Class Outline

Questions

Paper Topics

 

 

 

Phil. 350, Principles of Bioethics (Spring ‘11)

 

Instructor Information: Instructor, Dr. Norman Lillegard

Office: HU 229   Phone 7384    E-mail   nlillega@utm.edu

Office Hours: 10-11 a.m. TTh and by appointment.

 

Texts: Defining the Beginning and End of Life ed. John Lizza (this book will be referred to as ‘L’ from now on)

            The Death of Ivan Illich by Tolstoy

            Various essays, and other sources on-line.

            Materials on this page.

            Sources in Library on reserve.

 

            The purposes of this course:

1. To provoke critical reflection on our “medicalized culture.”

2. To familiarize students with some of the standard issues in bioethics and some of the  principal cases illustrating those issues. 

3. 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. 

4. 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.

5. To think carefully about what it is to be a human person, and the bearings of that concept upon how we think about abortion, euthanasia, genetic manipulations, and related ‘biomedical’ issues.

 

 

            Course Requirements: Attend class and participate, study the assigned readings, do all written assignments, pass the exams. 

           

            Two exams ( a mid-term, 100 pts and a comprehensive final worth 150): The exams will be T/F and multiple choice, with possible essay questions on the final.  Study questions will be included with assignments throughout the course, with answers to be collected on assigned dates (ca. 100 pts).  (350 pts total)

 

            A medium paper (i.e. not less than 2500 words): Topics may be chosen by the student from the list below, but must be approved by the instructor.  There are LOTS of juicy topics. (150 pts. Total).  First draft of paper must be turned in by Midterm (March 8th). NO EXCEPTIONS.

Philosophy majors who want to write a paper for inclusion in their portfolio may expand their paper, with instructor input.  Some extra credit may be available.

 

            Weekly short quizzes: these will be worth ca. 6 = 12 pts each and will be unannounced. Ca. 100 pts. They cannot be made up. Every other one will be graded as extra credit points!

 

            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. 

            Extra Credit:  Quiz points, ca 40- 50 pts. possible. Some extra credit points for reviews of relevant films.

 

            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 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 your living quarters!).  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, www.utm.edu/staff/norm.

Best way to contact - e-mail: nlillega@utm.edu

You MUST visit www.utm.edu/staff/norm in order to get assignments, etc.

 

Class Schedule and ASSIGNMENTS: (Approximate: adjustments and changes are likely.) ‘Old Outline’ refers to materials at the bottom of Course Outline.

                                                                   

Class Schedule: (subject to adjustments)

Week I. Jan 18: The “socially constructed” nature of disease, health, and related concepts. Medicalization.

Read assigned web source and/or Find web resources to answer #2 and 3 under ‘questions.’

By Jan. 20 Answer questions 1 -3. Hand in.

           

Week II Jan 25.  Medicalization and Iatrogenesis. Clinical and Social Iatrogenesis.  Cultural iatrogenesis and the Politics of Health.

Use materials from Web sources and material in Course outline to Answer questions 4 and 5. Hand in.

.  

Week III Feb. 1:  Cultural iatrogenesis. Medicalization, self and other care, dying. Study Tolstoy. Study Tolstoy questions. Study course outline..

 

 

Week IV Feb. 8: The beginning and ending of life. The problem of status and identity. Read L, introduction, p. 1-19  

 

Week V Feb. 15: Concepts of persons, selections from L.

 

Week VI Feb. 22:                                          

 

Week VII Mar. 1:                                         

 

Review. MIDTERM EXAM, TH Mar 3.  

 

Week VIII.  Mar.8. Abortion  selections from L.  FIRST DRAFT OF PAPER DUE.

      Mar. 14-20 SPRING BREAK

 

Week IX. Mar. 22, Abortion, selections from L

 

Week X. Mar. 29  Abortion, genetic research¸IVF, etc. selections from L

 

Week XI Apr  5:  End of life. Selections from L

 

Week XII Apr 12:   

 

Week XIII Apr.19:  

 

Week XIV Apr 26: Discussions and presentations of papers.  

                  Apr. 28      
  

            Monday,  May 2, last day of classes.

            FINAL EXAM – Mon May 9th, 10-12 a.m.                                                                            

Typ

 

 

 

 

COURSE OUTLINE

Typical bioethics courses. A list of ‘issues.’

 

A not so typical course; I. Medicalization.  II. Philosophical issues surrounding personhood.

 

I.

Bioethics and the medical status quo.

A ‘medical’ emergency; GDP and medical costs.

 

“Social construction.”

 

The importance of how we describe things: “health”, “disease,”  and “how the world is independently of our descriptions.”

            i. the general problem

            ii. e.g.  “health” (the “objective condition of being healthy!!!”)

 

Classification and discovery. Compare physics to psychiatry.

Social construction and medicalization (M)

Health as ‘normal.’ Sickness, disease, injury, as ‘abnormal.’

Notice the NORM in each. Norms are social rules. Satistical norms are not the issue (prove it).

As Psychiatrist Thomas Szasz points out:

Not having the faintest idea what caused most diseases, the medical mind went in search of a scapegoat and found it in self-abuse. By the end of the 1700s, it was medical dogma that masturbation caused blindness, epilepsy, gonorrhea, tabes dorsalis, priapism, constipation, conjunctivitis, acne, painful menstruation, nymphomania, impotence, consumption, anemia, and of course insanity, melancholia, and suicide.

How did physicians know and why did people believe that masturbation caused all these diseases? The same way that physicians now know and people believe that chemical imbalances cause mental diseases, such as attention deficit disorder: by "diagnosing" and "treating" the (involuntary, child) "patient" and by discovering "cures" for the disease. Among the widely accepted treatments of masturbation, the most important were restraining devices and mechanical appliances, circumcision, cautery of the genitals, clitoridectomy, and castration. As recently as 1936, a widely used pediatric textbook recommended some of these methods.v

THE MOVE FROM ‘NORMAL’ TO ‘ABNORMAL’  AND THE INCREASING TENDENCY TO CLASSIFY ALL ABNORMALITY MEDICALLY . People used to be ethically, religiously, ethnically and in various ways physically, abnormal.  More and more of these kinds of deviance are now classified as ‘sickness.’

THE MOVE FROM ‘NORMAL’ TO ‘ABNORMAL’  AND THE INCREASING TENDENCY TO CLASSIFY ALL ABNORMALITY MEDICALLY . People used to be ethically, religiously, ethnically and in various ways physically, abnormal.  More and more of these kinds of deviance are now classified as ‘sickness.’

 

1. justification for M

 

“Medicalization” and the idea of medical progress (using Medical Nemesis, I. Illich, 1975).

 

. See OO

 

2. Problems with M

 

Progress (?) %90 of etc. p. 6, 7,  n.16 etc

 

Progress and “overreaching”  Compare the medicalization of life(M) and the automobilization of transportation (A).

 

Problem of unintended effects:

 

            i. some of the aims  of A

 

            ii. some of the unintended results of A (nemesis)

 

            iii. some of the aims of M

 

            iv. some of the unintended results of M

 

            the budget

 

            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 West Nile virus.

 

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.

 

The medicalization of ordinary happiness/unhappiness.

 

------------------------------------------------------

 

3. M and iatrogenesis.

 

Iatrogenesis”= medically induced sickness or injury.

 

“Nemesis”=the result of “overreaching”

 

Medical Nemesis (three kinds)

 

            i. Clinical-- e.g. children suffering from non-existent cardiac disease p. 20 and n.60. %7 of all patients. . .21. Includes technological (CT scans)

 

            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

 

 

 

4. ABORTION

 

Teams:   pro choice = Patrick, Sigrid, Jarod, Tyler, Jayme

 

               Pro-life= John, Trevor, Vashon, Alan

 

 

           

 

How big an issue? 1.2 million whats a year? Intentional killing of innocent persons? Removal of growing tissue?

 

Factual matters:

 

Abortion rates also vary depending on the stage of pregnancy and the method practiced. In 2003, from data collected in those areas of the United States that sufficiently reported gestational age, it was found that 88.2% of abortions were conducted at or prior to 12 weeks, 10.4% from 13 to 20 weeks, and 1.4% at or after 21 weeks. 90.9% of these were classified as having been done by "curettage" (suction-aspiration, Dilation and curettage, Dilation and evacuation), 7.7% by "medical" means (mifepristone), 0.4% by "intrauterine instillation" (saline or prostaglandin), and 1.0% by "other" (including hysterotomy and hysterectomy).[68] The Guttmacher Institute estimated there were 2,200 intact dilation and extraction procedures in the U.S. during 2000; this accounts for 0.17% of the total number of abortions performed that year.[69] Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 to 19 weeks, and 1.5% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical.[70] Later abortions are more common in China, India, and other developing countries than in developed countries.[71]  \

 

PICTURES

 

Pictures: why not?

Abortion pictures:why not?

 

                Reason #1  offensive                    Reason #2. produces merely emotional reactions.

 

 

Reasons why: know the facts.  Develop appropriate feelings.

 

 

NYC antismoking add.

 

5                                  late 2tri (24?) salt poisoned

 

 

 

 

 

 

 

5

 

What sorts of things have a ‘right to life’ or ought not to be killed? Human beings? Persons? The people in our ‘in group’? (only they ARE persons?)

 

A zygote is a human being (INDISPUTEABLE, in one sense!). So is a severed finger.

 

‘human being’ must mean more than ‘a thing that is genetically human.’

 

What ‘more’? What property, ∏, must a being that is human have, in order to be a ‘human being’ or a PERSON?

