There must have been the occasional psychologist in the crowd, but it is difficult to recall any. Too often, the interactions between social scientists and philosophers were futile and frustrating exercises in mutual unintelligibility. Philosophers were trained to map the intellectual landscape, parse whatever interesting concepts they found there, and articulate and critically evaluate ethical arguments.
Philosophers were, with rare exceptions, not trained to create, interpret, or critique empirical studies. Social scientists, on the other hand, understood how to frame and answer certain kinds of empirical questions — those within the purview of their field and methodologies — but they were often mystified by the forms of reasoning and argument employed by philosophers. What does a Kantian distinction between heteronomy and autonomy have to do with whether physicians should tell patients they have cancer?
In , whether to tell the truth about a grave diagnosis such as cancer was still a contentious issue within medicine. An uneasy truce existed between scholars who traffic in normative claims — right and wrong, good and bad — and social researchers unfamiliar with philosophical methods and uncomfortable with claims that cannot be empirically tested. In part the difficulties were based on habits of the mind and heart, in part on struggles over intellectual supremacy and political and economic power.
The role of anthropologists, sociologists and medical historians in medical education was diluted by the arrival of philosophers and theologians. The resentments persist to this day. Social scientists upbraided philosophers for failing to take into account social context and structure, culture, power, and the findings of empirical social research. Philosophers mocked social scientists for their clumsiness at formulating moral arguments and their reluctance to reach moral conclusions.
Or so at least many people thought. The reality turns out to be much richer and vastly more interesting. The National Science Foundation had funded a proposal to study ethical and conceptual issues in non-therapeutic drug use. Where do people use drugs as performance enhancers? Setting aside for now the caffeine in my coffee that keeps me alert, the most widespread and best documented use of performance enhancing drugs was in sport, especially high-level sport such as the Olympics and professional leagues such as the NFL.
The conceptual problems were knotty: What distinguishes enhancement from therapy? What forms of enhancement are acceptable, even praiseworthy? What forms are unethical? What, for that matter, makes something a drug? Most opponents of performance enhancing drugs in sport appealed to paternalistic reasons: Athletes will hurt themselves if they use drugs. Unfortunately, this argument has many flaws.
A communitarian ethic emphasizes a community's other shared values, ideals, and goals and suggests that the needs of the larger community may take precedence, in some cases, over the rights and desires of individuals. If proponents of a communitarian ethic accept the four principles of Beauchamp and Childress 1 , they will tend to interpret those principles through the lens of community, stressing, for example, benefits and harms to community and communities as well as the need to override autonomy in some cases.
Major examples arise in the context of public health. However, in considering the proper framework for communitarian ethics, questions arise in a pluralistic society about which community is relevant. For instance, is the relevant community one embodied in particular traditions eg, one religion or is it the broader, pluralistic society?
Even though there is a broad consensus that communal values and interests sometimes trump personal autonomy, disputes persist about exactly when it is justifiable to override personal autonomy. To take one example, apart from laws that specify which diseases are reportable, physicians may have to balance a patient's claims of privacy and confidentiality against risks to others.
Different judgments about the appropriate balance often hinge on an assessment of risks: How probable and serious must the harm be to justify a breach of privacy and confidentiality? In a final approach, case-based reasoning sometimes called casuistry , ethical decision making builds on precedents set in specific cases 18, This is analogous to the role of case law in jurisprudence in that an accumulated body of influential cases and their interpretation provide moral guidance.
This approach analyzes current cases requiring decisions in light of relevantly similar cases that have already been settled or gained a rough consensus. Case-based reasoning asserts the priority of practice over both ethical theory and moral principles. It recognizes the principles that emerge by a process of generalization from the analysis of cases but views these principles as always open to future revision. In considering a particular case, someone taking this approach would seek to determine whether there are any relevantly similar cases, either positive or negative, that enjoy an ethical consensus.
If, for example, a new research protocol is relevantly similar to an earlier and widely condemned one eg, the Tuskegee Syphilis Study , that similarity is a reason for moral suspicion of the new protocol. A question for this approach is how to identify relevant similarities and differences among cases and whether ethical principles are sometimes useful in this process. An example of how the different ethical frameworks and perspectives might address a particular case is shown in the box.
From this analysis of different approaches, it is plausible to derive the following conclusion: enlightened ethical decision making in clinical medicine cannot rely exclusively on any single fundamental approach to biomedical ethics. The metaphor of toolbox or toolkit may provide a useful way to think about these different approaches to ethical decision making Some ethical tools may fit some contexts, situations, and cases better than others, and more than one—or even all of them—usually are valuable. It is helpful to have access to a variety of ethical tools because clinical problems often are too complex to be resolved by using simple rules or by rigidly applying ethical principles.
Indeed, virtues such as prudence, fairness, and trustworthiness enable clinicians to apply ethical principles sensitively and wisely in situations of conflict. The specific virtues that are most important may vary from one circumstance to another, but in women's health care, there must be particular sensitivity to the needs of women. Furthermore, in many, perhaps most, difficult situations requiring ethical insight, tensions exist between the well-being and interests of the individual patient and the interest of the "community," however that is defined.
