Phil. 350, Principles of Bioethics (Fall ’06)
Instructor Information: Instructor, Dr.
Office: HU 229 Phone 7384 E-mail nlillega@utm.edu
Office Hours: 8-9 a.m. MWF and by appointment.
Texts: Medical Nemesis by Ivan Illich (it does not matter what edition you use; a new edition is titled Limits to Medicine: Medical Nemesis.
The Death of Ivan Illich by Tolstoy (this story can be found in many collections; it would help if we all had the same one, but that is unlikely to happen; there is, by the way, absolutely no connection between these two “Illichs.”
Various essays, all of which can be found in Bioethics: An Anthology (Blackwell Philosophy Anthologies (Paper)) Helga Kuhse, Peter Albert David Singer but most of which can be also be found elsewhere.
The purpose of this course: To provoke critical reflection on our “medicalized culture.” To familiarize students with the standard issues in bioethics and some of the principal cases illustrating those issues. To encourage thoughtfulness about the nature of medical practice, its relations to religious, ethical and social norms and ways of life, and its relations to science both as purportedly objective knowledge of the world and as purportedly socially constructed activity. To familiarize students with the sudden burgeoning of genetic research and its (financially) profitable applications, and to encourage thoughtfulness about the significance of this major challenge to ethical and religious norms and concepts.
Course Requirements: Attend class and participate, study the assigned readings, do all written assignments, pass the exams.
Three exams (two mini exams, 60 pts each, a mid-term, 100 pts and a comprehensive final worth 150): The first three exams will be T/F and multiple choice. The final will be a selection of answers to essay questions. The questions will be handed out throughout the course. Instructor evaluation of answers to those questions will be available on a scheduled basis prior to the final. (370 pts total)
A short paper (i.e. not less than 1500 words worth 150 pts): Topics may be chosen by the student but must be approved by the instructor. There are LOTS of juicy topics. (150 pts. Total). Preview of your work by instructor is suggested, and is free of charge.
Philosophy majors who want to write a paper for inclusion in their portfolio may expand their paper, with instructor imput. Some extra credit may be available.
Occasional short quizzes: these will be worth ca. 6 pts each and will be unannounced. Ca. 45 pts. They are extra credit points!
Attendance, quizzes, in class assignments, outside assignments. Regular attendance and informed participation in class are essential since (a)you will need to be there to take quizzes and do in-class assignments (b) you will need help with this material, and that is what class sessions, and the instructor, are for. Points will depend upon actual attendance and upon the quality of work in class. About 25 points just for attendance. One unexcused absence will be allowed, after which 10 points will be deducted for each unexcused absence. There will be two or three outside assignments, worth 30 pts total. These will consist in viewing and reporting on videos. 55 pts total.
Extra Credit: Extra points for early return of study questions for review (total 10 pts.) Quiz points, ca 40- 50 pts. possible
Total points ca. 575. Normally %90 of total points gets you an 'A', %80 a 'B' and so forth, but significant adjustments for curve are made when necessary.
Conduct of class, Role of the Instructor: Classes will be a mix of lecture, discussion, and also possibly some special presentations by students or others. Those who need individual help should feel free to ask, provided they have been spending a reasonable amount of time on the material. I want each student to perform to the best of his or her ability, and I will do all that I can to bring that about (short of patrolling the dorms!). At the same time I will hold each student responsible for completing all the work. Moreover, all students are responsible for knowing what has transpired in every class. Policies on student conduct, and other possibly pertinent information may be found on the instructor’s home page,
Best way to contact - e-mail: nlillega@utm.edu
Also- 731 881 7384 (Office, Voice)
You MUST visit www.utm.edu/staff/nlillega/lillegard.htm Read the rest of the syllabus, etc.
Course Outline: (Approximate: adjustments and changes are likely.) (Study questions, i.e. those questions which will constitute the final exam, will be provided as we proceed. You are responsible for having a complete and correct list of these questions.)
Week I (Aug. 28) The “socially constructed” nature of
disease, health, and related concepts. Clinical iatrogensis. Read Medical Nemesis (MN)
Week II (Sept. 6, the 4th is llabor day) Social Iatrogenesis. Read MN section II
Week III Sept. 11: Cultural iatrogenesis and the Politics of Health. Read MN sections III and IV.
Week IV Sept. 18: Read Tolstoy.
Mini-exam I, Monday.. Sept. 25.
Week V Sept. 25: Singer sec.
I and II, selections to be assigned.
Selections: Finnis, Tooley, Marquis, Thomson, Purdy, Purdy, Purdy.
Week VI Oct. 2: Singer sec.