 

Notice differences between zygote (Z) and severed finger. List: individual identity; totipotent cell(s); inside/outside another person

 

 Do some of them, or all of them, amount to ∏? (person-making property)

 

GRISEZ

 

            I. ∏ is something bestowed by others (cf. Geertz and others)

 

            II.          develops out of Z

 

            III.      is something that results from union of that human entity, Z, with a non-bodily substance. (when?)

 

            IV.     is something that results when pre-personal human entities become capable of intellectual acts

 

            V         is something that emerges with the primitive streak (2-3 weeks)

 

            VI        is something there from fertilization

 

About I: Social realities (including institutions, statuses, practices) are in some sense produced by people. Baseball games, for instance, are social realities. They don’t ‘grow’ naturally. They require people (persons) who give meaning to certain practices and actions. People acting or deciding together somehow bestow person status.

 

OBJ.: Notice, social realities seem to presuppose persons acting together to give meaning to activities, etc. Therefore? This objection may apply to all ‘social construction’ views. Cf. Geertz, e.g.

 

Suppose I is right. OBJ.:How many others? (Parents, one parent, the dominant social group?)

 

Warnock: that X is a person must be ‘decided.’ By a court for instance. Corporations are persons under the law in some places.

 

What criteria can the court use? NOT ‘whether X is wanted.’ (some children are not wanted. Are they not persons then?) Warnock claims that criteria cannot be included BECAUSE it is not generally applicable (some are wanted, some aren’t).  Apparently she thinks morally significant concepts and categories must be constructed out of generalizable criteria. A sort of Kantian / golden rule approach.

 

OBJ.: not generally applicable to whom?  To rule out such a criterion as ‘not wanted’, you must assume you have already identified the ‘whom.’ But what criteria do you use for that?

 

Cf. Standing Bear and Big Snake. Since by some criteria or other (not being white, not being xtian, not being ‘wanted’, not being civilized?) Big Snake was not a person, the golden rule did not apply to him. So it was possible to kill him without violating the golden rule.  (do unto ‘others’ etc. WHICH others? Not fish, for example).

 

No workable criteria?

 

About II: Tooley; start from intuitions about which properties X must have to have a right to life. That X will also be a person.

 

Main property – being an individual capable of non-momentary interests. i.e. being the sort of X that can think about its life,  its future and past. Obviously excludes zygotes, embryos etc from personhood. But also neonates, according to Tooley.!!

 

OBJ: why not count as persons those who will become Xs that have non-momentary interests? Tooley simply stipulates that beings lacking certain traits should not count as persons. A non-stipulative def treats people of all ages (including neonates, and, why not, embryos by virtue of potential) as persons??  Tooley’s argument for moral irrelevance of potentiality. See OO.

 

About III: classical dualism; splits us in two; but ‘I’ experience ‘myself’ as a unity of thought etc. and bodily action.

 

About IV: personhood emerges as brain develops. Delayed hominization. A possibly Aristotelian view. Personal soul can exist only in a highly organized body. One with at least a cortex, senses, etc. Thus embryos of early months don’t count as persons.

 

OBJ: brain of a fetus (or even a neonate) is merely the precursor to the brain needed for rational functioning.  So why not back up to the precursors to the precursors to the precursor. Even a zygote is a brain precursor, i.e. it has everything needed to develop a cortex etc. Also IV requires a notion of a ‘substantial change’ at a certain point (3 months, birth, whatever). Thus Norm at 4 weeks is a different thing (being, substance) from Norm at 7 months. Or 2 days old. An ontologically crowded world!?

 

SUBSTANCE.   ONTOLOGY. No entity without identity.

 

Other arguments for IV:  a person is dead, goes out of existence, when brain ceases to function. So, a person comes into existence when brain begins to function. 

 

OBJ: ‘Brain death’ means irreversible loss of function. But non functioning of fetus brain is not irreversible.

 

Also, brain death may mean loss of cerebral function only (not whole brain, including e.g. autonomic functions). But not all accept that loss of cerebral function=death (end of personal life).

 

Another pro IV: ‘it’ only begins to LOOK like a human person after several weeks. 

 

OBJ: ignores the argument.  What matters here is not what we see but what we know, and what we (perhaps) must think (about individuation, identity, etc.). Compare C3PO to R2D2.

 

About V: A zygote is indeed a human individual. But it has inherent capacity to twin (turn into TWO individuals). That lasts until appearance of the primitive streak. So prior to prim streak we do not have a person. Otherwise, absurd consequences follow; e.g. a zygote would be the parent of its twin, or, ceases to be (dies?!), or, it, one thing, would be two things. And its ‘parents’ in the usual sense could be grandparents of the twins!!

 

Also, zygote develops into tissues abandoned at birth (among other things).

 

Also, possibility of a chimera coming out of two (fertilized ovae). So, pre streak is too indeterminate to count as a unique individual, as that which becomes me or Obama or. A mass of cells, which to be sure function towards a single end (but so does the sperm and egg), becomes ONE only at prim streak stage.

 

Also, possibility of formation of hydatidiform mole.

 

OBJ: no active potentiality to twin. i.e. zygotes that did NOT twin developed normally, rather than missing out on an inherent possibility.

 

Secondary tissues are an organ of the embryo.

 

No active potentiality to become chimeras either.

 

Mole has NO potentiality to become anything other than secondary tissue, or a non-viable mixture.

 

Note p. 307 on ‘grandchildren.’

 

What about all the zygotes that spontaneously abort? Did half the human race die before birth? Should we mourn?

 

OBJ: many had abnormalities that precluded development. AND, how do we feel about high infant mortality (in the past or even in some places in the present).

 

         Other arguments relating to abortion.

 

            Thomson

 

An argument from analogy:

 

Grant that X is a person from conception.

 

1. The mother attached to X(fetus etc.) against her will is like someone attached to a famous violinist against her will.

2. It would not be wrong for the mother to break her connection to the violinist, even if it meant his death.

3. Therefore, it would not be wrong for her to break her connection to X.

 

Breaking her connection would = directly killing X.  The disconnecting fails the conditions of the principle of double effect.

      If directly killing an innocent person is always wrong, (thus even to defend oneself from certain death) Thomson’s argument does not work. That is the default position for some.

 

Argument from analogy:

X is a, b, c, d. (suppose X is my ’55 chevy)

Y is a, b, c.

So, Y is d also.

            A good argument from analogy determined by

             

             # of similarities

            Relevance of similarities (a,b,c) to d.

            Degree of Absence of relevant dissimilarities.

 

      There are several arguments from analogy in Thomson. How good are they?

 

Notice that the prohibition against “shedding innocent blood” does not necessarily depend upon the idea that persons have a “right to life.” Might depend upon notion that life is sacred.?

 

The child conceived by rape does not have a “right to the use of the mother’s body” anymore than the violinist does.

Response: the child does not “use” the mother’s body (perhaps a Tooley-like argument would show that!). Of course the violinist does not either so long as he is unconscious (but then the friends DO. What corresponds to the violinist’s friends in the pregnant woman’s case?).

 

Thomson does not think that just any old abortion is permissible (cf. minimal samaritanism, etc.)

 

            An argument AGAINST abortion.

                                                                        Marquis

 

What makes killing anyone wrong?

 

You take away his future (Clint Eastwood).

Notice that this is NOT the potentiality argument, which depends upon the concept “person.”

 

What account of the badness of killing besides the  “taking away x’s future” account is there that at the same time avoids the anti abortion consequence?

 

      Not the “desire account”

         What an individual desires doesn’t have much weight (cf. the momentarily suicidal)

 

      Not the discontinuation account.

         Immediate past experiences are not a factor in assessing the wrongness of killing.

 

So, the anti-abortion view is unavoidable.

 

            Another pro choice argument - Purdy

 

What does a woman owe her fetus?

 

·         Conflicting intuitions: they owe more/they owe less, than they do to actual children.

 

      i. They can be subject to bodily invasion (Cesaearean) or something worse (cf. Angela Carder) for the sake of the child.

                 or

      ii. They cannot even be required to avoid what would directly injure the fetus.

 

         Purdy holds that they owe just as much as (and no more than) they owe to born children. Potentiality idea.

               i. however, since fetuses are not actual persons, they can be killed (!!)

 

         Who gets to say what is to be “paid” in terms of suffering on the part of the woman? the woman? The state?

         Even if women owe as much to a fetus as a born child, they should not be excessively blamed when their failures are due to social conditions over which they have no control (e.g. contaminated workplaces).

         Presently woman are required to sacrifice more for a fetus than for a born child, esp. poor women etc. That is plainly unjust.

 

Interlude: taking things for granted: the Zeitgeist vs. thoughtfulness

 

Two kinds of considerations: ideological

     e.g. what thoughts are permissible given that you have correct views on feminism (or some version of it).

 

                                                                              Logical/philosophical

      What questions are begged? What is tendentious? Where are the strawmen? What other fallacies are there? How are things identified?

What general ethical position(s) are taken for granted (e.g. utilitarianism, Kantianism, virtue theory, contractualism etc.)

 

Consequentialism in Purdy. Unexamined use of key notions (benefit,  socially valuable, “creating” a child, “reproduction” etc.)

 

Some peculiarities of ethics: starting from typical intuitions (cf. Aristotle, and Kant, and Mill).

 

 

                                                                           IVF etc.

            The status of a pre implantation embryo is probably less important for thinking about abortion than for thinking about IVF.

 Picture of IVF embryo - this is a fertilized human egg (also called oocyte)
This is seen the morning after an IVF egg retrieval when we check the eggs for signs of fertilization
Male and female genetic material (DNA) are contained in the 2 pronuclei seen in the center of the photo

 

 

IVF possibilities:egg and sperm both taken from natural parents: one taken from natural parents, the other from a donor; both taken from donors; resulting embryos transplanted to a surrogate.

 

Advantages (supposed) of IVF: children for couples with conception problems; children for couples where one or more is infertile; children for gay parents; children for women past menopause or over 40; women with unexplained history of miscarriages; PGS and PGD to root out diseases, to abort defective embryos, to do germ line or somatic cell line therapies; enhancement therapies; sex selection (perhaps to avoid a disease).