Finally, current ethical decisions can be improved by awareness of and guidance from existing precedents.
Psychology Should Be in Dialogue with Bioethics – Association for Psychological Science – APS
In short, even though a principle-based approach may provide a reasonable starting point for ethical decision making, it is not adequate by itself and needs the valuable contributions and insights of other approaches. Principles often serve as initial points of reference in ethical decision making in obstetrics and gynecology, however, and the next section examines several ethical principles in detail.
Clinicians and others often make decisions without appealing to principles for guidance or justification. But when they experience unclear situations, uncertainties, or conflicts, principles often can be helpful. The major principles that are commonly invoked as guides to professional action and for resolving conflicting obligations in health care are respect for autonomy, beneficence and nonmaleficence, and justice 1.
Other principles or rules, such as fidelity, honesty, privacy, and confidentiality, also are important, whether they are viewed as derived from the four broad principles or as independent. Autonomy, which derives from the Greek autos "self" and nomos "rule" or "governance" , literally means self-rule. In medical practice, the principle of respect for autonomy implies personal rule of the self that is free both from controlling interferences by others and from personal limitations that prevent meaningful choice, such as inadequate understanding 1.
Respect for a patient's autonomy acknowledges an individual's right to hold views, to make choices, and to take actions based on her own personal values and beliefs. Respect for autonomy provides a strong moral foundation for informed consent, in which a patient, adequately informed about her medical condition and the available therapies, freely chooses specific treatments or nontreatment.
Respect for patient autonomy, like all ethical principles, cannot be regarded as absolute. At times it may conflict with other principles or values and sometimes must yield to them. The principle of beneficence, which literally means doing or producing good, expresses the obligation to promote the well-being of others. It requires a physician to act in a way that is likely to benefit the patient. Nonmaleficence is the obligation not to harm or cause injury, and it is best known in the maxim, primum non nocere "First, do no harm.
Although there are some subtle distinctions between nonmaleficence and beneficence, they often are considered manifestations of a single principle. These two principles taken together are operative in almost every treatment decision because every medical or surgical procedure has both benefits and risks, which must be balanced knowledgeably and wisely.
Beneficence, the obligation to promote the patient's well-being, may sometimes conflict with the obligation to respect the patient's autonomy. For example, a patient may desire to deliver a fatally malformed fetus by cesarean because she believes that this procedure will increase the newborn's chance of surviving, if only for a few hours. However, in the physician's best judgment, the theoretical benefit to a "nonviable" infant may not justify the risks of the surgical delivery to the woman.
In such a situation, the physician's task is further complicated by the need to consider the patient's psychologic, physical, and spiritual well-being. Although the several approaches to ethical decision making may all produce the same answer in a situation that requires a decision, they focus on different, though related, aspects of the situation and decision. Consider, for instance, how they might address interventions for fetal well-being if a pregnant woman rejects medical recommendations or engages in actions that put the fetus at risk. A principle-based approach would seek to identify the principles and rules pertinent to the case.
These might include beneficence—nonmaleficence to both the pregnant woman and her fetus, justice to both parties, and respect for the pregnant woman's autonomous choices. These principles cannot be applied mechanically. After all, it may be unclear whether the pregnant woman is making an autonomous decision, and there may be debates about the balance of probable benefits and risks of interventions to all the stakeholders as well as about which principle should take priority in this conflict. Professional codes and commentaries may offer some guidance about how to resolve such conflicts.
A virtue-based approach would focus on the courses of action to which different virtues would and should dispose the obstetrician—gynecologist. For instance, which course of action would follow from compassion? From respectfulness? And so forth. In addition, the obstetrician—gynecologist may find it helpful to ask more broadly: Which course of action would best express the character of a good physician?
An ethic of care would concentrate on the implications of the virtue of caring in the obstetrician—gynecologist's special relationship with the pregnant women and with the fetus. In the process of deliberation, individuals using this approach generally would resist viewing the relationship between the pregnant woman and her fetus as adversarial, acknowledging that most of the time women are paradigmatically invested in their fetus' well-being and that maternal and fetal interests usually are aligned.
Instead, he or she should seek a solution in identifying and balancing his or her duties in these special relationships, situating these duties in the context of a pregnant woman's values and concerns, instead of specifying and balancing abstract principles or rights. The clinician would focus attention on important social and family relationships, contexts or constraints that might come to bear on [a] pregnant [woman's] decision making, such as her need to care for other children at home or to continue working to support other family members, or whatever life project occupied her, and attempt to provide relief in those areas….
As this example suggests, a feminist ethics approach would attend to the social structures and factors that limit and control the pregnant woman's options and decisions in this situation and would seek to alter any that can be changed. Finally, a case-based approach would consider whether there are any relevantly similar cases that constitute precedents for the current one. For instance, an obstetrician— gynecologist may wonder whether to seek a court order for a cesarean delivery that he or she believes would increase the chances of survival for the child-to-be but that the pregnant woman continues to reject.
