Phil. 350, Principles of Bioethics (Fall ’06)
Instructor Information: Instructor, Dr.
Office: HU 229 Phone 7384 E-mail nlillega@utm.edu
Office Hours: 8-9 a.m. MWF and by appointment.
Texts: Medical Nemesis by Ivan Illich (it does not matter what edition you use; a new edition is titled Limits to Medicine: Medical Nemesis.
The Death of Ivan Illich by Tolstoy (this story can be found in many collections; it would help if we all had the same one, but that is unlikely to happen; there is, by the way, absolutely no connection between these two “Illichs.”
Various essays, all of which can be found in Bioethics: An Anthology (Blackwell Philosophy Anthologies (Paper)) Helga Kuhse, Peter Albert David Singer but most of which can be also be found elsewhere.
The purpose of this course: To provoke critical reflection on our “medicalized culture.” To familiarize students with the standard issues in bioethics and some of the principal cases illustrating those issues. To encourage thoughtfulness about the nature of medical practice, its relations to religious, ethical and social norms and ways of life, and its relations to science both as purportedly objective knowledge of the world and as purportedly socially constructed activity. To familiarize students with the sudden burgeoning of genetic research and its (financially) profitable applications, and to encourage thoughtfulness about the significance of this major challenge to ethical and religious norms and concepts.
Course Requirements: Attend class and participate, study the assigned readings, do all written assignments, pass the exams.
Three exams (two mini exams, 60 pts each, a mid-term, 100 pts and a comprehensive final worth 150): The first three exams will be T/F and multiple choice. The final will be a selection of answers to essay questions. The questions will be handed out throughout the course. Instructor evaluation of answers to those questions will be available on a scheduled basis prior to the final. (370 pts total)
A short paper (i.e. not less than 1500 words worth 150 pts): Topics may be chosen by the student but must be approved by the instructor. There are LOTS of juicy topics. (150 pts. Total). Preview of your work by instructor is suggested, and is free of charge.
Philosophy majors who want to write a paper for inclusion in their portfolio may expand their paper, with instructor imput. Some extra credit may be available.
Occasional short quizzes: these will be worth ca. 6 pts each and will be unannounced. Ca. 45 pts. They are extra credit points!
Attendance, quizzes, in class assignments, outside assignments. Regular attendance and informed participation in class are essential since (a)you will need to be there to take quizzes and do in-class assignments (b) you will need help with this material, and that is what class sessions, and the instructor, are for. Points will depend upon actual attendance and upon the quality of work in class. About 25 points just for attendance. One unexcused absence will be allowed, after which 10 points will be deducted for each unexcused absence. There will be two or three outside assignments, worth 30 pts total. These will consist in viewing and reporting on videos. 55 pts total.
Extra Credit: Extra points for early return of study questions for review (total 10 pts.) Quiz points, ca 40- 50 pts. possible
Total points ca. 575. Normally %90 of total points gets you an 'A', %80 a 'B' and so forth, but significant adjustments for curve are made when necessary.
Conduct of class, Role of the Instructor: Classes will be a mix of lecture, discussion, and also possibly some special presentations by students or others. Those who need individual help should feel free to ask, provided they have been spending a reasonable amount of time on the material. I want each student to perform to the best of his or her ability, and I will do all that I can to bring that about (short of patrolling the dorms!). At the same time I will hold each student responsible for completing all the work. Moreover, all students are responsible for knowing what has transpired in every class. Policies on student conduct, and other possibly pertinent information may be found on the instructor’s home page,
Best way to contact - e-mail: nlillega@utm.edu
Also- 731 881 7384 (Office, Voice)
You MUST visit www.utm.edu/staff/nlillega/lillegard.htm Read the rest of the syllabus, etc.
Course Outline: (Approximate: adjustments and changes are likely.) (Study questions, i.e. those questions which will constitute the final exam, will be provided as we proceed. You are responsible for having a complete and correct list of these questions.)
Week I (Aug. 28) The “socially constructed” nature of
disease, health, and related concepts. Clinical iatrogensis. Read Medical Nemesis (MN)
Week II (Sept. 6, the 4th is llabor day) Social Iatrogenesis. Read MN section II
Week III Sept. 11: Cultural iatrogenesis and the Politics of Health. Read MN sections III and IV.
Week IV Sept. 18: Read Tolstoy.
Mini-exam I, Monday.. Sept. 25.
Week V Sept. 25: Singer sec.