 

Problems:  physical: LBW, birth defects (e.g.cleft palate, heart defects), low rate of success (average for BEST age (35<) about %40,  combined with high cost ($12-20 thousand); multiple births (EIGHT in a recent case, to a single mother who already had six children!!!!!).

 

Ethical;

May involve destruction of unused embryos …if an embryo is an innocent human person, then that would be murder (manslaughter or some such).

 

With or without Surrogate Mothering

IVF may involve separating

 

·         sex and reproduction

 

·         reproduction and child rearing

 

·         reproduction and marriage

 

So what?

How many “parents” might a child have? Does it matter?

 

Some supposed further advantages to IVF and/or  Sur. Moth.

         Alleviating fertility problems, ergo more “happiness”

        Optimising transfers of risk and burden ( surrogate mother may have less of them than ‘natural’ mother)

         Prevention of serious genetic diseases.

        Enabling of non-traditional families

 

Objections

         It is not right to shift those burdens (replies)

         Not right to “separate”   (replies)     

         Contracts and prostitution (replies)       

          Baby selling (replies. Not like slavery)

            What is good (what is not bad) about ‘non-traditional families’?

 

As for prevention of genetic diseases;  =

            PGD(pre implantation genetic diagnosis), and PGS (pre implantation genetic screening)

READ WIKIPEDIA ARTICLE ON PGD 

BE FAMILIAR WITH HUNTINGTON’S DISEASE, AND CYSTIC FIBROSIS

 

Germ line (GL) and Somatic cell (SC) therapies.

The uncertain relation between GL and SL.  Crossing the Weismann Barrier.

 

Manipulations IV, using genetic techniques.

 

Somatic cell therapy – repair of a defective gene affecting the person who is “repaired.”

 

e.g. SCID (an immune deficiency resulting from defective gene(s)).

 

Heart Disease

 

Getting the kid you want.

 

Germ line therapy – repair of defective gene(s) that are passed on, thus affecting those not yet born. 

 

e.g. Huntington’s disease. Lesch-Nyhans disease. (self injury)

 

Intelligence, etc.

 

Requires manipulation of sperm, eggs, also early embryos or as described above.

 

Advantages of GL

 

·         Treatment of some conditions not treatable by SC

 

·         Elimination of need for pre-natal diagnosis and selective abortion

 

·         Eugenic change

 

 

These therapies assume the moral permissibility of IV manipulations of any kind.

 

Ethical problems in GL:

 

·         Proxy consent, finality of GL, and inability to predict.

 

                  i. GC and unintended GL changes ( should possible secondarily impacted person be allowed to reproduce?!!)

                  ii. principle of double effect.

 

·         Experimentation on fertilized eggs and embryos-discarding those that do not turn out.

 

·         Enhancement -- Eugenics?

 

·         Playing God

 

Notice that almost all justifications for surrogate motherhood, IVF, selective abortions and genetic engineering of most kinds, are utilitarian in form.

 

            “Benefit”   “Happiness” etc. Remember Illich on “disabling” effect of medicalization.

 

Types of Prenatal “manipulation” and Genetic Engineering

 

·         Elimination of certain kinds of people by pre-natal counseling and selective abortion.

 

            Sex selection, mongoloidism, etc.

 

·         Use of various techniques to remove hereditary defects.

 

            Germ line interventions to eliminate Huntington’s Chorea, SCIDS, etc.

 

·         Use of various techniques to implant selected enhancements

 

·         Production of designer people by cloning.

 

PROBLEMS/CONTROVERSIES WITH RESPECT TO  PRE- NATAL INTERVENTIONS, PGD, GENETIC ENGINEERING etc.

By Mike Celizic

TODAYShow.com contributor

updated 8:42 a.m. CT, Tues., March. 3, 2009

Imagine ordering a baby like dinner: “We’ll take the boy in the Greek-god model, but can you make him 6-foot-4 instead of 6 feet? And gimme the green eyes instead of the blue; ash-blond hair — a little curly, but not too much; olive complexion; 140 IQ; heavy on the fast-twitch muscles.”

Sound like science fiction? Maybe not: The news that a California fertility clinic is offering prospective parents the opportunity to improve the odds of having children with preselected hair, skin and eye color has renewed the debate over “designer babies.”

But Dr. Jamie Grifo, director of the Division of Reproductive Endocrinology at the NYU School of Medicine, told TODAY’s Meredith Vieira Tuesday in New York that the issue is overblown.

Story continues below


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“I think this is more hype than reality,” Grifo said.

Sticker shock
Grifo is a pioneer in a technique called preimplantation genetic diagnosis (PGD) that has been widely used to screen for genetic diseases for 17 years. The procedure involves taking a cell from an embryo a few days after fertilization and scanning the DNA for certain diseases, such as Tay-Sachs, Down syndrome and a predisposition for certain types of cancer. It can also be used to select the gender of a baby.

The California clinic is using the same technique to increase the chances of having a baby with a specified eye, hair or skin color.

Grifo said that surveys conducted by NYU show a high percentage of parents who would screen for mental retardation or genetic diseases, but few who want to determine physical appearance.

“Demand for that is not that high. Patients don’t do it when they find out what’s involved,” he told Vieira. “You have to go through IVF. It costs a lot of money. It doesn’t always work.”

Published reports put the cost of selecting for the likelihood of physical traits at $18,000, and because it has to be done through in vitro fertilization, the procedure often has to be repeated multiple times before a viable fetus develops.

Is ‘Gattaca’ here?
The ability to choose a higher likelihood of certain physical traits is being advertised by the Fertility Institute, a California fertility clinic headed by Dr. Jeffrey Steinberg, who was on the team of doctors that created the first so-called test-tube baby in the 1970s. Steinberg’s clinic claims a 100 percent success rate over the years in selecting the gender of nearly 1,000 babies.

 

 

1. IF the aim is to get rid of defects, what counts as a defect?

 

    Huntingdon’s Chorea, Deafness? Mongoloidism? Small breasts? Missing a limb? Being the 10th kid? Being female? Being a gypsy?  (cf. le Huitieme Jour) (cf. Asch)

 

2. If the aim is to make improvements, what counts as an improvement?

 

Having a boy? Greater intelligence? Blue eyes and blond hair? Courage? Altruism? (seriously?)

 

3. Treating (actual or possible) people as means (violates the Cat. Imp.)

            Producing children for donor purposes.

            “objectifying people.” “Commodifying people.”

 

4. Violating autonomy

 

5. Proxy consent

 

6. ANYTHING that involves direct killing of a human being. ( IV production of embryos for donor purposes and discarding some, etc.)

 

AND, the other  BIG ISSUE in this neighborhood.  Embyronic stem cell research.

 

         READ the following articles (or find something equivalent)

http://www.firstthings.com/article/2009/01/002-what-we-know-about-embryonic-stem-cells-26

 

http://www.firstthings.com/article/2008/01/001-getting-stem-cells-right-24

 

 

 

 

 

 

 

LIFE/DEATH ISSUES, BRAIN DEATH, PVS, EUTHANASIA etc.

The british doctors: the patients (the demented, Alzheimers, etc.) “are less of a problem than WE. THEY are generally more akuthentic about what they are feelings and doing; man of the polite veneers of earlier life been stripped away. THEY are clearly dependent on others, and usually come to accept that dependence; wheras many “normal” people, living under an ideology of extremem individualism, strenuously deny ther dependency needs. THEY live largely in the present, because certain parts of their memory function have failed. WE often find it very difficult to live int e present, suffering constant distraction, the sense of the present is often contaminated by regrets about the past and fears about the future.”

 

BRAIN DEATH AND DEATH

*p. 16

Distinguish ‘no longer alive’ from ‘no longer a person.’

Distinguish ‘rights of persons’ from ‘rights of person-remains.’

You cannot euthanatize someone who is already dead!

 

            Death =df ?

1. Cessation of pulse, respiration

2. Permanent loss* of consciousness (Cruzan) (Cortex is dead). PVS. See p.15, 2.

3. Permanent loss of unassisted organic functioning (whole brain death)

4.  When the assistance is turned off.

 

When are you dead?

1 –what if it is not permanent? Must be irreversible. ?

2. Is there no ‘you’ in that case? Cf. Nancy’s niece’s remark. What conception of a ‘person’ does this involve?

3. Aren’t ‘you’ more than, or other than, an integrated functioning organism, a body?

 

The Harvard Ad Hoc com definition of death, 1968. Cf. a ‘cadaver’ that is still breathing, blood circulating – what a boon to medical science! Not only fresh organ parts, but, why not, experiments with diseases, blood, etc.

 

Look at views -  

Bernat – An X in 3 is just a collection of organs. Already dead. (notice comparison to blastocyst, which on some views is just a collection of cells).

 

‘Dualist’  not dead till soul leaves body. Soul/breath connection.

Or perhaps soul – integrative functioning connection (more Aristotelian)

Or perhaps soul/

 

Meilander

 Thought experiment; what would ‘resurrection’ be like?  Of babies, amputees, etc. I would be ‘most truly me’?

Froats – living out the destiny of the body vs. ‘personhood’ ala Fletcher.

Personhood and ‘capacities’ (thus, functionalism) Capacities, not bodily life, make the person.

 

When is care ‘futile’? An action is futile when, no matter how often repeated, it cannot achieve its goal. (Sisyphus, shoveling in snow etc.)

Futility – applied to comatose vs PVS. Some comatose patients will die soon no matter what is done.  PVS patient will continue to live if nurtured, thus not obvious that care for her is ‘futile.’ Care of comatose is ‘quantitatively futile.’ (no matter how much).  Contrast that to

‘qualitative futility’ Treatment of PVS is qualitatively futile insofar as it cannot reach a ‘qualitatively’defined goal, e.g. renewed rational functioning.

Importance of autonomy ideal understood in relation to futility. P.69 Treatment which cannot restore rational autonomy is futile.

       Contrast that with ‘living out the destiny of the body.’