In considering what to do, the physician may ask, as some courts have asked, whether there is a helpful precedent in the settled consensus of not subjecting a nonconsenting person to a surgical procedure to benefit a third party, for instance, by removing an organ for transplantation. Rethinking maternal-fetal conflict: gender and equality in perinatal ethics.
Obstet Gynecol ;— Justice is the principle of rendering to others what is due to them. It is the most complex of the ethical principles to be considered because it deals not only with the physician's obligation to render to a patient what is owed but also with the physician's role in the allocation of limited medical resources in the broader community. In addition, various criteria such as need, effort, contribution, and merit are important in determining what is owed and to whom it is owed.
Justice is the obligation to treat equally those who are alike or similar according to whatever criteria are selected. Individuals should receive equal treatment unless scientific and clinical evidence establishes that they differ from others in ways that are relevant to the treatments in question. Determination of the criteria on which these judgments are based is a highly complex moral process, as exemplified by the ethical controversies about providing or withholding renal dialysis and organ transplantation. The principle of justice applies at many levels.
At the societal level, it addresses the criteria for allocating scarce resources, such as organs for transplantation. At a more local level, it is relevant to questions such as which patients and physicians receive priority for operating room times. Even at the level of the physician—patient relationship, the principle of justice applies to matters such as the timing of patient discharge. The principle also governs relationships between physicians and third parties, such as payers and regulators.
In the context of the physician—patient relationship, the physician should be the patient's advocate when institutional decisions about allocation of resources must be made. In order to guide actions, each of these broad principles needs to be made more concrete. Sometimes the principles can be addressed in more definite rules—for instance, rules of voluntary, informed consent express requirements of the principle of respect for personal autonomy, and rules of confidentiality rest on several principles see "Common Ethical Issues and Problems in Obstetrics and Gynecology".
Nevertheless, conflicts may arise among these various principles and rules. In cases of conflict, physicians have to determine which principle s should have priority. Some ethical theories view all of these principles as prima facie binding, resist any effort to prioritize them apart from particular situations, and call for balancing in particular situations 1. Some other theories attempt to rank principles in advance of actual conflicts Obstetrician—gynecologists, like other physicians, often face a conflict between principles of beneficence— nonmaleficence in relation to a patient and respect for that patient's personal autonomy.
In such cases, the physician's judgment about what is in the patient's best interests conflicts with the patient's preferences. The physician then has to decide whether to respect the patient's choices or to refuse to act on the patient's preferences in order to achieve what the physician believes to be a better outcome for the patient.
Paternalistic models of physician—patient relationships have been sharply challenged and often supplanted by other models. At the other end of the spectrum, however, the model of following patients' choices, whatever they are, as long as they are informed choices, also has been criticized for reducing the physician to a mere technician Other models have been proposed, such as negotiation 23 , shared decision making 24 , or a deliberative model, in which the physician integrates information about the patient's condition with the patient's values to make a cogent recommendation Whatever model is selected, a physician may still, in a particular situation, have to decide whether to act on the patient's request that does not appear to accord with the patient's best interests.
These dilemmas are considered in greater detail elsewhere Almost everything obstetrician—gynecologists do in their professional lives involves one or more of the ethical principles and personal virtues to a greater or lesser degree. Nevertheless, several specific areas deserve special attention: the role of the obstetrician—gynecologist in the society at large; the process of voluntary, informed consent; confidentiality; and conflict of interest.
In addition to their ethical responsibilities in direct patient care, obstetrician—gynecologists have ethical responsibilities related to their involvement in the organization, administration, and evaluation of health care. They exercise these broader responsibilities through membership in professional organizations; consultation with and advice to community leaders, government officials, and members of the judiciary; expert witness testimony; and education of the public.
Justice is both the operative principle and the defining virtue in decisions about the distribution of scarce health care resources and the provision of health care for the medically indigent and uninsured. Obstetricians and gynecologists should offer their support for institutions, policies, and practices that ensure quality of and more equitable access to health care, particularly, but not exclusively, for women and children.
The virtues of truthfulness, fidelity, trustworthiness, and integrity must guide physicians in their roles as expert witnesses, as consultants to public officials, as educators of the lay public, and as health advocates Often, informed consent is confused with the consent form. In fact, informed consent is "the willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention with its risks and benefits and of the alternatives with their risks and benefits" The consent form only documents the process and the patient decision.
The primary purpose of the consent process is to protect patient autonomy. By encouraging an ongoing and open communication of relevant information adequate disclosure , the physician enables the patient to exercise personal choice. This sort of communication is central to a satisfactory physician—patient relationship.
Unfortunately, discussions for the purpose of educating and informing patients about their health care options are never completely free of the informant's bias. Practitioners should seek to uncover their own biases and endeavor to maintain objectivity in the face of those biases, while disclosing to the patient any personal biases that could influence the practitioner's recommendations 28, A patient's right to make her own decisions about medical issues extends to the right to refuse recommended medical treatment.