II
Assigned questions for Midterm due Oct. 6.
Week VII Oct. 9:. Review. MIDTERM
EXAM, Wed. Oct 11.
Week VIII Fall Break,
Oct. 16-17 Oct. 18:
Singer II cont.
Week IX Oct. 23: Singer III Lappe, Muller-Hill.
Week X Oct. 30. Singer III
Week XI.Nov. 6:
Singer IV .
Mini-exam II Nov. !0
Week XII Nov. 13: Singer IV
Week XIII Nov. 20: Singer IV,
V. (Nov. 22-24, Thanksgiving
Break)
Week XIV Nov. 27: Singer V. Further selections. Thinking about the way applied ethics is
done (suggested readings)
PAPER DUE NOV. 27, NO LATE PAPERS ACCEPTED.
Week XV Dec. 4: Assigned questions II for final are due for
review Dec. 4. Review. Dec. 8, last day of classes.
FINAL EXAMS Dec. 11-15 (see schedule).
Syllabus etc.
“Medical”=
The importance of how
we describe things: “health”, “disease,” “progress,” and “how the word is independently
of our descriptions.”
i. the
general problem
ii. e.g. “health” (the “objective condition of being
healthy!!!”)
Progress (?) %90 of
etc. p. 6, 7, n.16 etc.
Progress and
“overreaching” cf. the medicalization of life(M) and the automobilization
of transportation. (A)
i. some of
the aims of A
ii. some of the unintended results
of A
iii. some of the aims of M
iv. some of the unintended results
of M
cf. technical disease control and
corrupted environments “biting back” n. 27
In general, the development of
“undefeatable” disease vectors as a result of “treatment.” Mosquitoes, etc. n.
33
New diseases as well
as persistence of old
e.g. Aids (not known when this book
was written). Heart disease, Cancers
--physical and cultural environment.
What is the primary
determinant of the overall health of a population? p. 7
Health and “self
medicating” (using soap!)
The resistance of the
medical establishment to non-professional, non-medical “interventions”
Semmelweis.
------------------------------------------------------
“Iatrogenesis”=
medically induced sickness or injury.
“Nemesis”=the result
of “overreaching”
Medical Nemesis
i.
Clinical-- e.g. children suffering from non-existent cardiac disease p. 20 and
n.60. %7 of all patients. . .21
ii. Social-- e.g. exclusion of home
births
iii. Cultural e.g.—declining ability
to face death. “The sound of one siren
in a Chilean village . . .”
I. Clinical iatrogenesis – see answers to ques.
1,2.
II. Social iatrogenesis – (bad) socio-economic changes/arrangements
made attractive or possible or necessary by the “medical.”
THE MEDICALIZATION OF LIFE (HEALTH) v. p 33
for summary.
1. radical monopoly
2. medicalization
of the budget
3. pharmaceutical invasion
4. diagnostic imperialism
5. preventive stigma
6. Terminal ceremonies
7. black magic
8. Patient majorities
1. RADICAL MONOPOLY=a
monopoly that makes people unable (in se) to do things on their own;
a. mutual
care and self-medication become no-nos (even in some
cases crimes).
b.
production of new categories of sickness/patients. People angered, sickened or impaired by
industrial/social arrangements become patients (passive sufferers needing
“treatment”), not active resisters.
i. note especially psychiatric “illnesses” and the
political use of “disease categories.” (more openly cynical in
ii.
development of “therapies” that “ought not to be used” but are anyway because
they are medical v. n.13 thus abasing and pacifying people.
iii. A 1 b is enabled by a general
sociological fact – groups with power to label (as sick or not sick,
e.g.). I get to say what the problem
with you is, and what to do about it (who?).
iv.
all deviance as medical. No longer any moral, religious, political, deviance.
The use of “sick” for
all sorts of conditions.
c. Thus
(from b iv) the eclipse of the moral dimension of medicine, in order to expand
its reach. P.40 (how, why?) Cannot be
hedged by ethics, religion, traditions.
2. MEDICALIZATION OF THE BUDGET. %s
spent, private and public. Notice increase in % of GDP from ’64 to ’75. In rich and
poor countries!!!!
a. enabling role of
third party payments – motivation to get new equipment etc. Giving the
“customer” more than he ever would have been willing to pay for on his own.
b. spending public money
on “CARE” (the province of the “medical”) rather than environmental change (p.
49). (cf. Recent NYC legislation, in contrast).
i. keep in mind different ways in which public money
(taxes) are spent on the medical. Who
says taxes should be spent that way? Monopoly again.
a.
education. Note special unjust burden on poor countries.
ii. keep in
mind who it is that identifies the NEED for these expenditures, and the proper
recipients.
a.
experts vs. non-experts. Cf. the changes in Chinese medicine.
iii. the
devaluation of goods and services that cannot be bought.