The body’s history  - cf. Illich’s reflections on his life. The smell and feel of things.

 

Could autonomy mean ‘taking into ones self, ones ‘personhood’ , dependence, old age, dementia, decay of the flesh, dieing.’?

Could personhood require social context (v. ‘nursing home ethics’)?

                    

On the other hand, suppose autonomous choice is itself what matters, see 71

Living wills , advance directives, health care power of attorney –implies centrality, to personhood, of power to take control of ones personal history.  Original idea was to limit intrusion by physician, when there is not general agreement on what makes a person a person.  By deciding ‘for ourselves’ when life is no longer personal life, or life with dignity, or worth living, or whatever, we do away with need for agreement on personhood.

                           BUT

In practice, autonomous choice becomes definitive of personhood.(thus, a capacities approach)

 Thus, where it(choice) no longer exists = no longer a person. THEN WHAT???

       THEN you get cases like Helga Wanglie’s. (87 yrs old)

Her caregivers did not want to give ‘’’futile” care = care that could not reach qualitative goal, renewed rational functioning. Cf. quotes, p. 73

      

How Wanglie’s physicians are

       Right (indeed, my past decisions should not determine present care)

       Wrong (care does not become futile in old(first) sense of ‘futile’)

How the physician’s position is incoherent – they elevate rational autonomy, and denigrate it at the same time.

 

How living will conflicts with ‘bodily history’ view.  How it conforms to functionalist and capacities approaches.

 

Cf. Poplawski, Eberl.

       The personal is not just an example of the universal form; …the general characteristics exist in and through the individual person. P. 75.

       A PERSON is always a SOMEONE WHO, someone who was once little, once broke an arm, once loved certain others, feared, struggled, someone who belongs to and is partially defined by, relations to communities (a ‘thou’ in them) etc.  THIS notion of person applies just as fully to a mongoloid, a demented, and even a PVS, person, as to anyone else.

      

When do you ‘harm’ a ‘person?’  cf. Rachels, biological vs. biographical. Only the latter matters. BUT, why does that part of my biography that includes my final demented days not count? Rachel’s thinks it does not because there is no possibility of ‘conscious life’ (what goes beyond the biological)

 

We are what we were, and are, and will be. We were unconscious, we may be that again, and who knows what we will be ultimately? Whatever the answer, the person we are IS that WHOLE history (cf. Poplawski), which may extend into eternity.

 

KITWOOD

       3 Different accounts of ‘personhood.’ Transcendence, ethics, social psych

Personhood as status bestowed – implies ‘recognition.’  Whom do we recognize?  Problem of inclusion. Cf. the way in which the enemy in warfare is made into a non-human class, not ‘one of us.’

 

Analysis of personhood is often detached, no place for emotion.

BUT, ability to live in relationship often involves emotions more crucially than ‘reason.’  Technological culture and cold rationality vs. humane feeling relationships.

Buber:  I and Thou  vs. I and It.

Cf. The Eighth Day. The ‘experience’ of freedom and relationship to a thou.

No mechanical object can be treated as a thou. Human persons are not mechanical objects or reducible to such.

 

The depersonalization of the demented etc. A social consensus according to which such people are not accorded full personhood. Cf. 253

 

Reactions to demented, and old people generally,  rooted in fear (of what?).

Cf. 254, and recall Tolstoy.

Need for a many sided conception of personhood. Consider all the factors that make each person who they are.  Ability to do this varies non systematically. (no ‘theorist’ has an advantage)

 

VEATCH   

Whole brain death turns out to NOT be whole brain.

 

Distinction between brain stem and spinal activity not clear.

The ‘whole brain’ proponents are on a slippery slope.

The ‘higher brain’ folk are not.  Read 490-91.

 

‘capacity’ is ambiguous.

A major dissimilarity between aborting an embryo and unplugging a PVS. The PVS has no ‘active potentiality’ for rational functioning.

 

Conscience clauses: a default def of death could allow those who disagree to indicate their own treatment by advance directives.  What about Wanglie’s doctors? Their behavior would be a no no. But see  below.

 

What should the default def be? Maybe, ‘irreversible cessation of the capacity for consciousness’

NOTE; no reference to the brain in that definition.

 

What conscience clause should there be? Individuals can choose what def they want applied to them, so long as doing so does not threaten interests of others (but is that what Wanglies doctors were after?)

 

JONAS

What criteria should be used to decide when to let death take place unopposed, as opposed to, what criteria give a definition of death.

The motivation for the new ‘definitions’ is availability of fresh organs for transplant.

Consider where Jonas and Veatch agree. There can be no ‘precise’ definition of death using physical criteria.

 

death of the organism as a whole;’ p. 501

 

The problem; on the new definitions (death as ‘brain death’), treatments of what are corpses under them can, and probably will, include truly monstrous acts, all in the name of medical science and helping people.   Such acts as . . injection with diseases, all sorts of ghoulish procedures, experimental surgeries, etc.

 

Singer:

 

The “new” criteria constitute a “revolution without opposition.”  What is it? Why did it go thru?

 

Why do people use the expression “brain dead” and deny its implications?. Because of the persistence of obsolete criteria in our thinking?  How about, because they (the brain dead!) can still have babies?

 

So, the brain dead are not really DEAD. The ad hoc committee’s definition is ad hoc. A convenient fiction. With a PURPOSE that is not stated.

 

Get rid of the fiction.

 

B death can’t mean cessation of ALL brain functions. So, how about those relating to consciousness? This leads away from the idea of the sanctity of “life.”  ‘Life’ = human-life-with-certain-properties. (Think back to the Abortion debate).

 

The “law Lords” have already moved in this direction.  Anthony Bland (like Cruzan). In British law. Involuntary active euthanasia is legal in the case of PVS. That would be KISS.

 

 

Diagnostic imperialism?

 

 

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.

 

 

 

Life is “sacred.” Means?

 

Directly Killing humans is intrinsically wrong,

 

because? . . . being alive is intrinsically valuable.

 

For whom? The permanently comatose?  Not “subjectively” (so what?). 

 

Those who are “merely conscious?”  Applies to animals too.

 

Where life is “worth living?” What shows that? The desire to keep living? That doesn’t work either (why?)

 

A life is worth living if it meets the criteria held by the person whose life is in question.  !!!

 

Euthanasia and the Morality of Killing.

 

The Sacred Congregation: life is sacred because it is a gift of God. (specifically human life is the kind of gift that matters here).

 

No suicide, no killing of others (apart from duties as police etc.) is permissible.

 

·         Use of painkillers is permissible. With qualifications.

 

·         Use of drugs that hasten death might be permissible if the intention is, e.g. to lessen pain (double effect).

 

·         Refusal of some treatments may be justifiable.  OK sometimes to “make do” with “normal” treatment.

 

·         Interruption of treatments that are “disproportionate” in various ways may be permissible.

 

Problems in applying any of these. Consider the Cruzan case.

 

Grisez and Boyle:

 

Killing: an action contrary to “the good of life.”

 

Killing in the strict sense (KISS=murder?): adoption of a plan (presumes deliberation) to bring about someone’s death. Period.

 

Contrast with “deadly deeds.”  The enraged wife. The dutiful soldier.

Contrast with self-defense (double effect there)

Suicide and euthanasia are KISS.

 

Contrast with acting in a way that will bring death (Martyrs, etc.)

Voluntary (active) euthanasia is KISS (where it really is deliberated)

Non-voluntary (unusual term, not=involuntary) (active) euthanasia is KISS

Euthanasia by omission (passive) is KISS (e.g. refusal of treatment, as with many defective infants).

Omissions that do not include the proposal that someone die are NOT KISS:

 

            TRIAGE.

 

 

Refraining from treatment because of expected bad consequences. (financial, psychological etc. Focus on means and their bad consequences). Motive cannot be desire to get rid of a poor quality life.

Rachels:

 

Active and Passive Euthanasia (AE and PE)

 

Statement of the AMA: AE is wrong, PE (withholding) is OK (the “difference thesis”) 

 

Critique of the difference thesis:

There is no morally relevant difference between the two (unless AE is actually morally preferable, as with the Downs baby).

 

The analogy: the uncle, Smith, who actively drowns the nephew, vs. Jones, who merely lets him drown.  The two cases must be alike in every other respect (e.g. same intention) in order for the analogy to work.

 

Nesbitt:

can the difference thesis be dismissed so easily?

 

No. The Rachel’s example shows that our intuitions about Jones have to do with his intention to kill (cf. Boyle).  We would make THE SAME JUDGEMENT ABOUT JONES EVEN IF HE HAD NEITHER ACTED NOR REFRAINED. (suppose HE tripped and got knocked unconscious, and thus could not even LET the nephew drown).

 

Smith on the other hand is worse than Jones because he is an active threat, while Jones, we can imagine, “draws the line” at active killing. We would rather have lots of Joneses around than lots of Smiths.

 

Kuhse’s response to Nesbitt:

Would we? Not if the Smiths were well motivated. Cf. shooting the trapped and burning truck driver. And that is precisely the case with many cases of active euthanasia.

 

Some Kuhse assumptions:

 

·         The only relevant considerations in the AE cases, according to Kuhse,  have to do with the suffering of the patient. (What about slippery slopes? The nature of medical practice? Damage to virtuous dispositions and the sufferings of the killer (cf. Williams on utilitarianism )? )

 

·         The guy caught in the truck draws a KISS reponse.  (That is not obvious. How deliberated? A plan to bring death? Or a reaction to agony?)

 

What might we conclude from this debate?

 

·         That killing is generally worse than letting die, since (for one thing) in killing it is not possible to say that the cause of the death is anything other than oneself.

 

·         That in cases where one feels one must kill, the killing is still a bad thing to have to do.

 

·         That cases of letting die are also bad. Some (triage) are bad but not a bad reflection on the agent. Some may be just as bad as AE. Some fall in between.

 

DISABLED NEWBORNS and EUTHANASIA

 

Kinds: Prematurity, Birth defects, Contacted disease.