The freedom to accept or refuse recommended medical treatment has legal as well as ethical foundations. As previously noted, one of the most important elements of informed consent is the patient's capacity to understand the nature of her condition and the benefits and risks of the treatment that is recommended as well as those of the alternative treatments A patient's capacity to understand depends on her maturity, state of consciousness, mental acuity, education, cultural background, native language, the opportunity and willingness to ask questions, and the way in which the information is presented.
Diminished capacity to understand is not necessarily the same as legal incompetence. Psychiatric consultation may be helpful in establishing a patient's capacity, or ability to comprehend relevant information. Critical to the process of informing the patient is the physician's integrity in choosing the information that is given to the patient and respectfulness in presenting it in a comprehensible way.
New dimensions in bioethics : science, ethics and the formulation of public policy
The point is not merely to disclose information but to ensure patient comprehension of relevant information. Voluntariness—the patient's freedom to choose among alternatives—is also an important element of informed consent, which should be free from coercion, pressure, or undue influence Confidentiality applies when an individual to whom information is disclosed is obligated not to divulge this information to a third party.
Rules of confidentiality are among the most ancient and widespread components of codes of medical ethics. For example, Canada and the United States have taken quite different approaches to financing access to health care, control of firearms as a public health hazard, reproductive technologies and any number of other public policy areas with an important ethical dimension. This is another version of the earlier discussion of how ethical standards change, but with the comparison carried out across space rather than time. The tension that exists here cannot be resolved easily, and perhaps cannot be resolved at all.
Philosophically, the discussion in the preceding paragraphs strongly suggests that the wrongness of some practices and conversely the rightness of others is sufficiently fundamental that it cannot be reduced to a question of prevailing societal values or standards. Practically, it may not be easy to identify ethically impermissible or for that matter ethically obligatory practices in our own place and time, since it is impossible to set ourselves entirely outside the cultural assumptions of our own society.
On the other hand, it is important to note that there was substantial opposition and resistance to such practices as racial segregation and the subordination of women for many years before they were officially regarded as impermissible and politically suspect. In other words, the politics of the time provided ample opportunities for ethical learning, although those opportunities were for a long time ignored and denigrated, if not actively suppressed.
For purposes of suggesting directions for governmental decision making, the best that can be done here is to propose two courses of action. First, in making ethical decisions, governments and the individuals who judge governments should identify core values or standards of ethical acceptability — principles that are especially basic.
Human rights provide a basis for insisting that for instance race- based or gender-based exclusions from opportunities to participate fully in the life of a society were wrong a century ago just as they are today, and for the same reasons. Second, governments and the individuals who judge governments must always be sensitive to the nature of ethics as a learning process, and to the provisional nature of many of our ethical choices. Those choices that depend on changing situations must be intellectually rigorous yet fluid, and must always be interrogated and re-examined in light of new options Mahoney and P.
Mahoney, eds. This book as a whole provides a remarkable explanation of how human rights are relevant to a range of ethical issues including gender discrimination, political repression, health care and access to food, to name but a few. Dimensions of Ethical Decision Making This chapter considers three dimensions of ethical decision making.
First, ethical decisions can be made on the basis of one of several schools of ethics or ethical traditions — that is, sets of basic and necessarily quite general substantive principles. Second, ethical decisions can be made at a variety of levels, ranging from the individual to the societal and even the trans-national. Third, ethical decisions can be made based on standards that are specific to a particular domain of human activity, such as business or education.
An adequate basis for deciding on the ethical acceptability of particular actions or policies at the governmental level must take into account the implications of choices made within each dimension — for instance, about the appropriate level of analysis, or about which schools of ethics can contribute the most to resolving a particular policy question. Major Schools of Ethics There are numerous schools of ethics, or ethical traditions. Here we can only provide a brief and highly simplified overview. To come back to a point made in Chapter 1, reasons matter. Utilitarianism holds that the ethically best decision, or in some variants of utilitarianism the best rule for making decisions, is the one that will produce the greatest good for the greatest number.
Utilitarianism is the most familiar example of a general approach to ethics that is called consequentialist, because it judges the ethical acceptability of actions or policies based on their consequences. However, the approach taken to consequences can be much broader; the consequences that are considered to be of ethical importance can be environmental, social or even spiritual.
As this example shows, it is important to be clear in any form of consequentialist argument about the values that define what counts as a benefit or as a harm. What is the greatest good, and how do we measure it? Readers interested in more detail can find it in literally dozens of introductory texts. One particularly useful one, which combines original writings and contemporary commentary both by philosophers and by social scientists, and thus provides a sense of the history of various ethical traditions, is Peter Singer, ed.
Another, which has the advantage of being organized around both critical and constructive evaluations of the various schools of ethics, is Thomas Beauchamp and James Childress, Principles of Biomedical Ethics, 4th ed. Oxford: Oxford University Press, , pp. Kantian or obligation-based ethics, named after the philosopher Immanuel Kant, with whom it is most closely associated, holds that the ethically acceptable decision is one that conforms to certain fundamental principles. In the first, to be ethically acceptable, one should conduct oneself according to principles that one could wish to see universally applied to everyone.