I and II, selections to be assigned.
Selections: Finnis, Tooley, Marquis, Thomson, Purdy, Purdy, Purdy.
Week VI Oct. 2: Singer sec.
II
Assigned questions for Midterm due Oct. 6.
Week VII Oct. 9:. Review. MIDTERM
EXAM, Wed. Oct 11.
Week VIII Fall Break,
Oct. 16-17 Oct. 18:
Singer II cont.
Week IX Oct. 23: Singer III Lappe, Muller-Hill.
Week X Oct. 30. Singer III
Week XI.Nov. 6:
Singer IV .
Mini-exam II Nov. !0
Week XII Nov. 13: Singer IV
Week XIII Nov. 20: Singer IV,
V. (Nov. 22-24, Thanksgiving
Break)
Week XIV Nov. 27: Singer V. Further selections. Thinking about the way applied ethics is
done (suggested readings)
PAPER DUE NOV. 27, NO LATE PAPERS ACCEPTED.
Week XV Dec. 4: Assigned questions II for final are due for
review Dec. 4. Review. Dec. 8, last day of classes.
FINAL EXAMS Dec. 11-15 (see schedule).
Syllabus etc.
“Medical”=
The importance of how
we describe things: “health”, “disease,” “progress,” and “how the word is independently
of our descriptions.”
i. the
general problem
ii. e.g. “health” (the “objective condition of being
healthy!!!”)
Progress (?) %90 of
etc. p. 6, 7, n.16 etc.
Progress and
“overreaching” cf. the medicalization of life(M) and the automobilization
of transportation. (A)
i. some of
the aims of A
ii. some of the unintended results
of A
iii. some of the aims of M
iv. some of the unintended results
of M
cf. technical disease control and
corrupted environments “biting back” n. 27
In general, the development of
“undefeatable” disease vectors as a result of “treatment.” Mosquitoes, etc. n.
33
New diseases as well
as persistence of old
e.g. Aids (not known when this book
was written). Heart disease, Cancers
--physical and cultural environment.
What is the primary
determinant of the overall health of a population? p. 7
Health and “self
medicating” (using soap!)
The resistance of the
medical establishment to non-professional, non-medical “interventions”
Semmelweis.
------------------------------------------------------
“Iatrogenesis”=
medically induced sickness or injury.
“Nemesis”=the result
of “overreaching”
Medical Nemesis
i.
Clinical-- e.g. children suffering from non-existent cardiac disease p. 20 and
n.60. %7 of all patients. . .21
ii. Social-- e.g. exclusion of home
births
iii. Cultural e.g.—declining ability
to face death. “The sound of one siren
in a Chilean village . . .”
I. Clinical iatrogenesis – see answers to ques.
1,2.
II. Social iatrogenesis – (bad) socio-economic changes/arrangements
made attractive or possible or necessary by the “medical.”
THE MEDICALIZATION OF LIFE (HEALTH) v. p 33
for summary.
1. radical monopoly
2. medicalization
of the budget
3. pharmaceutical invasion
4. diagnostic imperialism
5. preventive stigma
6. Terminal ceremonies
7. black magic
8. Patient majorities
1. RADICAL MONOPOLY=a
monopoly that makes people unable (in se) to do things on their own;
a. mutual
care and self-medication become no-nos (even in some
cases crimes).
b.
production of new categories of sickness/patients. People angered, sickened or impaired by
industrial/social arrangements become patients (passive sufferers needing
“treatment”), not active resisters.
i. note especially psychiatric “illnesses” and the
political use of “disease categories.” (more openly cynical in
ii.
development of “therapies” that “ought not to be used” but are anyway because
they are medical v. n.13 thus abasing and pacifying people.
iii. A 1 b is enabled by a general
sociological fact – groups with power to label (as sick or not sick,
e.g.). I get to say what the problem
with you is, and what to do about it (who?).
iv.
all deviance as medical. No longer any moral, religious, political, deviance.
The use of “sick” for
all sorts of conditions.
c. Thus
(from b iv) the eclipse of the moral dimension of medicine, in order to expand
its reach. P.40 (how, why?) Cannot be
hedged by ethics, religion, traditions.
2. MEDICALIZATION OF THE BUDGET. %s
spent, private and public. Notice increase in % of GDP from ’64 to ’75. In rich and
poor countries!!!!
a. enabling role of
third party payments – motivation to get new equipment etc. Giving the
“customer” more than he ever would have been willing to pay for on his own.
b. spending public money
on “CARE” (the province of the “medical”) rather than environmental change (p.