 

·         Prematurity

 

Terms: VLBW,1500 g ≤ ; ELBW 1000g      2.2 lbs.  (11-14  thousand a year in US)

 

Problems for VLBW and ELBW

 

                        RDS- respiratory distress syndrome  -ventilator damages baby’s lungs.  How long should care continue? How certain does death have to be to warrant discontinuation? Ventilator dependence – possible to reach a point where best therapy cannot keep baby comfortable.

 

                        IVH - bleeding into brain. About half of ELBWs.

Extreme hemorrhage produces permanent brain damage. When should care be withdrawn? (extent of damage difficult to determine early on).

 

                        NEC-necrotizing enterocolitus – loss of some or all of bowel (surgery needed to remove dead bowel tissue). Suppose it is obvious that so much colon is lost that the baby will be permanently on IV feeding. IV feeding can produce terrible miseries, e.g. liver failure, which leads to edema, hemorrhage. Should IV feeding be withdrawn?

 

Apply Boyle/Grisez to cases of RDS, IVH

 

Are scheduled feedings for IVH babies “care” or “treatment”? (comparable to a respirator?)

 

THINK about Illich’s notion of medicalization, and the allocation of extraordinary resources to medical treatment coupled with minimal allocation to other less “medical” health initiatives and interventions.

 

Think about the medicalization of the budget and the sense of limitless resources (for the “medical”)

 

Consider possible relations between treatments of ELBWs and triage. 

 

Allocation issues: extremely high costs for treatment of LBWs. ($400,000 15 years ago; doubtless millions now)

 

Cf triage-like situation: chance of survival less than %10. Diverting care from those who can profit more from it.

 

·         Birth defects:

 

Fixable: bypass cardiac surgery. Expensive, but survival rates are high, and subsequent life is normal.

 

Not fixable (assumption!):

 

                                    Potter’s syndrome (no kidneys)

 

                                    Anencephaly- see pictures above (missing skull etc.)

 

                                    Trisomy 18- all cells abnormal.  Extreme mental deficiency, (possibly not truly conscious), many problems with heart, esophagus, etc.

 

Are decisions not to treat in such cases based on quality of life?

 

Do they have to be?

 

In such situations is PE really better than AE?

 

Severely handicapped

            Spina bifida  (can be detected in womb and aborted)

 

            Left heart syndrome: all used to die peacefully. Now, expensive treatments, including even a heart transplant, can keep a few alive. Treatment involves much pain for baby. Is it worth it?

 

Should treatment be withheld (PE) or should some be actively killed (AE).

Is there a moral difference.

 

Kuhse:

 

            Rehearsing the difference principle in relation to a “defective” infant.

 

            As Kuhse relates the “English law” it contains no distinction between intended effects (of an action) and foreseen unintended effects. Poor English law!

 

            “Causing X” (a death e.g.). cf Hart and Honore on causation and “what does the trick”, whether it be an act or an omission.

 

What counts as “What does the trick” determined in relationship to “the normal course of events”

 

            Normal course of events

 

·         Wind blows a bit

 

·         Generally dry

 

·         Oxygen

 

·         Combustible stuff

 

FIRE

 

Cause?=cigarette

 

            Normal course of events

 

·         Child is born alive with blockage

 

·         Treatment is readily available

 

·         Treatment is “normally” not given

 

·         CHILD DIES

 

Cause? Genetic factors etc. Not omission of treatment.

 

What counts as “normal” may include things normally done (omitted) by people. Suppose doctors normally omit to treat certain conditions. Then their so doing would not, on this account, be said to cause, e.g. a death. !

 

Kuhse’s solution to this tangle. Get rid of this difference principle and then bite the bullet on the “logical” consequence, viz.

 

            active killing (KISS) should sometimes be   permissible.

 

It is only thought impermissible because of the “sanctity of life” principle, but the honest application of that principle (i.e. without the help of the difference principle) is just too too implausible (or so she claims).

 

How much treatment of seriously defective newborns is ‘futile’ on Meilander’s FIRST meaning of ‘futile?’                       

-------------------------

 

------------------------------

 

Alison Davis: So what ABOUT her?

 

Spina Bifida occurs in 7 out of every 10,000 live births in the United States.  Birth certificate data from the National Vital Statistics System, a component of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), indicate a drop in the rate of Spina Bifida; however, Spina Bifida is considered to be underreported on birth certificates so the drop in the rate could be due to lack of reporting, not an actual decrease in occurence.  In addition, a number of Spina Bifida pregnancies are voluntarily terminated and we cannot be certain how many pregnancies are terminated versus carried to term.

 

Davis has the second most severe form. What kind of a life is that? Definitely worth living, according to HER.

 

Hare:

 

Basic principle: we should treat the interests of all people affected by our actions as of equal weight

 

            Subordinate other principles to that one. How? Examples:

 

            How about Andrew, his older sister Alison.  How does THE BASIC principle help here?

 

Decisions, quandaries.  Question begging, e.g. see how B is after birth and kill her if it looks bad, or, “terminate” (kill).

 

Good illustration of utilitarian reasoning in bioethics, with a TYPICAL conclusion. One that is in line with a standard objection to U.

 

Suicide, Euthanasia and Alzheimers, etc. and other adults.

 

Margo – a demented woman who seems happy enough (enjoys her peanut butter and jelly sandwiches). Suppose she had left an ‘advance directive’ indicating that if she should ever become demented, she should be allowed to die should she need medical care to stay alive, or perhaps even,  should be killed. Should we honor her ‘precedent autonomy.’??

 

Dworkin

 

Alzheimers.  Description

 

            1 in 10 over 65, and rising with increased age

 

            Monetary cost – est. 80 billion annually in 1990

 

            Can be very distressing to care givers.

 

How should affected people be treated? (what is in their “best interests”)

 

·         Dignity – the patient has no sense of it. Should we? Does it depend upon seeing his life as a whole?.

 

·         Autonomy – normal (how normal?) adults have a right to decide for themselves about all sorts of things (“decisions ‘defining their own live’” - really?)

 

·         Consider  Margo – how much autonomy should she have?

 

·         Why should we honor what people think is best for themselves in the first place? Why care about autonomy?

Because, either

            i. the evidentiary view, i.e. the view that we should respect what people think is best for them, since they know better than others what is best for them – does not account for the autonomy of the akratic. Ergo?

            or

            ii. integrity view – autonomy protects the “general” capacity for self-creation. Does the Alzheimer’s patient have that capacity?

            or

            iii. precedent autonomy view, pros and cons – why should we care what someone used to think?  Cf. the “Jehovah’s witness.” Its only value is the light it sheds on  the present.

            But perhaps precedent autonomy is decisive, the witnesses past views would reemerge after the emergency in which he received the transfusion.

 

Apply to Margo- suppose in the past she claimed she did not want various treatments or even ordinary care, should she become demented. On the precedent autonomy view, we should withhold various treatments.

 

But, she is “happy” now.  Surely we cannot just kill her?

 

Dworkin thinks because we respect people’s  “critical interests” by honoring precedent autonomy, that that is the default position.

 

Critical interests = interests reflecting a developed view of how to live.

 

---------------------------

 

Dresser

 

Dworkin might sound nice, but can’t be reasonably applied.

 

·         Precedent autonomy is not that important to most people.

 

·         What must Margo understand to make such a decision? How consistent is she likely to be?

 

·         It is impossible to know what I will want in the future since the future will contain elements (e.g. new treatments) that cannot be foreseen.

 

·         Personal identity issues – Margo then and “Margo” now.

 

·         Critical interest/experiential interest contrast is doubtful to begin with.

 

What if Margo left no directive? We use the best interest model. How?

 

What Dworkin is really up to (?)

 

How much of the problem is with Margo and how much with us?

 

Cf. the 2 British scholars.  Connect to other cases of “disability” and our view vs. their’s (the disabled).p.372

 

Chris Hill = a ‘high living’ young man reduced to paraplegia by an accident. Wants to be killed because life has become meaningless.

 

A classical case of aestheticism. (No self, no character. Life as a collection of experiences)

 

A good description of the miseries of paraplegia.

 

Otherwise, what can we learn from this?

 

Think of Tolstoy – how does the experience of pain vary with one’s conception of oneself and how to live?

 

Callahan

 

            Euthanasia (involving assistance)and

 

Self determination

 

·         What is it? (Individualism)

 

·         How justify bringing another person in, the killer? (Social act)

 

·         How is the killer supposed to decide? Can’t just use patient request. (why?) Should the doctor use his/her own criteria for deciding “which lives are worth living”?

 

Killing, letting die.

 

·         Must distinguish causality and culpability. No omissions are causes, though some are culpable. (cf. the analysis of causality given under Kuhse (Hart), according to which some omissions could be causes).

 

·         Rejection of this distinction in effect makes the doctor more powerful. Even where death is not caused by the omission, the doctor is responsible. Mr. Dr. God, who is always deciding when HE should terminate.

 

Consequences of Euth.

 

1. inevitability of abuse

 

      a. low enforcement priority.

 

2. difficulty of enforcing Euth. Laws.

 

      a. terminology (e.g. “unbearable suffering”) is inherently vague.

 

       b. reporting is minimal, no way to prevent that (but maybe there is!).

 

3. slipperiness of moral reasoning

 

      a. if self determination is fundamental, then there is no reason to confine killing to people who are sick (at all!)

 

      b. if self determination is fundamental, then those without it (e.g. very retarded) will just have to suffer.

 

      c. if relief of suffering is fundamental, no need to get consent for euthanasia (involuntary active E looks OK)

 

Euthanasia and medical practice

 

·         Medicalizing suicide. Cf. Illich. What gives doctors the competence (legal sense) to do these things?