In other words, before deciding to commit fraud or make promises we have no intention of keeping, we must ask whether it even makes sense to think about a society in which everyone acted as we propose to act. The second formulation requires that we avoid treating other people exclusively as means to an end, rather than as ends in themselves. Kantian ethics is the most familiar example of a more general category of ethics known as deontological ethics, whose key characteristic is that some actions are held to be inherently or intrinsically right or wrong — that is to say, right or wrong independent of their consequences.
Declaration of Independence, in the Bill of Rights that is an integral part of the U. Constitution, and more recently in the Canadian Charter of Rights and Freedoms. Sometimes, as in the case of the U. In the latter respect rights-based and Kantian ethics overlap. The idea of a contract is central to what many philosophers regard as a distinct school of ethics: contractarian ethics, which tries to derive principles of morality from the idea of a hypothetical contract entered into by members of a society.
Implied consent to the terms of Dimensions of Ethical Decision Making such a contract becomes the source of both rights and duties. Some variants of contractarian ethics have strongly Kantian elements: Rawls, for example, bases his analysis on the kind of contract individuals actually, heads of households would rationally enter into from behind the veil of ignorance.
Both rights-based and contractarian ethics are characterized by what might be called intense individualism. At least one author has explored the idea of a covenant among individuals as the defining basis for moral obligations;67 unlike a contract, a covenant is not motivated primarily by considerations of self-interest, and can include a notion of obligation arising from sources other than individual human will or consent. We have coined the rather awkward neologism covenantial ethics to describe this middle ground. It is strongly egalitarian in its conception of how people ought to treat one another, and is especially sensitive to inequalities of power.
At the same time, writers in this school or tradition emphasize the limitations of rights-based or contractual conceptions of an ethical point of view toward others, pointing out that in many situations just leaving people alone is not enough, and that in some relationships like those between mothers and children a strictly rights-based conceptions of respect for others make no sense.
Robert M. Kittay and D. Meyers, eds. Virtuous people that is, those who act according to such motives as generosity, compassion or fidelity to their obligations are those most likely to make ethically acceptable decisions. Ethical acts are not necessarily those carried out by following rules, but from motives like doing good or fulfilling obligations.
This formulation is especially attractive in situations where people are faced with a set of choices imposed by circumstances outside their control, all of which are ethically repugnant in different ways, or when the consequences of a particular action simply cannot be known. This school sometimes carries out ethical analysis starting with the premise that people have a right to fulfil their obligations to others, for instance, parents to decide for their young children on medical treatment. Casuistry is an ethical tradition or style holding that we are too concerned with principles.
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For the casuist, ethical decisions can be made only on a case-by-case basis, although the decisions made in previous cases can provide a source of wisdom to draw upon; indeed, ethical judgments can be made when there are no principles to draw upon, or when disagreement on principles is profound. An appropriate analogy may be with the operation of precedent in the legal system. Particularly in biomedical ethics, which often have to focus on individual cases in a clinical setting, there has recently been a revival of interest in casuistry as a response to what is viewed as excessive preoccupation with abstract principles in that field.
In subsection 2. This may explain why the preceding schools of ethics deal primarily with the relationships among human beings. Although many people are concerned about problems like pollution primarily because of their effects on human beings, it is also possible to argue that environmental ethics is now a distinct school of ethics, because many variants explicitly hold that human beings have duties and obligations not only to each other, but also to non- human beings and to the natural environment as a whole.
In addition, there is considerable overlap between many of the schools, which are not mutually exclusive approaches separated by clear boundaries. For example, the overlap between rights-based Westra and J. Lemons, eds. Dimensions of Ethical Decision Making and Kantian ethics has already been noted, and environmental ethics may be deontological, consequentialist or a combination of both. The discussion does illustrate, however, the range of perspectives that can be brought to bear on the decisions governments must make. When the situation looks similar through all the prisms or lenses, governments are likely to find their choice relatively simple to make.
However, different schools of ethics will often want to treat a situation quite differently. For instance the issue of contract pregnancy or as it is more often but less accurately called, surrogate motherhood looks quite different through the prisms of a rights-based ethics and of the ethic of care.
Choices about how thoroughly to treat industrial pollutants that may threaten human health, or about where to locate hazardous waste landfills, look quite different through a Kantian or Rawlsian prism than they do when made on the basis of a cost-benefit analysis. Conversely, various infringements of rights are justified, in ethics and in Canadian law, with reference to the good of the community, or the protection of certain kinds of valued relationships. Thus prohibitions on contract pregnancy, which on some accounts infringe on individual rights in the area of bodily security and freedom of contract, were before Parliament when it was dissolved in Spring, The tradeoff between equity and efficiency in economic policy is another commonly mentioned example.