49). (cf. Recent NYC legislation, in contrast).
i. keep in mind different ways in which public money
(taxes) are spent on the medical. Who
says taxes should be spent that way? Monopoly again.
a.
education. Note special unjust burden on poor countries.
ii. keep in
mind who it is that identifies the NEED for these expenditures, and the proper
recipients.
a.
experts vs. non-experts. Cf. the changes in Chinese medicine.
iii. the
devaluation of goods and services that cannot be bought.
3. THE PHARMACEUTICAL INVASION
a. The world wide spread of (insufficiently
monitored) DRUGS
b. drug companies
pushing drugs
i. Cloramphenicol p. 59.
Thalidomide (notice underreporting, n. 63).
c. drugs for what are
not medical conditions. Tranquilizers. Sleeping pills. V. p. 63
d. Fundamental cause? An
(unwarranted) BELIEF. About control of
life conditions.
i. evidence of lack of warrant– ineffectiveness of actual
drugs. Views on how many drugs are actually needed. P. 69
ii. included
in that belief – the notion of what can be purchased. Buying a fix from the experts.
4. DIAGNOSTIC IMPERIALISM
a. M gets to say who is
sick, cannot work, can be a soldier, can miss class, can go to jail rather than
the nut house, etc.
i. getting health certificates n. 131
b. the medicalization of stages – each stage of life has medical
“problems” that define it.
For example: the
diagnosis – OLD. !!
Life as a “pilgrimage through
check-ups” p.73.
Medicalization
of birth.
PREVENTIVE STIGMA (diagnosis and its various hazards)
a. Being turned into patients (being
labeled as sick) without being sick. The medicalization
of prevention.
i. treatment of the old is most conspicuous. Being treated
for an incurable condition (to prevent an unpreventable condition )
b. stigma attaching to mental
“illness”, heart attack victims, former alcoholics, aids patients, sickle cell
carriers,
c. the search for health produces a
“dragnet” designed to apprehend and label those needing “treatment” p.85 and
notes. Tests, tests, and . . .benefit?
You were healthy when you went in,
you are sick coming out!!
d. The diagnostic rule: better to
diagnose what is not there, than miss what is there. V. p.87
e. diagnostic bias, error, and
AGRESSION. Me in the hospital with a heart cath. V.
89
f. p. 90 “diagnosis always . . .
TERMINAL CEREMONIES
v. n. 186
a. M transforms an occasion for
personal integration (cf. Tolstoy!) into a stress situation.
b. the doctor as absolute master,
even over death (cf. the film “Coma.”)
Replacing priests and their ceremonies.
c. death as technical crisis –
orientation towards crisis justifies ineffectiveness (cf. homeland security).
d. the medicalization
of death = death in hospitals (enormous increase by ’76. Now?)
i.
1200% increase in cost of “last days.”
ii. that does not
include my old Swedish lady. She went, supposedly,
for treatable stuff. She represents lots of people.
Tombs used to be
expensive (the pyramids). Now the money goes into the hospital ward.
iii. note the
enlightenment switch n.201
and Tolstoy.
e. physician’s own fear of death.
Doctor as carrier of infectious fright.
i.
doctor dissimulation etc. (now?)
f. the limits of the physician’s
duty, the facies hippocratica cf.
n. 209
i.
the category of the irreversible does not fit the ethos of M ( or those who are
M ized. )
ii. people who do accept
the regnant categories are stigmatized, described as stupid, fools, etc.
(M:what,
you are refusing treatment? You must be crazy!
O: but no one has shown that it really works. M: of course it works,
everything we do works, except when it doesn’t, and we will fix that soon.
Meanwhile, quit acting up.)
g. physician assisted dying and
increase in “dependency.”
i.
possible relation of this to euthanasia debate, cf. p.98.
h. cf. cardiac intensive care p.
101.
BLACK MAGIC
The history of medicine and magic,
religion, ethics.
a. medicine organized around care –
cf. p.104
i.
varieties of functions;
b. the late 20th cent.
doctor is a new thing – combining many features. M exercises symbolic and other
non-technical powers.
i.
compare the effects of magical spells to the effect of negative diagnoses. The
reverse of the placebo effect. P. 108.
n. 243
PATIENT MAJORITIES
a. turning over the huge number of
“new sick” to people with “reflected medical prestige.”