3. THE PHARMACEUTICAL INVASION
a. The world wide spread of (insufficiently
monitored) DRUGS
b. drug companies
pushing drugs
i. Cloramphenicol p. 59.
Thalidomide (notice underreporting, n. 63).
c. drugs for what are
not medical conditions. Tranquilizers. Sleeping pills. V. p. 63
d. Fundamental cause? An
(unwarranted) BELIEF. About control of
life conditions.
i. evidence of lack of warrant– ineffectiveness of actual
drugs. Views on how many drugs are actually needed. P. 69
ii. included
in that belief – the notion of what can be purchased. Buying a fix from the experts.
4. DIAGNOSTIC IMPERIALISM
a. M gets to say who is
sick, cannot work, can be a soldier, can miss class, can go to jail rather than
the nut house, etc.
i. getting health certificates n. 131
b. the medicalization of stages – each stage of life has medical
“problems” that define it.
For example: the
diagnosis – OLD. !!
Life as a “pilgrimage through
check-ups” p.73.
Medicalization
of birth.
PREVENTIVE STIGMA (diagnosis and its various hazards)
a. Being turned into patients (being
labeled as sick) without being sick. The medicalization
of prevention.
i. treatment of the old is most conspicuous. Being treated
for an incurable condition (to prevent an unpreventable condition )
b. stigma attaching to mental
“illness”, heart attack victims, former alcoholics, aids patients, sickle cell
carriers,
c. the search for health produces a
“dragnet” designed to apprehend and label those needing “treatment” p.85 and
notes. Tests, tests, and . . .benefit?
You were healthy when you went in,
you are sick coming out!!
d. The diagnostic rule: better to
diagnose what is not there, than miss what is there. V. p.87
e. diagnostic bias, error, and
AGRESSION. Me in the hospital with a heart cath. V.
89
f. p. 90 “diagnosis always . . .
TERMINAL CEREMONIES
v. n. 186
a. M transforms an occasion for
personal integration (cf. Tolstoy!) into a stress situation.
b. the doctor as absolute master,
even over death (cf. the film “Coma.”)
Replacing priests and their ceremonies.
c. death as technical crisis –
orientation towards crisis justifies ineffectiveness (cf. homeland security).
d. the medicalization
of death = death in hospitals (enormous increase by ’76. Now?)
i.
1200% increase in cost of “last days.”
ii. that does not
include my old Swedish lady. She went, supposedly,
for treatable stuff. She represents lots of people.
Tombs used to be
expensive (the pyramids). Now the money goes into the hospital ward.
iii. note the
enlightenment switch n.201
and Tolstoy.
e. physician’s own fear of death.
Doctor as carrier of infectious fright.
i.
doctor dissimulation etc. (now?)
f. the limits of the physician’s
duty, the facies hippocratica cf.
n. 209
i.
the category of the irreversible does not fit the ethos of M ( or those who are
M ized. )
ii. people who do accept
the regnant categories are stigmatized, described as stupid, fools, etc.
(M:what,
you are refusing treatment? You must be crazy!
O: but no one has shown that it really works. M: of course it works,
everything we do works, except when it doesn’t, and we will fix that soon.
Meanwhile, quit acting up.)
g. physician assisted dying and
increase in “dependency.”
i.
possible relation of this to euthanasia debate, cf. p.98.
h. cf. cardiac intensive care p.
101.
BLACK MAGIC
The history of medicine and magic,
religion, ethics.
a. medicine organized around care –
cf. p.104
i.
varieties of functions;
b. the late 20th cent.
doctor is a new thing – combining many features. M exercises symbolic and other
non-technical powers.
i.
compare the effects of magical spells to the effect of negative diagnoses. The
reverse of the placebo effect. P. 108.
n. 243
PATIENT MAJORITIES
a. turning over the huge number of
“new sick” to people with “reflected medical prestige.”
Cf. 111, and n. 248. The welfare
receiver in the sexual domain.
b. M’s definition of “disease” and
the “control of deviance” go hand in hand. Control is no longer through, e.g.
morality, law, religion. SOCIAL control.
i. a predominant task of M – to exonerate the sick
from responsibility for being sick. So their LIVES get turned over to the
mechanics who fix them.
CULTURAL IATROGENESIS
What does, or can,
“culture” do? Equip people with abilities to cope with sickness, pain,
impairment, death. Cf. the Javanese –
Cf. the traditional ars moriendi.