This is the route that has been followed by many biomedical ethicists in North America since the publication in of the first edition of Principles of Biomedical Ethics, by Thomas Beauchamp and James Childress. Beauchamp and Childress, Principles of Biomedical Ethics, 4th ed. This does not mean ethical decision making in such settings has thereby become easy or routine; far from it.
None of the four principles can be regarded as binding in all cases; since situations in which applicable principles conflict are relatively common, the best that can be done is to treat each principle only as prima facie binding — in other words, binding in the absence of more compelling moral considerations involving a competing principle. Micro, Meso, Macro and Megaethics In ethics we sometimes do an analysis at three different levels. The meso level involves ethics within the group, institution or organization such as a hospital, university or government department.
The macro level involves ethics at the society-wide level, for example, as reflected in the decisions of provincial or national governments about domestic policy. To this list, we should add mega- ethics, which refers to ethics at the transnational or cross-cultural level.
Human rights is an illustration of a mega-ethical concept, although it has applications at other levels and indeed is probably most meaningful when applied to specific policy situations at the micro, meso or macro-levels. Timothy C. Callahan, Sharon J. Durfy and Albert R. DuBose, R. Hamel and L. Ferment in U. Somerville, comments in Ethics Roundtable, Dimensions of Ethical Decision Making Table I illustrates these four levels as they play out in analyzing various issues related to medicine and health care, and suggests the interplay among different levels of analysis.
It may be useful to take a single example — access to costly and therefore scarce therapy — and to work through the issues and tensions, in a way that is necessarily a bit dogmatic. Table 1. Should a patient who faces the possibility of progressively more serious disability and more intense pain from amyotrophic lateral sclerosis ALS be granted her request for medical assistance in committing suicide once her pain has become unbearable?
Should physicians inform patients about the possible benefits and risks of all available treatments? Should physicians always try to seek organ transplants or bypass surgery for patients who might benefit? How should physicians decide which of two potential recipients is to receive an organ transplant, when only one organ or donor is available?
How should physicians decide which of two patients should be placed in the one available intensive care bed? Meso group or! What policies should a hospital adopt with respect to DNR do not resuscitate institutional orders for terminally ill patients?
Bioethics as a Governance Practice
Should health maintenance organizations HMOs prohibit physicians from informing patients about the existence and possible benefits of treatments whose costs the HMO will not cover? What principles or codes should transplant centres adopt for prioritizing transplant recipients when available organs are scarce? How should hospitals allocate available intensive care beds?
How should they allocate their budgets between various functions such as emergency medicine, chronic care and specialized surgical units e. Does an institutional policy of giving priority for coronary bypass surgery to patients younger than a certain age violate human rights, by amounting to impermissible discrimination based on age?
What values are at stake? How should the criminal law treat physician-assisted suicide? Should Parliament legalize physician-assisted suicide? Should the courts treat existing prohibitions as deprivations of fundamental rights? How should health care be financed? Is there a right to a basic minimum of health care? If so, what constitutes the basic minimum, and how should its provision be financed?
Does a policy of not providing insurance coverage for coronary bypass surgery on patients above a certain age violate human rights, by amounting to impermissible discrimination based on age? Is health care a human right? Why, or why not? Mega across societies! At the micro level, not only is it entirely appropriate for a physician to seek the best treatment for his or her patient, but on many accounts the physician is obliged to do so, and for him or her to make decisions about treatment options based on other priorities, like cost containment, is almost certainly unethical.
The institution cannot get away from these choices; as in many other situations, making no decision is a decision in itself. Such choices can be and have been made in a variety of ways, and more than one principle for doing so including the apparent non-principle of first-come, first-served, which is really a variant of the lottery principle may be ethically defensible. What is probably not defensible is leaving the decisions to be made on the basis of whichever patient has the most effective, most persistent or loudest advocate in the form of his or her physician.
Also not defensible, however, are meso level policies that interfere with the physician- patient relationship and the ability of the physician to act as an advocate for the patient, for instance by prohibiting physicians under contract to a particular health management organization HMO from telling patients about treatments that the HMO will not cover. Such policies, which have threatened to become widespread in the United States, have a strictly commercial motivation.
They have in turn led to macro level policies, in the form of legislation in many states that prohibits such practices. A more basic macro level choice, This view is not universally held, however. Dimensions of Ethical Decision Making which exists in every country and affects the choices available at all the other levels, is how the health care system should be financed, and how access will be governed. A number of resource allocations may all be ethically acceptable, but there will probably also be some clearly unacceptable ones — for example, closing hospital units primarily in opposition-held constituencies in order to make a political point, or locating a new unit in a remote area where utilization rates will be low, but which happens to elect a member of Cabinet.
As suggested in the Table resource allocations that have the effect, even if not the intent, of discriminating on the basis of age should probably also be judged ethically unacceptable. However, there are signs that this emphasis is changing. We bioethicists must stop approaching problems from a philosophical perspective and adopt a political science perspective. Two examples will serve to demonstrate the value of such macro level analysis. Audrey R. By designing a health care system that keeps all people as close as possible to normal functioning, given reasonable resource constraints, we can in one important way fulfill our moral and legal obligations to protect equality of opportunity.