Cf. 111, and n. 248. The welfare
receiver in the sexual domain.
b. M’s definition of “disease” and
the “control of deviance” go hand in hand. Control is no longer through, e.g.
morality, law, religion. SOCIAL control.
i. a predominant task of M – to exonerate the sick
from responsibility for being sick. So their LIVES get turned over to the
mechanics who fix them.
CULTURAL IATROGENESIS
What does, or can,
“culture” do? Equip people with abilities to cope with sickness, pain,
impairment, death. Cf. the Javanese –
Cf. the traditional ars moriendi.
Does M culture do
these things? Or induce an inability
to cope or live within these ‘facts of life?’
THE KILLING OF PAIN
a. Compare “it hurts, fix it, I have
a right to have it fixed” with “it hurts, I have to live through it, I must do
my best if relief is marginal or non-existent.”
Dealing with pain as a performance, and the physiological dimension as
secondary.
i.
cf.the list of virtues, p. 130.
b. the experience (quantity and
quality) of pain depends upon physiology, genetic endowment, PLUS ….
c. iatrogenic effect of current
culture disables these.
d. physician control, not patient
control, matters. Physician’s VIEW is what matters. View of a physiological
treatable condition. (doesn’t even have to be experienced!)
e. variety of language relative to
pain – anguish, suffering, affliction, torture, hard work, etc. (136). What are
the implications?
f. Illich’s
thesis-p. 138
i.
The “act of suffering pain.” (performance, p. 145)
ii. The questions that
come with pain – if a doctor ignored them, ignored the “humanistic” dimension,
he would be cut off from our humanity. That happens.
iii. the variations in
response to pain killers in the lab and in life. 139. cf. b.
g. culture provides words, drugs,
myths, models. Examples
i.
compare Greeks and Chinese on pain. Aristotle on the soul and suffering.
ii. man’s experience of
a marred universe, 146. “the meaning of pain was . . .”
h. the mechanization of the body
(Descartes, Leibniz). Pain as a
technical problem, a light on the dashboard indicating a malfunction.
i.
the horror of NOT experiencing pain 150.
THE INVENTION AND
ELIMINATION OF DISEASE
A. Enlightenment and politicization
of sickness etc. Rousseau and beaucracy!!
i.
in the restoration, polit and beau continue, but in
connection with M.
B. the hospital as the scene for
study, development of taxonomy, “clinical standards of normality” (as opposed
to social, religious etc.)
i.
now, the whole society has become a clinic
C. All disease is socially
constructed !!!???
i.
the denial that mental diseases are diseases reinforces the idea the physical
ills are NOT constructed.
D. What seems plausible here? There
is a history, there is construction, there is waste and misallocation of
resources, power for new groups, etc.
but, there is also –
FACTS.
CULTURAL IATROGENESIS
What does, or can,
“culture” do? Equip people with abilities to cope with sickness, pain,
impairment, death. Cf. the Javanese –
Cf. the traditional ars moriendi.
Does M culture do
these things? Or does it induce an inability
to cope or live within these ‘facts of life?’
THE KILLING OF PAIN
a. Compare “it hurts, fix it, I have
a right to have it fixed” with “it hurts, I have to live through it, I must do
my best if relief is marginal or non-existent.”
Dealing with pain as a performance, and the physiological dimension as
secondary.
i.
cf.the list of virtues, p. 130.
b. the experience (quantity and
quality) of pain depends upon physiology, genetic endowment, PLUS ….132
MacDonald’s father. Scottish highland culture. Tolstoy’s mother.
c. iatrogenic effect of current
culture disables these.
d. physician control, not patient
control, matters. Physician’s VIEW is what matters. View of a physiological
treatable condition. (doesn’t even have to be experienced!)
e. variety of language relative to
pain – anguish, suffering, affliction, torture, hard work, etc. (136). What are
the implications?
f. Illich’s
thesis-p. 138
i.
The “act of suffering pain.” (performance, p. 145)
ii. The questions that
come with pain – if a doctor ignored them, ignored the “humanistic” dimension,
he would be cut off from our humanity. That happens.
iii. the variations in
response to pain killers in the lab and in life. 139. cf. b.
g. culture provides words, drugs, myths,
models. Examples
i.
compare Greeks and Chinese on pain. Aristotle on the soul and suffering.
ii. man’s experience of
a marred universe, 146. “the meaning of pain was . . .”
h. the mechanization of the body
(Descartes, Leibniz). Pain as a technical
problem, a light on the dashboard indicating a malfunction.
i.
the horror of NOT experiencing pain 150.