 

·         It is not medicine’s place to lift the burden of every kind of suffering. Illich once again. Relieve pain of body, but not pain of soul over “meaning (or lack thereof) of life”

 

-------------

 

Lachs

 

·         You cannot make Callahan’s distinction between body pain/soul pain.  Why not?(How about psychiatry? he says. Indeed, how about it?).

 

·         Patients seeking a lethal injection are not seeking an anwer to the meaning (Callahan says “riddle”) of life.  Why not? What supposedly bothers some people who request E is that they can no longer perform activities that give life meaning (387).  So they are worried about the meaning of life.

 

·         Problem; doctors control lethal drugs, thereby making efficient suicide impossible.

 

           i. Lachs accuses Callahan of being “coy” about suicide. After all, Callahan  gives no argument against. But Lachs gives no      arguments for it. The arguments pro and con       are well known. E.g. Kant.

 

·         Callahan assumes “transfer of power over oneself” to another is always bad. But it isn’t. (does he assume that? Where?)

 

1. what fixes the limits of such transfer? Lachs answer; human society sets limits . . .on account of its (e.g. slavery’s?) unacceptable costs. (Sic!!)

 

Admiraal

 

The usual terminology – unbearable suffering, etc.

 

“Consent, based on respect for the patient’s autonomy, is the centerpiece . . .governing VE” 397.

 

Isn’t that a problem?

 

Callahan’s question: if consent is what matters, why confine VE to people who are suffering “terribly” (in any way? E.g. psychologically?) or suffering at all?

 

 

-----------------------------------------------------------------------------------------------------------------------------------.

 

Questions

 

Week I

 

1. Explain what is meant by the ‘social construction’ of a concept. Illustrate using ‘disease’ and ‘sick’.

 

2. Give two examples of ‘medicalization.’

 

3. Briefly describe the medicalization of happiness (web source: http://www.orthodoxytoday.org/articles/DworkinDrugs.php)

 

Week II

 

4. Explain what is meant by ‘iatrogenesis’  and illustrate with clinical examples.(Use the web)

 

5.                                                                                                   social  “ (see OO)

 

Week III

 

Tolstoy:The Death of Ivan Illich – Questions to Ponder

 

1. This story begins with Illich dead.  How does it end? (Don’t be too literal minded!)

 

2. What is the larger significance of the answer to #1?

 

3. Mention one way (at least) in which Ivan, his wife,  and the doctors, deceive themselves, OTHER THAN self-deception regarding the reality of death.

 

4. ditto #3 but regarding the reality of death.

 

5. In the gospel of John (ch. 8 v. 44) it is said that “the devil is the father of lies.” This statement relates directly to a story from Genesis ch. 3 (read it!). What are the most governing, determinative, lies in Tolstoy’s story?  How are they related to these biblical passages? (don’t forget that self deception is lying).

 

6. Cite as much evidence from the story as you can that shows that Ivan’s “social climbing” is closely related to, or is part of, his denial of death and is at the same time the thing that makes him dead. (again, don’t be literal minded, but don’t miss the literal either)

 

7. Present evidence that the peasant Gerasim is, perhaps with the exception of Ivan’s young son, the only person in this story who is presented as thoroughly truthful. Relate that fact to (a) his ability to care  (b) Ivan’s responsiveness to his care (c) biblical ideas about children and the lowly (the crude, the foolish, the uneducated etc.)  (d) the Nemesis themes of care vs. treatment, human responsiveness to “suffering” (not just pain) vs. the “treatment” of pain and related stigmatized conditions.

 

8. Does Ivan’s death fit into any of the stages in the development of the idea of a natural death as described in Medical Nemesis? Discuss.

 

9. What determines Ivan’s differing reactions to the PAIN of his dying? Does Tolstoy’s portrayal of these reactions strike you as plausible? Discuss and explain. Relate to the Nemesis discussion of pain (ch. III)

 

10. What roles does the notion of “scientific objectivity” play in this story? There are several. Attend to Ivan himself, and to the Doctors. Attend to the role of this notion in self deception.

 

11. Ivan is a judge, or court magistrate.  How does he think of his work?

 

12. Explore the ironies (or ironical reversals) in the fact that Illich is a judge.

 

13. In the light of this story, what do you think Tolstoy might have to say about current emphases upon “self esteem?”  That emphasis aims to increase happiness or well being. Consider the different kinds of happiness and well being explored in this story.

 

14. This story is obviously meant to provoke some thought about both life and death, both what it is to be truly alive, and about different ways of being dead (e.g. dead to the world, dead to the truth, dead to human community, physically dead, “spiritually” or ethically dead etc.) Discuss what it is to be truly alive, per this story.

 

15. Tolstoy wrote this story late in his life, after he felt that he had found in the gospels the solution to the riddles of life. It helps in reading these late works to have some familiarity with the bible and the gospels specifically. If you don’t, it is never too late! (well, almost never).  Consider in particular the sermon on the mount (matt 5-7 ) as it might apply to this story, and don’t forget Gerasim.

 

 16. One theme in this story has to do with the acceptance of dependency. Discuss.

 

Week IV

 

6. Be able to define the following: conceptus, zygote, morulla, blastocyst, embryo, primitive streak. Then make a time line.

 

7. Relate each of the six ‘positions’ in Grisez to one of the views on personhood in the intro to L.`1

 

Week V

 

8. Read Kuhse/Singer (#20). In brief, what is the status of the pre-born, according to them.

 

9. It seems that a zygote could not be a person.  Because …

 

            Twinning problem

 

            Chimera problem

 

            High % of spontaneously aborting zygotes

 

Explain each of these. Then,  Give Griesez’s response to each.

 

WEEK VI

 

10. Read p.167-169. Explain the following: substance; substantial kind; natural substantial kind.

 

      

 

11. Read Warren (p.351-66). a.What are the criteria of personhood according to Warren? List them.  b. in your opinion, which of these criteria, if any, are satisfied by a week old infant?

 

 

 

ADDITIONAL QUESTIONS FOR MIDTERM EXAM

 

12. Why do Kuhse/Singer (KS from now on) think that the fact that the cells that make up any of the stages from zygote to primitive streak are totipotent count against the claim that any of them are persons?

 

 13. Why does Grisez think otherwise? Why does Eberl think otherwise?

 

14. Is there biological evidence that the totipotent cells of e.g. a blastocyst are working in coordination with each other in the development of single individual?

 

15. Think about Warren’s criteria for personhood. Then ask yourself, if the alien we encounter does not look at all like us (suppose it is an amorphous blob on sliders), is not being cared for, and meets no more of criteria 1-3 (supposing there is any way we could know) than does a 1 week old human infant, is there any chance we would count it as a person? If not, what follows about her criteria?

 

16. Warren argues that the rights of a potential person never outweigh even the most trivial rights of an actual person. She uses an analogy to enforce this point. Is there a significant DISANALOGY between the explorer/potential clones and the pregnant women/fetus, in all cases but rape?

 

17. What are the advantages of IVF? (include advantages of genetic manipulations in vitro, as well as advantage to the infertile).

 

18. What are the moral objections to IVF?  There are different kinds of objections for different uses, as well as objections to ANY IVF.

 

19. What non-moral hazards of IVF support objections to it?

 

20. Does Warren give any reasons for thinking that being able to carry on an intelligent conversation with someone is a morally more important interaction than simply holding hands or touching noses?

 

 

 

 

 

Week VII

 

Read Poplawski.

 

21. Does Pop have the same reasons for counting a zygote as a person as does Eberl?

 

Week IX

22. State the pro abortion arguments from Thomson and Purdy.

23. State the pro life argument of Marquis

24. Distinguish germ line and somatic cell genetic manipulations.

25. Discuss Huntingdon’s Chorea, and what genetic manipulation might be used to eliminate it. 

26. What is the problem with ‘crossing the Weismann barrier’?

27. Discuss one disease that could be attacked with germ line therapy.

 Week X

Cruzan questions

28. CRUZAN /meilander

29. What is Veatch’s proposed def of ‘death’ and why (a) does he think it is better than whole brain or (b) higher brain?

30. Discuss Veatch’s conscience clauses. Why are they necessary, on his view?

31. Jonas argues that the new definitions of death should be rejected.  Why?

32. towards the end of his essay Jonas offers several reasons for rejecting what he sees as a ‘new dualism’ of brain vs. body. What are they, and do you think he is on to something important. 

 

 

 

 

 

OO

 

1. Discuss the following pro and con: (supposed) improvement in overall health is the result of the development of new medical technologies, medical research etc. Cite six evidences for and  six against. Number them.

 

            For: elimination or reduction of (1)polio (vaccine), (2)death from pneumonia (antibiotics), (3)whooping cough (vaccine),  (4) prevention of caries (fluoridation), (5) increased survival of trauma (transfusions etc.), (6) early discovery of cervical cancer through smear test and successful treatment.

 

            Against: (1)%90 of reduction in mortality from scarlet fever, diphtheria, etc. (1860-1965) occurred before medical therapies were discovered; correlation of nutritional improvement and reduction in (2) rickets and pelegra; (3) correlation of political equality and age of death etc. (4) non-correlation of doctor density and health not attributable to other factors (5) increase in new diseases such as diabetes and heart conditions due to bad food (6)  role of non-professional or non-medical procedures in reduction of illness (use of soap, treatment of water and sewage.

 

2. Present six examples of clinical iatrogenesis.

 

            1. dangerous drug treatment of high blood pressure

 

            2. administration of contaminated drugs

 

            3. production of treatment-resistant strains of bacteria etc. through use of antibiotic

 

            4. treatment of cardiac non-disease in children (n. 59,60)

 

            5. administration of drugs that cause direct harm (thalidomide)

 

            6. hospital “accidents” (wrong treatment, non-treatment where right treatment was known, etc)

 

3.  Explain and illustrate what “social iatrogenesis” is by reference to Illich’s 8 headings. Give at least one example for each.

 

4. Discuss and illustrate with an example or two the first two headings in ch. III, i.e. THE KILLING OF PAIN, and THE INVENTION AND ELIMINATION OF DISEASE.