These examples are crucially important outside the area of medicine and health care because policy analysts may shy away from explicitly ethical analysis at the macro level as being too difficult or politically contentious. There are, after all, substantial risks associated with making an argument that the policy or course of action supported by agency administrators, ministers in a Westminster system or politically important client groups is ethically Dimensions of Ethical Decision Making unacceptable, or even in suggesting the possibility.
Physicians and lawyers thus have certain obligations to maintain confidentiality with respect to information about their patients and clients. Fiduciary duties and respect for trade secrecy are required in a variety of business settings. It has been argued that distinctive sets of ethical principles are appropriate to govern the conduct of scientists and of environmental professionals.
Unless they can be shown to be unreasonable, these goals count as justificatory values for their respective domains. And moral standards that obtain in a domain are justified in relation to them as well as in relation to other values. However, the idea of domain- sensitive ethics leaves a key question unanswered. What values, if any, can we rely on as the basis for concluding that certain goals or purposes of a specific domain are unreasonable?
What happens when the goals and purposes of two domains, such as business and medicine, come into conflict? This is not merely an academic issue. The argument is often made that business should be assessed based on standards related to human rights or environmental performance — in other words, that it should be ethically accountable to stakeholders other than its Winkler and J. Coombs, eds. This argument might be rejected after careful consideration, but cannot be dismissed out of hand, or by reference solely to the goals of business.
The purposes of business and medicine are now clashing frequently in the United States health care system, as a result of the rapid expansion of for-profit managed care provision. This apparently had much less to do with protecting patient interests than with protecting the profits of the HMO.
They further state that: On our bioethics rounds and in our ethics educational programs, perhaps the single most pressing problem cited by staff nurses and managers is a concern that practice standards are changing to enhance profits. These may not be compatible with the ethical standards distinctive to the profession,96 such as full disclosure of all findings in the case of scientists, or with more general obligations to protect public health or environmental quality.
In such situations, when does the legitimate reach of organizational goals end? When, for example, are life-shortening decisions about the allocation of health care resources justified by the goals of the business world, or with reference to politically mandated cost containment objectives? David J. Dimensions of Ethical Decision Making So while acknowledging the value of standards of ethical acceptability, such as professional codes of ethics, which address the distinctive ethical challenges in a particular domain, governments must recognize that actions or policies are not necessarily ethically acceptable simply because they meet certain standards that are specific to a given domain.
Domain- sensitive standards of ethical acceptability are not enough. If we regard politics, or government, as a domain with its own standards of ethical acceptability, the same is true: there may be practices that are acceptable according to the norms or standards of that domain, but which fail to stand up to a more general and demanding form of ethical scrutiny. On this point, it should be noted that the four principles approach to bioethics, organized around respect for autonomy, beneficence, non-maleficence and justice, derives much of its power from the fact that the principles in question are not specific to the domain of medicine and health, although their application and interpretation may be.
Beneficence and justice, for example, are norms with broad applicability in other domains as well. Some observers might see this generality as a weakness, but it can also be considered a strength. Daniels, Light and Caplan, Benchmarks of Fairness.
Harvard researchers, others share their views on key issues in the field
Ethical Tensions or Conflicts and the Government of Canada As the preceding discussion shows, determining what policy choices are ethically acceptable is hardly an easy task, yet it is one that governments cannot avoid. They seldom have the luxury of not making a decision. Deciding not to decide, or to postpone a decision, is itself a decision — one that may have important ethical implications.
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For instance, if the legal status of the child of a so-called surrogate mother or the fragile habitat of an endangered species of fauna is unclear, then postponing a decision to enact legislation clarifying their status pending further study amounts to accepting the status quo, with all that entails. Without reference to a specific situation or policy field, it is impossible to determine in advance what an ethically acceptable decision or outcome, or the range of ethically acceptable decisions and outcomes, might be.
Reflecting our emphasis on ethics as process and as learning, we outline here several axioms that should guide government in making those decisions. Each of these axioms is discussed at greater length later in this chapter. First, government cannot use a single school of ethics for example, utilitarianism as the starting point for its decision making, although it may in the end choose to emphasize the considerations that are central to one particular school. Likewise it should take into account all the relevant domains of ethics, rather than limiting itself to considering the domain that looks most directly relevant at first glance, or is most widely accepted.
An approach to decision making that incorporates inputs from various disciplines, sectors and cultures is likely to be particularly valuable. Second, government must always carry out ethical analysis at the macro level before making a decision, although it need not ultimately assign priority to macro level or societal ethical concerns. Third, identifying the ethical assumptions underpinning government policies is crucial. Identifying and clarifying the initial presumptions guiding the various participants in an ethical debate is a crucial learning and problem-solving device.