THE INVENTION AND
ELIMINATION OF DISEASE
A. Enlightenment and politicization
of sickness etc. Rousseau and beaucracy!!
i.
in the restoration, polit and beau continue, but in
connection with M.
B. the hospital as the scene for
study, development of taxonomy, “clinical standards of normality” (as opposed
to social, religious etc.)
i.
now, the whole society has become a clinic
C. All disease is socially
constructed !!!???
i.
the denial that mental diseases are diseases reinforces the idea the physical ills
are NOT constructed.
D. What seems plausible here? There
is a history, there is construction, there is waste and misallocation of
resources, power for new groups, etc.
but, there is also –
FACTS.
DEATH AGAINST DEATH
A. a society’s image of death
reveals 172, n.3
B. Evolution of “natural death”
i.
devotional dance of death – each type of person dances with the dead version of
themselves. Cimitiere des Innocents, 1424. Intimacy with death – Chaucer, Villon. Contrast
with earlier medieval image of struggle between angels (good and bad) over the
dying.
a. death is
no longer the work of an external agent. It is intrinsic to life.
ii. Danse
Macabre (by end of 15th cent)
death becomes an
independent figure, not just one of the four horsemen. Death as figure of a moment, not a lifelong
companion.
a. new
clocks and the sense of a moment of death. Clocks and bones. 180 (n. 18)
b. the ars moriendi – personal
instructions on how to die. (not, on how to live with death). P.183
c. death as
‘natural’ in Paracelsus 184
d. gradual
reduction of corpse to mere object. (Obscene object). History of dissection of
corpses in 16th, 17th centuries. Dissection at Carnivals!
Holbein and
Playboy!!!
iii Bourgeois Death
Paying to keep death away. Only one
class can do it.
a. old age for the rich in greater comfort.
iv. Clinical Death
Death as the outcome of
specific diseases (no more “death in general”)
a. clinical
death emerges as a function of the consciousness of scientifically trained
doctors.
v. Trade Union Claims to
a Natural Death
A deeply medicalized ideal (cf. 1792) of “natural” death (any death
not caused by disease etc.) Workers claim a right to it. Not just the Bourgoise.
a. the good
death is the death available to the consumer of M.
b. the
doctor stands between us and death. Cf. images, 197
vi. Death under
Intensive Care – mechanical death conquers and destroys all other deaths.
Tolstoy
* The fact of temporality, finite existence in time, and the end of that existence in death, provides the strongest basis for escape from the tyranny of the “they” and fallenness.
My death is one thing I cannot share with others. It is the end of myself, the end of the defining feature of dasein as anxious life in the face of possibility.
* The “they” tries to strip death of its power to clarify the nature of existence, by assimilating my personal death to the idea that “everyone dies.”
Authenticity is possible where one accepts the revelation of existence that death gives. Such authenticity is being towards death.
(Sein and Zeit)
The principle of double effect:
An action which has both a good and a bad
effect will be permissible just in case
1.
The action is itself morally neutral or morally good
2.
The bad effect must not be the means by which the good effect is brought about
3.
The motive for the action must be the bringing about of the good effect only
4.
The good effect must be equivalent in importance to the bad effect.
Finnis:
1.
Living human individuals are persons.
2.
The moment a child is conceived it is a living human individual.
3.
Therefore, a Zygote, which is what a child is the moment it is conceived (and
anything following it up until birth), is an (innocent, obviously) human person
(from 1 and 2).
4.
It is always wrong to intentionally kill an innocent human person.
5.
It is always wrong to intentionally kill* a zygote (and anything following it
up to birth) (from 3 and 4).
QED
*
·
“Intentionally
kill”= perform a “direct abortion.”
·
Some
abortions are indirect (not directly “willed”– e.g. ectopic
pregnancy.
·
See
principle of double effect + Finnis’ four conditions.
Some consequences of 5.
5i.
Rape;
·
attempts to prevent conception
are legitimate (they are not contraception).
·
Post
coital pills may be permissible
·
Once a
child is conceived, aborting by any means is not permissible.
5ii. Pre-natal screening done with the
intent of aborting where results are “negative” are not permissible, nor is
cooperation with such activities.
5iii. Any
experimentation with embryos that is not to their benefit is not permissible.
·
Obviously,
production of embryos with the intention of selecting from them is grossly
immoral, no matter how good the motives.