Does M culture do
these things? Or induce an inability
to cope or live within these ‘facts of life?’
THE KILLING OF PAIN
a. Compare “it hurts, fix it, I have
a right to have it fixed” with “it hurts, I have to live through it, I must do
my best if relief is marginal or non-existent.”
Dealing with pain as a performance, and the physiological dimension as
secondary.
i.
cf.the list of virtues, p. 130.
b. the experience (quantity and
quality) of pain depends upon physiology, genetic endowment, PLUS ….
c. iatrogenic effect of current
culture disables these.
d. physician control, not patient
control, matters. Physician’s VIEW is what matters. View of a physiological
treatable condition. (doesn’t even have to be experienced!)
e. variety of language relative to
pain – anguish, suffering, affliction, torture, hard work, etc. (136). What are
the implications?
f. Illich’s
thesis-p. 138
i.
The “act of suffering pain.” (performance, p. 145)
ii. The questions that
come with pain – if a doctor ignored them, ignored the “humanistic” dimension,
he would be cut off from our humanity. That happens.
iii. the variations in
response to pain killers in the lab and in life. 139. cf. b.
g. culture provides words, drugs,
myths, models. Examples
i.
compare Greeks and Chinese on pain. Aristotle on the soul and suffering.
ii. man’s experience of
a marred universe, 146. “the meaning of pain was . . .”
h. the mechanization of the body
(Descartes, Leibniz). Pain as a
technical problem, a light on the dashboard indicating a malfunction.
i.
the horror of NOT experiencing pain 150.
THE INVENTION AND
ELIMINATION OF DISEASE
A. Enlightenment and politicization
of sickness etc. Rousseau and beaucracy!!
i.
in the restoration, polit and beau continue, but in
connection with M.
B. the hospital as the scene for
study, development of taxonomy, “clinical standards of normality” (as opposed
to social, religious etc.)
i.
now, the whole society has become a clinic
C. All disease is socially
constructed !!!???
i.
the denial that mental diseases are diseases reinforces the idea the physical
ills are NOT constructed.
D. What seems plausible here? There
is a history, there is construction, there is waste and misallocation of
resources, power for new groups, etc.
but, there is also –
FACTS.
CULTURAL IATROGENESIS
What does, or can,
“culture” do? Equip people with abilities to cope with sickness, pain,
impairment, death. Cf. the Javanese –
Cf. the traditional ars moriendi.
Does M culture do
these things? Or does it induce an inability
to cope or live within these ‘facts of life?’
THE KILLING OF PAIN
a. Compare “it hurts, fix it, I have
a right to have it fixed” with “it hurts, I have to live through it, I must do
my best if relief is marginal or non-existent.”
Dealing with pain as a performance, and the physiological dimension as
secondary.
i.
cf.the list of virtues, p. 130.
b. the experience (quantity and
quality) of pain depends upon physiology, genetic endowment, PLUS ….132
MacDonald’s father. Scottish highland culture. Tolstoy’s mother.
c. iatrogenic effect of current
culture disables these.
d. physician control, not patient
control, matters. Physician’s VIEW is what matters. View of a physiological
treatable condition. (doesn’t even have to be experienced!)
e. variety of language relative to
pain – anguish, suffering, affliction, torture, hard work, etc. (136). What are
the implications?
f. Illich’s
thesis-p. 138
i.
The “act of suffering pain.” (performance, p. 145)
ii. The questions that
come with pain – if a doctor ignored them, ignored the “humanistic” dimension,
he would be cut off from our humanity. That happens.
iii. the variations in
response to pain killers in the lab and in life. 139. cf. b.
g. culture provides words, drugs, myths,
models. Examples
i.
compare Greeks and Chinese on pain. Aristotle on the soul and suffering.
ii. man’s experience of
a marred universe, 146. “the meaning of pain was . . .”
h. the mechanization of the body
(Descartes, Leibniz). Pain as a technical
problem, a light on the dashboard indicating a malfunction.
i.
the horror of NOT experiencing pain 150.
THE INVENTION AND
ELIMINATION OF DISEASE
A. Enlightenment and politicization
of sickness etc. Rousseau and beaucracy!!
i.
in the restoration, polit and beau continue, but in
connection with M.
B. the hospital as the scene for
study, development of taxonomy, “clinical standards of normality” (as opposed
to social, religious etc.)
i.
now, the whole society has become a clinic
C. All disease is socially
constructed !!!???
i.
the denial that mental diseases are diseases reinforces the idea the physical ills
are NOT constructed.
D. What seems plausible here? There
is a history, there is construction, there is waste and misallocation of
resources, power for new groups, etc.
but, there is also –
FACTS.