Being clear about where people are coming from, in ethical terms, is essential to understanding the policy positions they adopt. Fourth, good faith debate among committed proponents of particular ethical positions is critical for governmental efforts to arrive at ethically acceptable policy positions. Principles for structuring consultation with a view to achieving such debate are briefly outlined. Fifth and finally, there may be situations in which all the relevant perspectives on a particular decision or policy have been considered; the different perspectives yield different outcomes; and government must choose and give priority to one perspective in its decision making.
Ethical Tensions or Conflicts and the Government of Canada be answered in the abstract, without reference to the particular issues at stake. Governments, like individuals, must live with the uncertainty that accompanies hard ethical choices in such cases. At the same time, they have not only the opportunity but also the obligation to exercise moral leadership, by making decisions that embody a clear commitment to certain ethical principles. This does not mean that governments have no guidance in situations where different schools of ethics yield different answers.
There are important but not absolute commitments to rights-based ethics in the Charter of Rights and Freedoms99 and in federal and provincial human rights legislation, for example. Both the letter and the spirit of such commitments should be respected. In addition, in some cases or situations, it will be entirely appropriate for governments to select a policy that emphasizes the concerns that are central to one particular school of ethics.
For example, in response to concerns that hazardous industrial plants and waste disposal facilities were disproportionately located near African-American and other minority neighbourhoods, U. President Clinton issued an Executive Order in directing federal agencies to identify and address disproportionately high environmental and health effects of their policies on minority and low-income populations.
Many critics of the policy toward firearms control in most U. Significantly, the Charter, probably our most important policy commitment to a rights-based ethical discourse, incorporates both the s. For reasons explained in subsection 3.
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What government would be doing in such a case is, in effect, saying that the values of one domain deserve priority over all competing considerations. In some cases, this may be a defensible conclusion, but it should only be reached after appropriate debate and consultation with those who might be affected by such a choice. As the example of restrictions on health maintenance organizations HMOs suggests, the more common and more easily justified role for government is that of determining the limits beyond which the values and ethical commitments that characterize a particular domain must yield to questions of the broader public interest, or to the higher priority assigned to certain values that transcend the boundaries of particular domains.
This is true not only of domains of ethical analysis but also of levels of analysis. When Levels of Ethical Analysis Conflict Governments must make their decisions based on ethical analysis at the macro level. In order to do this, they will need to consider ethics at other levels, especially the individual level. By their very nature, governments are decision makers for the society as a whole; at least under some circumstances, the choices they make are binding on everyone living under their jurisdiction. This means that governments have a special obligation to consider the justifications for the choices they make.
It also means that governments must think about the macro level in their decision making, in ways that individuals do not necessarily have to. The tendency of mass media coverage to focus on individual stories and micro level concerns only makes this role for governments more important. These ideas can be illustrated with respect to the issue of physician-assisted suicide, where Margaret Somerville argues that the tension between ethical concerns at the micro and macro levels should be resolved as follows: [I]f one accepts that persons have a right to a dignified death, and if one accepts that this includes a right to euthanasia and that at an individual level the benefits of recognizing this right outweigh its harms, nevertheless, the impact at a macro or societal level of recognizing such a right would still need to be considered.
It is proposed that at this level, the harms and risks of such recognition would outweigh any claim of an individual to have euthanasia made available. Stated another way, we cannot only consider individual rights, including any right to euthanasia, from the point of view of the individual, we must also consider the macro or societal level impact of recognition of such individual rights. The need for protection of human networks which, at their most macro level, establish the web which constitutes society, itself, must also be given proper consideration.
It is proposed that euthanasia is not acceptable at the societal A strong case could be made that on grounds of economic efficiency, most of the environmentally hazardous activities characteristic of an industrial society ought to be located in its poorest quarters, where land acquisition costs and property damages from pollution might be expected to be lower than elsewhere.
Ethical Tensions or Conflicts and the Government of Canada level, even if one has no personal moral inhibitions against it at the individual level and that its unacceptability at the societal level outweighs the acceptability of the best case argument for it at the individual level. For instance, a group of U. These authors were not ignoring the societal implications or deciding that they were ethically irrelevant. Rather, having considered them, they found the societal implications outweighed by the values just identified. So priority here has been given to the individual level after a macro level analysis, based on assigning highest priority to certain values rather than to others.
Indeed, one of the most controversial issues within the euthanasia debate is whether the prohibition of physician-assisted suicide or its legalization would cause greater erosion of values that are central to health care decision making, and in doing so have negative consequences for the society as a whole. The requirement for macro level analysis also does not mean acting at the macro level; a government might decide that no such action is necessary, but that is itself a policy choice of some significance. For example, former Prime Minister Trudeau famously said that the state has no place in the bedrooms of the nation.
The philosophical commitment here was and is simply that, however individual citizens might choose to interact with one another in intimate sexual relationships that did not raise concerns of serious harm to them, no societal interest existed that was sufficiently strong to justify intervention in those decisions. This is a macro level choice about the priority to be accorded to individual liberty and privacy, and not an abdication of responsibility for macro level analysis. It also was, and is, a choice to which some people objected on philosophical grounds having to do with the impact of individual conduct on the social fabric.
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