Challenges:
i. Tooley: not all
living individual humans are persons (~ 1).
ii. A zygote is not yet an individual since
it can twin. Killing it would not be killing some definite distinct human
individual. (The twinning problem) (~ 1 and ~2).
iii. Sometimes it is permissible to kill an innocent human person (Thompson). (~ 4)
Finnis responses:
Take i. A zygote does not actually have all
the traits of persons, but it has the capacities of one.
·
Cf.
Aristotle on different senses of ‘capacity.’
·
(See
Marquis for details on the “potentiality argument.”)
Take ii. A zygote can
become TWO human individuals. It cannot be identified with either one. What
happened to it? Did it die? Or was there never an individual there to begin with.
Finnis solution: !?
Take iii. An unborn
“child” can never be regarded as an intruder, aggressor, “user” etc. Why?
·
(Cf.
Thompson).
Tooley:
A zygote, and nothing following it even past birth, is
a human person, even though it is a
human being, until such time as it
makes sense to say it has a right to life.
·
X has a
right to life, just in case X is a subject of experiences, X is capable of
desiring to remain in existence, and X does wish to remain in existence
(normally).
·
Zygotes, and
even born infants, are not capable of desiring to remain in existence (that
desire requires mastery of concepts, such as the concept of “myself”,
etc. Therefore, etc.
What about the
potentiality principle?
1. There is no morally significant difference between actively
preventing X from progressing to F, and not doing
something which if done would allow X to progress to F.
2. It is not wrong to refrain from injecting a kitten with a chemical
that would make it develop human kinds of consciousness, so it is not wrong to
kill it after injected instead (by 1). In both cases, it will fail to develop
certain properties that confer a right to life.
3. The only difference between the injected kitten and the human zygote
(fetus etc.) is that one is human, the other feline. That is not a morally
relevant difference.
4. Therefore it is not wrong to kill a zygote etc. (by 2 and 3).
So, only an X that ACTUALLY possesses “person making properties” has a
right to life.
(if a kitten had those properties it would have
exactly the same right to life as any mature human).
Response: the argument depends upon a non-sensical
“thought experiment.” Cf. “if it were possible to inject a daisy etc.”
Otherwise put, it is arguably not possible to abstract such properties as self consciousness (as a morally significant property) from the kind of
bodily life humans have (cf. arguments from AI).
That Tooley does not see this is evident from
his worries about animals. Think about
“having a concept of oneself.” My injected dog has a
concept of himself.
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 Finnis.
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.
# 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.” What does
it depend upon?
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 mother’s case?).
Response: the wrongness of killing is not (primarily) due to the
violation of a right.
What is involved in having a “right?”
Thomson does not think that any abortion is permissible (cf. minimal samaritanism, etc.)
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.
Purdy
What does a woman owe her fetus?
·
Conflicting
intutions: 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?
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). N. purdy p. 93
Beware the naturalistic fallacy P. 94 (sic!)
---------------------------------------------------
Purdy:Surrogate Mothering
Surrogate mothering separates
·
sex and
reproduction
·
reproduction
and child rearing
·
reproduction
and marriage
So what?
Not discussed by Purdy: How many “parents” might a child have? Does it
matter?
Some supposed advantages to
·
Alleviating
fertility problems, ergo more “happiness”
·
Optimising transfers
of risk and burden
·
Prevention
of serious genetic diseases.
·
Enabling
of non-traditional families
Objections (moral?)
·
It is not
right to shift those burdens (replies)
·
Not right
to “separate” (replies)
·
Contracts
and prostitution (replies)
·
Baby selling (replies. Not like slavery)
Purdy: Genetics and
reproductive risk. Note the “facts” to which some are oblivious, p.116
Thesis: conception
can sometimes be wrong ( put it this way to avoid
abortion issue).
e.g. Huntington’s disease
Germ line (GL) and
Somatic cell (SC therapies.
Postive and negative therapies.
(examples of each)
What are the
combinations?
Lappe – the uncertain relation between GL and SL
zygote- first technique
four cell – third technique – reintroduce cell to blastocyst
8 cell – followed by morula and blastocyst – 2nd
technique (re-introduce treated cell to embryo)
Manipulations IV, using genetic techniques.
Somatic cell therapy – repair of a
defective gene affecting the person who is “repaired.”
e.g. SCID (an immune s. 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
Common techniques - IV
manipulations,
(Above pictures are from an IVF clinic. )
These therapies assume the moral permissibility of IV manipulations of
any kind.