 

5.  Briefly describe the various stages in the development of the idea of a natural death. Include all stages described by Illich.

 

Tolstoy questions (on handout)

 

Cruzan questions (on handout)

 

 

 

 

 

 

 

 

 

 

 

 

Questions on Singer Essays:

 

1.  How does Finnis define ‘human person?”

 

2. What is Finnis’ solution to the “twinning” problem? Give reasons for accepting it. Rejecting it.

 

3. How does Finnis deal with cases where the continued existence of a fetus may kill the mother?  How does he deal with cases of rape?

 

4. Discuss the following:

 

            a. How does Tooley define “person?”

 

            b. critique his definition

 

            c. How does he analyze ‘A has a right to x?” Give both the initial and revised analyses.

 

5. Critique Tooley’s response to the potentiality argument.

 

6. State the analogy that Thomson uses to argue that a woman who has gotten pregnant against her will (or unintentionally) is not obligated to “stay connected” to the resulting fetus.

 

7. Mention several cases in which a woman would be obligated to remain connected to her fetus, on Thomson’s account.

 

8. Discuss the following from Marquis:

 

            a. what shows the wrongness of abortion?

 

            b. how is his argument not the same as the potentiality argument?

 

            c. what does his argument suggest about a general pro-life position, e.g. one that also rejects the killing of the permanently comatose, or people in PVS?

 

9. Purdy argues that women owe certain things to their unborn children, but not some other things. 

 

            a. Mention several of each.

 

            b. Give her reasons in each case.

 

10.  How does Purdy respond to the claims that

 

            a. surrogate motherhood involves exploitation

 

            b.                                        involves empowerment.

 

11. Under what circumstances, according to Purdy, might it be wrong (immoral) to have children, and why?

 

12. There are two assumptions frequently made by proponents of prenatal diagnosis etc. that, according to Asch, are largely mistaken:

 

            a. what are they?

 

            b. why are they wrong?

 

13. What are some standard objections to having children for the purposes of “donations” to a sibling? (v. course outline)

 

14. Explain the distinction between germ line and somatic cell therapies. Which appears to by most morally problematic, and why?

 

15. What are some examples of supposed benefits to be had through gene manipulation? Mention at least six, of different kinds, and rate them in terms of how morally objectionable they are.

 

16. What problems can arise in somatic cell therapy, and does the principle of double effect help solve them? Explain. (Lappe)

 

17. Mention some of the aspects of the dark and distant past of eugenics. Discuss whether or not there is reason to fear these sorts of things in modern eugenics.

 

18. Glover argues that all that makes sense in the idea of the sanctity of life is that it is wrong to kill someone who has a satisfactory life. Critique this in as many ways as you can think of.

 

19. The “sacred congregation” claims that all kinds of killing and letting die are wrong except  . . . (fill in ) Why the exceptions?

 

20. What kind of killing is always wrong according to Grisez/ Boyle?  Does the distinction between killing and letting die generally have moral significance? Does it ever? Why? 

 

21. What is the “difference principle?”  Why does Rachels reject it?

 

22. Why does Nesbit accept some version of the difference principle?

 

23. Assess Kuhse’s critique of Nesbit.

 

23. Define the following: VLBW, ELBW

 

                        RDS

 

                        IVH

 

                        NEC

 

24. What might Boyle/Grisez have to say about how to deal with RDS, etc.?

 

25.What are two things that Illich might have to say about such cases?

 

26. Discuss: “letting die is the intentional causation of death.”  Include in your answer a discussion of intention and of causation.

 

27. State the criteria for “brain death” proposed by the Harvard ad hoc committee. What was the unstated purpose of this definition?  Discuss whether it is reasonable to think of brain dead people as being really DEAD.

 

28. What, according to Singer, is good about the Bland decision? What are its consequences for the traditional view of the sanctity of life?

 

29. Discuss “autonomy.”  Why is it supposedly important? What conditions must exist for a person to have it?

 

30.  Describe a typical case of Alzheimer’s.  Then discuss the rights of that person.

 

31. Discuss whether an Alz patient’s current wishes/beliefs should count more or less than past wishes/beliefs, in deciding how much “autonomy” to grant.

 

32. Discuss Dworkin’s views on the best approach to “Margo” and Dresser’s critique of Dworkin. Go into DETAIL.

 

33. Explain in detail Callahan’ objections to euthanasia, pro and con. Use Lachs if you have it. Otherwise, use your brains, which might work better anyway.

 

34. Why does Chris Hill think voluntary euthanasia is not only permissible but good in his case and similar cases?

 

35. How does Callahan distinguish killing from letting die? Will his distinction work? Ever?

 

36. Callahan mentions several bad consequences of VE. List them.

 

37. Admiraal claims that “consent is the centerpiece . . .governing VE.” How would Callahan respond to that claim? There are at least two main responses.

 

38. Menzel says “don’t we know how to count?”  What does he mean?

 

39. Admiraal claims that “consent is the centerpiece . . .governing VE. How would Callahan respond to that claim? There are at least two main responses.

 

40. Rescher proposes criteria for the basic screening stage and the final selection stage. What are they?

 

41. discuss the relative merits of anti-ageism and the fair innings argument.

 

42. Bring Tolstoy to bear on some of Harris’ claims.

 

43. Discuss at least three problems with the idea that doctors can reliably elicit consent from their patients.

 

44. Virtue theories vary in numerous ways but there are at least two things they generally share. Discuss those two things, and show how they can apply to thinking about bioethics.

 

 

 

Paper Topics

 

1. Enhancement surgeries

 

2. Enhancement drugs (cosmetic psychopharmacology; Kremer, etc.)

 

3. The social construction of medical categories

 

4. Applications of utilitarian thinking to selected biomedical cases*

 

5.                         Kantian                                                          

 

6.                       Christian (e.g. Natural law)                                        

 

7.  Virtue theory and medical ethics.

 

8. Literature and sickness/health/medicine (Tolstoy, Walker Percy etc.)

 

1-8 can vary in generality. In some cases it would be possible to take a single issue, e.g. assisted reproduction, and discuss it from perspective of 4,5,6 or 7.

 

9. Views about the self, authenticity, and its bearings on medicalization, or a specific issue in bioethics (cf. e.g. Carl Elliot).

 

10. Some concept of personhood (8 possible), applied to

 

            a. abortion

 

            b. euthanasia

 

            c. stem cell research/manipulation.

 

            d. other selected issues*

 

Papers must be argumentative. You must state a thesis or some theses, give reasons for believing it (them), and consider and reply to objections.

 

*Examples of issues:

 

            Abortion, euthanasia (for terminals, for the unhappy, for severely deformed infants, etc.), allocation of scarce resources, IVF, surrogate parenting, assisted reproduction in general, sperm donation, stem cell research, Pre-implantation genetic diagnosis and manipulation, cloning, informed consent and patient autonomy and living wills, organ donation, experimentation with human subjects, brain death, nursing issues, triage, etc.

 

 

 

Extra credit: Ethical analysis of issues raised in films (Lorenzo’s Oil, Coma, Whose Life is it Anyway, One Flew Over the Cuckoo’s Nest) or documentaries (Cruzan, PBS series or episodes).  Etc.

 

 

“Medicalization” and the idea of medical progress (using Medical Nemesis, I. Illich, 1975).

. See OO

2. Problems with M

Progress (?) %90 of etc. p. 6, 7,  n.16 etc

Progress and “overreaching”  Compare the medicalization of life(M) and the automobilization of transportation (A).

Problem of unintended effects:

  i. some of the aims  of A

  ii. some of the unintended results of A (nemesis)

  iii. some of the aims of M

  iv. some of the unintended results of M

  the budget

  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 West Nile virus.

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.

The medicalization of ordinary happiness/unhappiness.

------------------------------------------------------

3. M and iatrogenesis.

“Iatrogenesis”= medically induced sickness or injury.

“Nemesis”=the result of “overreaching”

Medical Nemesis (three kinds)

  i. Clinical-- e.g. children suffering from non-existent cardiac disease p. 20 and n.60. %7 of all patients. . .21. Includes technological (CT scans)

  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

 

4. ABORTION

Teams:   pro choice = Patrick, Sigrid, Jarod, Tyler, Jayme

     Pro-life= John, Trevor, Vashon, Alan

 

How big an issue? 1.2 million whats a year? Intentional killing of innocent persons? Removal of growing tissue?

Factual matters:

Abortion rates also vary depending on the stage of pregnancy and the method practiced. In 2003, from data collected in those areas of the United States that sufficiently reported gestational age, it was found that 88.2% of abortions were conducted at or prior to 12 weeks, 10.4% from 13 to 20 weeks, and 1.4% at or after 21 weeks. 90.9% of these were classified as having been done by "curettage" (suction-aspiration, Dilation and curettage, Dilation and evacuation), 7.7% by "medical" means (mifepristone), 0.4% by "intrauterine instillation" (saline or prostaglandin), and 1.0% by "other" (including hysterotomy and hysterectomy).[68] The Guttmacher Institute estimated there were 2,200 intact dilation and extraction procedures in the U.S. during 2000; this accounts for 0.17% of the total number of abortions performed that year.[69] Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 to 19 weeks, and 1.5% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical.[70] Later abortions are more common in China, India, and other developing countries than in developed countries.[71]  \

PICTURES

32. Discuss Dworkin’s views on the best approach to “Margo” and Dresser’s critique of Dworkin. Go into DETAIL.

33. Explain in detail Callahan’ objections to euthanasia, pro and con. Use Lachs if you have it. Otherwise, use your brains, which might work better anyway.

34. Why does Chris Hill think voluntary euthanasia is not only permissible but good in his case and similar cases?

35. How does Callahan distinguish killing from letting die? Will his distinction work? Ever?

36. Callahan mentions several bad consequences of VE. List them.

37. Admiraal claims that “consent is the centerpiece . . .governing VE.” How would Callahan respond to that claim? There are at least two main responses.