DEATH AGAINST DEATH
A. a society’s image of death
reveals 172, n.3
B. Evolution of “natural death”
i.
devotional dance of death – each type of person dances with the dead version of
themselves. Cimitiere des Innocents, 1424. Intimacy with death – Chaucer, Villon. Contrast
with earlier medieval image of struggle between angels (good and bad) over the
dying.
a. death is
no longer the work of an external agent. It is intrinsic to life.
ii. Danse
Macabre (by end of 15th cent)
death becomes an
independent figure, not just one of the four horsemen. Death as figure of a moment, not a lifelong
companion.
a. new
clocks and the sense of a moment of death. Clocks and bones. 180 (n. 18)
b. the ars moriendi – personal
instructions on how to die. (not, on how to live with death). P.183
c. death as
‘natural’ in Paracelsus 184
d. gradual
reduction of corpse to mere object. (Obscene object). History of dissection of
corpses in 16th, 17th centuries. Dissection at Carnivals!
Holbein and
Playboy!!!
iii Bourgeois Death
Paying to keep death away. Only one
class can do it.
a. old age for the rich in greater comfort.
iv. Clinical Death
Death as the outcome of
specific diseases (no more “death in general”)
a. clinical
death emerges as a function of the consciousness of scientifically trained
doctors.
v. Trade Union Claims to
a Natural Death
A deeply medicalized ideal (cf. 1792) of “natural” death (any death
not caused by disease etc.) Workers claim a right to it. Not just the Bourgoise.
a. the good
death is the death available to the consumer of M.
b. the
doctor stands between us and death. Cf. images, 197
vi. Death under
Intensive Care – mechanical death conquers and destroys all other deaths.
Tolstoy
* The fact of temporality, finite existence in time, and the end of that existence in death, provides the strongest basis for escape from the tyranny of the “they” and fallenness.
My death is one thing I cannot share with others. It is the end of myself, the end of the defining feature of dasein as anxious life in the face of possibility.
* The “they” tries to strip death of its power to clarify the nature of existence, by assimilating my personal death to the idea that “everyone dies.”
Authenticity is possible where one accepts the revelation of existence that death gives. Such authenticity is being towards death.
(Sein and Zeit)
The principle of double effect:
An action which has both a good and a bad
effect will be permissible just in case
1.
The action is itself morally neutral or morally good
2.
The bad effect must not be the means by which the good effect is brought about
3.
The motive for the action must be the bringing about of the good effect only
4.
The good effect must be equivalent in importance to the bad effect.
Finnis:
1.
Living human individuals are persons.
2.
The moment a child is conceived it is a living human individual.
3.
Therefore, a Zygote, which is what a child is the moment it is conceived (and
anything following it up until birth), is an (innocent, obviously) human person
(from 1 and 2).
4.
It is always wrong to intentionally kill an innocent human person.
5.
It is always wrong to intentionally kill* a zygote (and anything following it
up to birth) (from 3 and 4).
QED
*
·
“Intentionally
kill”= perform a “direct abortion.”
·
Some
abortions are indirect (not directly “willed”– e.g. ectopic
pregnancy.
·
See
principle of double effect + Finnis’ four conditions.
Some consequences of 5.
5i.
Rape;
·
attempts to prevent conception
are legitimate (they are not contraception).
·
Post
coital pills may be permissible
·
Once a
child is conceived, aborting by any means is not permissible.
5ii. Pre-natal screening done with the
intent of aborting where results are “negative” are not permissible, nor is
cooperation with such activities.
5iii. Any
experimentation with embryos that is not to their benefit is not permissible.
·
Obviously,
production of embryos with the intention of selecting from them is grossly
immoral, no matter how good the motives.
Challenges:
i. Tooley: not all
living individual humans are persons (~ 1).
ii. A zygote is not yet an individual since
it can twin. Killing it would not be killing some definite distinct human
individual. (The twinning problem) (~ 1 and ~2).
iii. Sometimes it is permissible to kill an innocent human person (Thompson). (~ 4)
Finnis responses:
Take i. A zygote does not actually have all
the traits of persons, but it has the capacities of one.
·
Cf.
Aristotle on different senses of ‘capacity.’
·
(See
Marquis for details on the “potentiality argument.”)
Take ii. A zygote can
become TWO human individuals. It cannot be identified with either one. What
happened to it? Did it die? Or was there never an individual there to begin with.
Finnis solution: !?
Take iii. An unborn
“child” can never be regarded as an intruder, aggressor, “user” etc. Why?
·
(Cf.
Thompson).
Tooley:
A zygote, and nothing following it even past birth, is a human person, even though it is a human