Somatic cell therapies can sometimes “get into” the germ line. Thus we get the chart on p. 201.
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-
1. IF the aim is to get rid of defects, what counts as a defect?
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 (cf. Glover p. 175)
5. Proxy consent
And, of course, ANYTHING that involves direct killing of a human being.
( IV production of embryos for donor purposes and discarding
some, etc.)
Life/Death Issues
Glover:
Objections to killing:
a.direct effects-harm to killee
b. indirect effects-harm to family, society (utilitarian measures of
that).
b does not account for fundamental moral intuitions.
But, what are they? Could be Marquis’ Could be
Kant’s.
OR, could be that
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 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: active is wrong, passive (withholding) is OK (the
“difference thesis”)
Critique:
There is no morally relevant difference between the two (unless AE is
actually morally preferable, as with the
The analogy: the two cases must be alike in every other respect (e.g.
same intention) in order for the analogy to work.
One could still justify “omissions” ala Grisez/Boyle.
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.
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:
Would we? Not if the Smiths were well motivated. And that is precisely
the case with many cases of active euthanasia.
Some Kuhse assumptions:
·
Nesbit’s Jones draws
the line at “actively killing” rather than “killing for gain” (but. v. p. 295) Nesbitt’s last
sentence is an overgeneralization.
Otherwise, Kuhse’s criticism clearly misfires.
·
The only
relevant considerations in the AE cases 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. )
What might we conclude from this debate?
·
That
killing is generally worse than letting die, since (for one thing) ones own
agency is involved.
·
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
Kinds: Prematurity, Birth defects, Contacted
disease.
·
Prematurity
Terms: VLBW, ELBW
RDS
IVH
NEC
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.
·
Birth
defects:
Fixable: bypass cardiac surgery
Not fixable (assumption!):
Potter’s
syndrome (no kidneys)
Anencephaly
Trisomy 18
Are decisions not to treat in such cases based on quality of life?
Do they have to be?
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 does the trick” depends upon “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).
--------------------------
Hare: utilitarian dance.
------------------------------
Alison Davis: So what ABOUT her?
Spina Bifida occurs in 7 out of every
10,000 live births in the
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.
Brain Death:
X is dead if and only
if
1. Unresponsive to stimuli
2. No movements or
breathing
3. No reflexes
4. flat
EEG
Declare death, THEN turn off the respirator.
Why?
Problems in the law? The Colemans. Conflicting accounts
of death.
Protection of physician against murder
charges.
Cf. Cruzan vs. cessation of brain stem
function (.p 343).
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? 347. Because of the persistence of obsolete criteria in our
thinking? How about, because they (the
dead!) can still have babies?
So, the brain dead are not really DEAD. The ad hoc committees
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. Changing the
answer to ques. #2.
Diagnostic imperialism?
----------------------------
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? Cf. the “suppose”
passage on 359.
·
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 other people think is best for them in the first place?
Why care about autonomy?
i. the evidentiary view – does not account for the
autonomy of the akratic. Ergo?
ii. integrity
view – autonomy protects the “general” capacity for self-creation. Does the
Alzheimer’s patient have that capacity?
iii.
precedent autonomy view, pros and cons – why should we care what someone used
to think? Cf. the “witness.” Its only
value is the light it sheds on the present.
Or ,
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 =
---------------------------
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 diabled).
Chris Hill
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 aEctivities
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?
ALLOCATION ISSUES
Menzel
How can we justify
allocation of multiple resources (e.g. transplant organs )
to one person to save one life when those same resources could be divided up to
save many lives? Can’t we count?
(The triage scenario
again, minus pressure for immediate decision)
Attempts to justify:
·
More
elaborate procedures need “trying out” on the chance they will benefit many.
But the problem of using many organs for one remains.
·
Urgency-
most urgent first. But all are urgent.
·
Numbers
don’t count. But they do here, since appeal for organs is appeal to saving
larger NUMBERS of people.
·
The
unlucky consent, since it is luck all the way anyway. Well, do they really?
Rescher;
Problem: how select,
out of a large class of those needing ELT to survive, that subclass that can
actually be served, given the shortages?
Criteria
for an acceptable ELT selection system.
I Basic screening stage - criteria
for completely ruling out entire classes of people.
a.
constituency factor
i. serve “our own” (e.g. our taxpayers) ??
b.
progress of science factor
i. serve those who can contribute
to research
(e.g. those of a certain blood type) ??
c.
prospect of success factor
i. people in certain classes (e.g.
very young)
might be excluded from, e.g. haemodialysis, on grounds that the
ELT is very unlikely to work.
