤Setting a standards of competence is a value choice, not a scientific fact ➤This standard is context-sensitive ➤It is about striking a balance between self-determination and individual well-being ➤There is no single standard RESULTS➤Standards of competence vary with the expected harms or benefits ➤Patient may be competent to accept treatment, but not competent to refuse treatment and vice versa ➤Competence is sensitive to risk (function of severity of benefit or harm, and probability of outcome as per treatment option) WHY IS INFORMED CONSENT SO CENTRAL TO MEDICAL ETHICS? WHY DO WE LIKE INFORMED CONSENT SO MUCH?➤Respects the rights of individuals to have their decisions properly regarded ➤Not just about treatment, but also about being the subject of a voluntary research study ➤The doctrine of informed consent also protects physicians from litigation when there are unforeseen harmful consequences to therapeutic intervention/research WHY DO WE LIKE INFORMED CONSENT SO MUCH?➤Informed consent doctrine also recognizes that information is relative to some human purpose, in particular the purpose of the patient/subject ➤When the physician informs the patient, it is not "all" the information, or even all of the relevant medical information ➤The patient couldn't even understand most of it ➤We must know for what purpose information is needed before we can answer the question, "What information must be given?" BENJAMIN FREEDMAN’S POSITION➤"... the informing of the patient/subject is not a fundamental requirement of valid consent. It is, rather, derivative from the requirement that the consent be the expression of a responsible choice. The two requirements which I do see as fundamental in this doctrine are that the choice be responsible and that it be voluntary" VOLUNTARINESS➤Choice must be voluntarily made ➤No threat or coercion ➤But what about reward? ➤Can rewards be so great that they inappropriately influence choice so that it can be considered involuntary? RESPONSIBILITY➤Physician cannot override decision just because, in the physician's view, the decision is irresponsible ➤Person's exercise of autonomy cannot always be subject to expert review, for then it would not be autonomous at all ➤“You can only make a free choice if you make the right choice” is equivalent to saying “you don’t have autonomy” RESPONSIBILITY➤Valid consent not just about ability to make choices and think through future consequences ➤Children can do that ➤What children lack is responsibility ➤Choice has to be more than just a free choice; it has to be a responsible and free choice ➤But who decides what choices are reasonable/responsible? Cashing this out in paternalistic terms is antithetical to the doctrine of informed consent RESPONSIBILITY➤We avoid these problems by saying that responsibility is defined relative not to the particular choice, but relative to the nature of the patient/subject ➤Is the person responsible, generally speaking? (Notice the big difference here with Buchanan and Brock!) ➤Responsibility is not defined case by case... it is a dispositional characteristic, and it is multi-track, so not really task specific either! (Take that, Buchanan and Brock!) ➤Freedman is arguing for a classical generalist position on informed consent INFORMED CONSENT IN CONTEXT➤I want to end this lesson by talking about informed consent in institutional context ➤We like informed consent because it respects the autonomy of the patient ➤But it also makes patients active participants in their own healthcare ➤Doctors may even try to cultivate this kind of participation ➤Patients advocate for themselves much more now than even just 20 or 30 years ago ➤Parents advocate for children ➤Take on a lot of care responsibilities INFORMED CONSENT IN CONTEXT➤But there is a darker side to patient participation ➤It has become a necessary part of healthcare, largely because healthcare is offloading oversight of health to patients ➤This is especially true of parents ➤Parents who are not active in the health of their children are viewed in the same way as parents who aren’t active in the education of their children ➤Lots of labour for parents ➤Mostly falls on mothers (as studies show) VACCINE HESITANT PARENTS ➤But what happens when healthcare systems DON’T want parents to take on this active role? ➤This happens a lot with vaccine hesitant parents ➤Parents (again, usually mothers) follow the script ➤They try to educate themselves using online tools, and speak to their doctors ➤In the case of vaccines, doctors normally shut down parents quickly ➤They are not treated as competent decision-makers ➤Qualitative data show that this is a point of friction in the patient/doctor relationships VACCINE HESITANCY➤Maya Goldenberg ➤Professor of Philosophy, University of Guelph ➤Does work on vaccine hesitancy ➤Argues that it is not a matter of the “death of expertise” ➤People still respect experts ➤Vaccine hesitancy is about an erosion of trust relations ➤A systemic problem with healthcare VACCINE HESITANCY➤Doctors and nurses often rush patients ➤They want to get vaccines done quickly, not spend time talking about them ➤Doctors set aside the very participatory nature of patient involvement that they have otherwise cultivated ➤Often treat vaccine hesitant parents as