38. Menzel says “don’t we know how to count?”  What does he mean?

39. Admiraal claims that “consent is the centerpiece . . .governing VE. How would Callahan respond to that claim? There are at least two main responses.

40. Rescher proposes criteria for the basic screening stage and the final selection stage. What are they?

41. discuss the relative merits of anti-ageism and the fair innings argument.

42. Bring Tolstoy to bear on some of Harris’ claims.

43. Discuss at least three problems with the idea that doctors can reliably elicit consent from their patients.

44. Virtue theories vary in numerous ways but there are at least two things they generally share. Discuss those two things, and show how they can apply to thinking about bioethics.

 

Paper Topics

1. Enhancement surgeries

2. Enhancement drugs (cosmetic psychopharmacology; Kremer, etc.)

3. The social construction of medical categories

4. Applications of utilitarian thinking to selected biomedical cases*

5.           Kantian           

6.         Christian (e.g. Natural law)       

7.  Virtue theory and medical ethics.

8. Literature and sickness/health/medicine (Tolstoy, Walker Percy etc.)

1-8 can vary in generality. In some cases it would be possible to take a single issue, e.g. assisted reproduction, and discuss it from perspective of 4,5,6 or 7.

9. Views about the self, authenticity, and its bearings on medicalization, or a specific issue in bioethics (cf. e.g. Carl Elliot).

10. Some concept of personhood (8 possible), applied to

  a. abortion

  b. euthanasia

  c. stem cell research/manipulation.

  d. other selected issues*

Papers must be argumentative. You must state a thesis or some theses, give reasons for believing it (them), and consider and reply to objections.

*Examples of issues:

  Abortion, euthanasia (for terminals, for the unhappy, for severely deformed infants, etc.), allocation of scarce resources, IVF, surrogate parenting, assisted reproduction in general, sperm donation, stem cell research, Pre-implantation genetic diagnosis and manipulation, cloning, informed consent and patient autonomy and living wills, organ donation, experimentation with human subjects, brain death, nursing issues, triage, etc.

  

Extra credit: Ethical analysis of issues raised in films (Lorenzo’s Oil, Coma, Whose Life is it Anyway, One Flew Over the Cuckoo’s Nest) or documentaries (Cruzan, PBS series or episodes).  Etc.

For bibliography, check with me, in Singer, check on line (be careful).

Applying Virtue Ethics (Rosalind Hursthouse)

It is often claimed that virtue theory does not tell us what we ought or ought not to do. Various deontological theories, including natural law and divine command theories, and consequentialist theories, on the other hand, claim to give us specific rules for conduct, or at least definite principles from which we can derive specific rules. Even if those theories are themselves subject to various criticisms, they are at least trying to do the thing that we supposedly want ethics to do, namely, give us guidance with respect to specific actions and moral dilemmas.  It seems that virtue theory cannot be applied in the ways required for medical ethics, business ethics, and other areas of applied ethics. Moreover critics of virtue theory allege that it cannot give the appropriate applications, not merely that most virtue theorists have not actually done so.

  There are in fact some applications of virtue ethics. Critics complain however that these exceptional cases still do not give us the definite answers we need to questions about our obligations.   Phillipa Foot, a major representative of virtue theory,  produced a well known discussion of euthanasia. But according to some critics she merely leaves our various and sometimes conflicting intuitions about euthanasia roughly where they were to begin with. We agree that taking a life is a serious matter, we agree that in some cases it nonetheless seems the best of the unsavory alternatives available, we realize there are many different sorts of cases, for example those which would involve giving lethal injections, as opposed to those which merely allow a person to die by removal of a respirator or feeding tube. Sometimes we feel inclined to say ‘yes, do it’ other times ‘absolutely not’ and still other times we are utterly unsure what to say. Some people believe that a moral theory should straighten up this messy situation, show where ordinary intuitions go wrong, if they do, and otherwise satisfy a need to get beyond the conflicting intuitions with which we start. But Foot, some claim, does not do that, whereas others have at least attempted to. For example in a famous article James Rachels tried to show that the distinction between killing and letting die had no moral significance. If our ordinary intuitions are to the effect that that distinction is important, then Rachels, if he is right, has cleared up some confusions rather than simply letting them stand. That is the sort of thing we hope to get from a philosophical ethicist.

(10) In brief, what is the objection to virtue theory stated in the preceding paragraph?

  These objections could amount to a request for an ethical algorithm or decision procedure. But hardly any moral theory can seriously claim to provide an algorithm for such complex cases. The quandaries are just that, quandaries. To expect a simple and straightforward rule for resolving them is to act as though something is simple which clearly is not.  But the objection could be more general: the claim may be that virtue theory offers no rules at all, not just no clear rules for resolving difficult cases. But that too is a mistake; the virtues imply rules. To value truthfulness is to endorse the rule “ tell the truth.”  A truthful person will follow that rule, with proper allowances for unusual and conflicted circumstances. 

  Perhaps the objection really has to do with the kind of rules derivable from virtue centered approaches. “Tell the truth”, “help those in need” and their like are relatively banal. What we need, critics may claim, are rules that tell us what to do in the complicated situations.

  It is easy to imagine an Aristotelian response to such a complaint. For on Aristotle’s view it is clearly appropriate that there be no such precise rules. Modern virtue ethicists will echo that idea, and point out that a theory which recognizes the truly baffling nature of some moral dilemmas should be credited for doing so, rather than criticized. Hursthouse thus claims that it should be “a condition of adequacy on a [moral] theory that it leave some cases unresolved.”  Virtuous people are, on her account, likely to be the first to admit that sometimes they do not know what should be done. That is certainly not, however, an admission that some rule is needed to supplement the virtues approach.

  Nor is admitting the unresolvability of some moral dilemmas equivalent to admitting that one virtuous person might consider a certain act clearly right and another equally virtuous person might think the same act wrong.  Two virtuous persons might act differently in the face of a difficult situation; one might opt for removing a feeding tube, another might refuse to do so. But they will share a great deal. In particular, we might expect that the virtuous person who takes the first option will feel distress, a sense of having had to act in a way that goes against the grain and may always be regretted.  The person who takes the second option will also feel the tug of the alternative, and a recognition that on the matter at hand equally virtuous persons might disagree about what the best (as opposed to the right ) action would be. In fact, if we understand choice in an Aristotelian way, this barely qualifies as a case of choice. Sometimes the capacity for genuine agency is defeated by terrible circumstances. And it is characteristic of the virtuous person that she recognize that fact also. And that is once again to the credit of virtue theory.

(10) Why does lack of a clear rule for deciding the euthanasia case not necessarily entail intractable moral disagreements, on the virtues approach. Illustrate.

(10) Hursthouse admits that two virtuous people might act differently when confronted with a moral dilemma.  What sorts of agreements are likely to still exist between two such people? Describe them.

  It might still seem, however, that the sorts of rules which  can  be garnered from virtue ethics are of little or no use. The person with the virtue of truthfulness may follow the rule ‘tell the truth’ because lying is a type of action which he cannot stomach. But the rules we need, critics may claim, are not related to character in that way. Lying certainly is out of keeping with a virtue or character trait, namely, truthfulness. But is disconnecting a feeding tube an act that is inconsistent with some virtue, and if so, which virtue? There is not generally a certain type of person, a person of a certain kind of character,  who “goes in for” that type of act, in the way that a truthful person “goes in for” telling the truth and the way a liar ignores it. Virtue ethics, critics may claim, cannot give us rules for these sorts of practical dilemmas, and such rules are the ones we really need in ethics.

  However, while it is true that the virtuous person may be unable to provide us with a rule for such a case, it is not true that they have nothing to say about it, or about closely related cases. Hursthouse considers the case, discussed by Judith Jarvis Thompson, of a woman who gets an abortion late in term in order to not miss a vacation.

  There is lots she could say about why it would be wrong of the woman in Thompson’s case to have the abortion. For instance, she could say that it would be wrong because it would be callous, wrong because it would be stunningly light minded, very likely (pending further details) to be wrong because it was very selfish, or self centered, or cruel. She could also say it was wrong because it was folly. And all such claims universalize in the required way; any abortion which is similarly callous, or light minded, or cruel, is wrong. So, in a way, virtue ethics can produce “rules governing abortion” – not of course the sort which the deontic theorist expected, but nevertheless rules which rebut the claim ‘virtue ethics can’t say anything about the rights and wrongs of acts such as abortion, and hence needs to be supplemented by rules governing them’.

Will this reply suffice? One might wonder why it is callous for the woman to act as she does. The answer seems to be “because killing babies is wrong”, and that would be a rule of a sort that deontologists take as basic.  This worry may reflect the idea that virtue ethics tries to reduce all moral concepts to virtues, and fails. But in fact virtue ethicists typically rely upon the concept of the good, a good life, happiness. And those concepts are not reducible to virtue concepts.

(10) Do you find any of the replies to the critics of virtue theory unsatisfying. If so, say why. If not, say which reply you think is weakest.

Hursthouse concludes with a suggestion about what motivates philosopher’s searches for something “better” than a virtues approach.

Perhaps what philosophers, as a body of professionals, tend to find uncomfortable about virtue ethics is that it makes all too explicit a fact we would like to think was not so; that we are not, qua philosophers, thereby fitted to say anything true or even enlightening on real moral issues. It requires that we give up the pretence that all we bring to bear on them is the expertise of our trade – our oft-claimed clarity and rigor in argument, our detachment, our skill in working out inconsistencies and dreaming up counter-examples.  It reveals that, if we are to say anything true about them, we must also bring our knowledge of the correct application of the virtue-vice terms – about which actions are, say, charitable or dishonest – and, moreoever, our knowledge of what is truly good and bad, of what is worthwhile, of what counts as a good, mature, developed human life, and what as a wasted, perverted, or childish one.