II Final Selection Stage: (Criteria
for Selection among the non-excluded)
a. relative likelihood of success –
obvious criterion
b.
life expectancy factor – obvious
c.
family role factor – cf. a mother of minor
children vs. a middle aged bachelor (ceteris
paribus, of course).
d.
future contributions factor – bothers egalitarian
types . examples.
Utilitarian?
e.
past services factor – equity or utility?
c, d, e, raise controversy of course.
e.g.
who decides, doctors or “laymen”?
notice the
classic quote on 415 (sec. VI) illustrating a couple Illichian
themes. Note also the end of sec. VI on
the “fiction.”
Clearly NOT only
doctors, if c, d, e are at all relevant.
Rescher: there must be a rationally defensible
system for allocating, but there is no uniquely rational one.
His suggestion; after applying a-e
to a second phase group, make the final selection on a lottery basis.
Advantages; “fair”
“Luck
is here to stay”
Takes a load off of adminstrators.
Harris:
Arguments
against Rescher II b. Anti-ageism arg.
My desire to go on
living is just as great or greater than some young person,
so why should it get lower value.
Fair innings – the
claims of the young trump those of the old (because they have had their share
of life. . .how old? Well, somewhere around 70. A 40
year old doesn’t get less consideration than a 30 year old. But
why not?
An argument from
analogy – depends upon comparing a life span to a race. So what are the
similarities and what the differences?
What about people
(there may be many) who have lived 70 years but have NOT lived a full life, but
might well live the next five to the full, bring something to completion that
needs it (a work, a love, etc. ) The
misfortune/tragic distinction is pretty crude (not
worthless?)
What counts most –
lives saved or life-years saved? 120000 for one month or 1000
people for ten years? (cf. a drug that adds 1 month to the former, vs. a
drug that adds 10 years to the latter).
Applied to the fair
innings arg, should we not invest in a treatment for
70yr olds if it could give a very large
number of them one extra month? Thus producing a significant increase in
life years saved? (but
does 1 month matter? What is the threshold of discrimination? 6 months, 1 year, etc.
How about worthwhile added time, not just plain old added
time? And what makes it worthwhile?
Attitudes
towards death – p. 434. False claims.
Veatch:
“Informed consent” is
an unworkable concept.
History: this is a
recent notion. Old notion is that doctor knows best, and prescribes
accordingly.
Implicit consent –
e.g. to drawing blood.
Explicit consent
required only where some special or complex treatment is being considered.
The whole idea rests
on the assumption that the Dr. can determine what is in the patient’s best
interest. But how does (s)he do that? How does anyone do it?
- For example, a surrogate? May need to
take into account more than the patient’s interests.
- How does the Dr. do it?
i. medical interest?
ii. how
trade off i with other interests?
iii.
how relate i to other claims on patient, e.g. moral duties, concerns for others, etc.
What
is “best” for the patient, or “in his best interest”, and theories of the good.
·
“hedonistic
theories” (happiness)
·
Desire
fulfillment theories (no matter what the desires are for, such as to be
miserable!)
·
Objective
list theories (what is objectively good regardless of what people desire or
feel). Such things as moral goodness, self-development, knowledge, deep
personal relations etc.
How is a dr.
to know enough about the patient to apply such criteria?
Distinguish
spheres of well being , e.g. organic, psychological,
social, religious, etc. Could anyone be well enough informed on any of these to
be able to propose a treatment to which a patient might genuinely consent?
Maybe Drs.
should stick to the organic/physical health aspect. Two problems
i. even in this domain there are
competing factors. E.g. relief of suffering vs. preservation
of life.
ii. what is medically best for a patient need not be what is
best altogether.
Example with
respect to i: v tach. PVC (premature ventricular contractions), i.e. heart arrhythmias. Many (over a hundred)
treatments, with many kinds of risk, side effects and benefit. The patient can hardly know what some other
doctor might have done, ergo cannot “consent” in any significant sense.
In any case, what is
the relation between the patient’s “medical good” and all the other goods that
matter? What if a patient feels constrained by duty to NOT maximize her own
well being? Such factors make meaningful medical judgment impossible for the
purpose of making “consent” possible.
.
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.
1. Enhancement surgeries
2. Enhancement drugs
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. 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.