stupid, or misguided VACCINE HESITANCY➤Poor treatment of patients further pushes them to other sources of information ➤Online groups cultivate a sense of community ➤They welcome parents, especially mothers, who are concerned about their children’s health ➤The problem perpetuates VACCINE HESITANCY➤Sociological data now shows that vaccine hesitant parents are very well educated (with higher than general pop rates for university degrees and advanced degrees) ➤Parents who spend a lot of time taking care of their kids ➤Respect experts, and almost always seek out the advice of experts VACCINE HESITANCY➤If Goldenberg is correct, the problem lies not with parents ➤It lies with healthcare practices that don’t provide enough time to have longer discussions about vaccines and vaccination schedules ➤Trust relationships require cultivation and time ➤Much responsibility lies with doctors and public health programs that make vaccine hesitant parents feel stupid instead of interacting with them as educated people concerned about their children VACCINE HESITANCY➤If we really take informed consent seriously, then we ought to respect it in all contexts ➤Hesitant patients are patients who are actively thinking about their healthcare ➤We cultivate this attitude in other contexts ➤We shouldn’t shut people down in the case of vaccines ➤We should also be sensitive to the (often gendered) hierarchy of doctor/patient interactions ➤Treating vaccine hesitant moms as if they are “Karens” asking to speak to the manager is insulting and harmful—the opposite of a cultivated relationship that prizes informed consent and trusted DEMANDS FOR INAPPROPRIATE TREATMENT INFORMED CONSENT REVISITED INFORMED CONSENT REVISITED➤In the previous unit, we spoke about informed consent and competence ➤We saw that it is generally the case that patients are respected as autonomous and that they have rights of self-determination ➤They make decisions about their treatment, except in very rare cases when there are grounds to think they’re incompetent ➤But are there restrictions on such a model aside from competency? ➤If a patients are competent to make decisions about their health, does this mean we must respect their requests for treatment? ➤If a patient asks for a certain kind of treatment, on what grounds can a physician or other healthcare provider deny such a request? GUIDING QUESTION: DOES THE PHYSICIAN HAVE A DUTY TO PROVIDE WANTED TREATMENT, WHENEVER IT IS DEMANDED BY THE PATIENT? AN EXAMPLE➤A patient goes to see a physician with very painful sinuses ➤Patient asks for strong antibiotics ➤The physician thinks this is a viral infection—one quite common to their practice and the region ➤The physician thinks providing a course of antibiotics might be on the whole bad for the patient (antibiotic use has risks, sometimes quite serious risks), a waste of resources, etc. ➤Most importantly, the physician’s decision is based on the futility of the treatment being demanded ➤It is very unlikely to ease the patient's suffering, or promote the patient's well-being, make the patient healthier, etc. DEMANDS FOR TREATMENT➤Patients will often ask for treatments that are not likely to make them better, or treatment options for which there is little evidence of their efficacy ➤And sometimes, even medical professional aren’t aware of how these treatment options are supposed to work ➤We need some grounds to reject inappropriate demands for treatment, and some standards for what counts as “inappropriate” ➤Decisions to reject demands for treatment have to be justified ➤They should also not be made in a unilateral manner COMPLICATING MATTERS➤The issue its complicated by these four contextual features of complex decisions: 1.Treatments used are complex and rapidly evolving. Hard for non- experts to keep up; patients and even General Practitioners are not always aware of what treatments are available, and how they work 2.Patient's prognosis or likelihood of recovery may be difficult to assess 3.Consequences are weighty—e.g., withdrawing ventilators or other such treatments often mean patients will die 4.Beds and other resources in ICU (and beyond) are scarce commodities—though this is NEVER supposed to enter into deliberations by physicians about particular cases, except in the most extreme cases where triage medicine is required CONFLICT➤When can the physicians say “no”? ➤On what grounds? ➤Patient self- determination seems to impose on the physician a strong duty of care, at least for competent patients ➤BUT , we definitely don’t want a system in which patients can get any treatment anytime they want, on demand ➤We also don’t want a system where physicians can deny requests for treatment without justification, and in a unilateral manner FUTILITY (GENERAL FORMULATION)➤One dominant way of conceiving of the grounds on which a physician can deny treatment is futility ➤Treatment is futile when the relevant medical professional or professionals judge that administering a particular treatment or plan of treatment is very unlikely to achieve the goals of patient care WHAT REASONS MIGHT WE HAVE FOR BEING WORRIED ABOUT FUTILITY AS GROUNDS FOR DENYING WANTED TREATMENT? PRECISIFYING THE CONCEPT OF FUTILITYSchneiderman, Jecker, Jonsen PRECISIFYING THE CONCEPT OF FUTILITY➤NOTE