PHL 223: Final
PHL 223: Final PHL 223
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This 11 page Study Guide was uploaded by Paola Araque on Thursday April 28, 2016. The Study Guide belongs to PHL 223 at University of Alabama - Tuscaloosa taught by Stuart Rachels in Summer 2015. Since its upload, it has received 113 views. For similar materials see Medical Ethics in PHIL-Philosophy at University of Alabama - Tuscaloosa.
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Date Created: 04/28/16
Lectures ● Friend got a heart transplant in college at the age of 19 ○ He saw the doctor friday, and got the heart monday. ○ Isn’t expected to live until 30 years old ○ He is now 45 ● Liver Transplant: a case study ○ Drindee: 50ish year old woman in Atlanta ○ PhD; hospital administrator, eating disorders ○ 1994, diagnosed with primary sclerosing cholangitis (PSC), which destroys the bile ducts in liver ○ Walter Payton had this disease ○ Cause of the disease, unknown ■ In her case, NOT due to alcohol ○ Only hope for cure: liver transplant ○ She ignored her doctor ○ In 2000, Drindee started having bad symptoms: ■ Weakness ■ Nausea ■ Pruritis (itching) ■ Bleeding esophageal varices (large varicose veins) ■ Mental lapses (couldn’t figure out how to start a car) ○ She cut back her hours at work, until she had to quit. ○ She wants a transplant, looks sick, but not too sick ○ In 2002, she got on “the list” at Emory Transplant List. ○ She had about 1 year to live ■ 3 times she had shunt operation. (esophagus) Shunt artificial tube, reroutes blood around needed area. ■ Experienced tremendous pain after shunt ○ Pain: doctors and nurses underestimated it ○ Good looking, but now ugly. ○ Her chances of getting a cadaveric liver: 50/50 maybe ○ Head of health in government, Shalala, changed the rules for getting an organ. ■ Now based entirely on 3 numbers ■ Took away all physician judgement ■ It meant that recipients will be close to death, and less likely to survive. ○ Bad for 2 reasons: ■ Those numbers are poor indicators of how sick someone with PSC is. ■ Alcoholics are more likely to get transplants ○ Drindee’s doctor, Thomas Heffran, advised her to seek living donors. ○ Adult to adult liver transplants began in the U.S. in 1997. ○ In 2002, 1 in 12 liver transplants were from living donors. ■ Must have same blood type, or your body will reject it. ○ Who donates their liver? ■ 75% blood relative family ■ 13% friend ■ 11% spouse ■ 1% altruist (stranger) ○ Drindee send a group email in March 2002. ■ Determination. ■ I was afraid. 20+ people called the surgeon. ■ They looked at 1 person at a time. Why? (expense to insurance company. Protecting the surgeon’s time.) ● Grim determination. Aware of situation. Why not me (Dr. Rachels)? ○ I (Dr. Rachels) was afraid ● 20 people called the surgeon ● The hospital looked at one person at a time. Why? ○ Expense to the insurance company ○ Protecting the surgeon’s time ○ Hospital had no method for prioritizing potential donor, because events like this didn’t happen frequently. ● Potential Donor #1: Bob ○ Eliminated, because he had a blood vessel out of place ○ Too big of a risk to operate on ● Potential Donor #2: Friend (college roommate) ○ Eliminated, because he was on a minor medication (prozac) ● Potential Donor #3: Friend ○ Eliminated, because she drank too much red wine. ○ Drinking alcohol in moderation is good for you. Drinking TOO MUCH is deadly, and destroys your liver. ○ Surgeon wasn’t sure if she was drinking more than the medically recommended ■ Doctors are cautious!! (If something goes wrong, whole operation shut down) ● May 2002: ○ I’ve got to do this soon (Dr. Rachels) ○ Had to begin exercising ● Potential Donor #4: Friend ○ Eliminated, because he changed his mind at the last minute. ○ Confidentiality broken, because the hospital told Dr. Rachels about the potential donor dropping out. ● Potential Donor #5: Friend (Dr. Rachels) ○ Got an appointment with Dr. Heffron & Emory Hospital in Atlanta, GA ○ What are the risks? ■ 1% chance of donor death ■ Really it’s more like 1/10th of 1%, or 1 in 1000. ■ 15% chance of significant surgical complications ■ 100% chance of pain and a big scar ● You won’t be writhing in pain ■ I could change my mind at any time, even the morning of the surgery ■ Hospital booted his car after surgery ■ On another day, they took my blood, and did an MRI. ■ Psychiatric Interview: ● Psychiatrist wanted to know if he was going to take the procedure seriously, and if he was a sound & normal adult. ● Psychiatrist tried to find out if Drindee was paying Dr. Rachels for his liver. ● “Everyone says they underestimated the pain.” ■ Liver biopsy, next step. ● Look at liver, see if cells are healthy in liver. ● Dr. Rachels was eliminated, because his liver was “too thick”. ● Potential Donor #6: Altruist (stranger) ○ Knew Drindee, because the daughter went to school with one of Drindee’s children. ○ Potential Donor backed out after 6 weeks. ● Drindee got a transplant 8/20/2002, but not from anyone she knew. ○ The liver came from a 9 year old boy who died in a car accident. ○ Successful surgery, hard recovery. ○ While she was sick, Drindee became religious but she lost it when she healed and became atheist again. ■ A minister had befriended her, but her husband felt like he was brainwashing Drindee. ● Bureaucracy ○ Dr. Rachels hospital bills were being paid by Drindee’s hospital bills, but he would get calls from Emory Hospital about whether or not he was going to pay his bills. ○ Drindee wrote a letter about how her body transformed after the surgery, ■ She hates her scar and says it looks like a “Mercedes Benz” logo. ■ Her midsection looks like a “war zone” ■ Her body was “butchered” and she feels “numb” around the scar ○ 2002 → Drindee had the transplant ○ 2004 →the disease came back ○ 2009 →she needed a second transplant and went into septic shock at one point ○ Adult to adult liver transplants are no longer done, because 1 donor out of 1,000 died. ○ January 2010 →she got the transplant ○ By then medicine has advanced, so the 2nd transplant was better than the 1st. ○ August 2010 →Drindee met the family of her first donor. ○ Living very well right now, still has a couple problems. ● Organ transplants ○ Everyday people in Drindee’s situation die waiting, 22 specifically ○ UNOS (united network for organ sharing) created in 1987 ○ To get a transplant you must live near a transport center ○ There are 250 centers. In AL, basically birmingham ○ Multiple listing: getting on the list at more than one center ○ Some people will live, others die because they have better insurance ○ Some people live because they know the system and can afford to be away from work ● Organ On Waiting List ● Kidney 100,419 ● Liver 14,753 ● Heart 4,158 ● Kidney & Pancreas 1,924 ● Lung 1,475 ● Pancreas 1,034 ● Intestines 271 ● heart/lung 43 ● Total #: 121,227 people waiting for a transplant ● Waiting in Alabama, 3269 waiting for a transplant ● In 2015, transplants performed = 30,969 ● Roughly half of those waiting will die waiting ● Donors are 60% cadaveric ● 40% are living ● Over 10x 9/11 people die ● 80% transplants are from dead people. ○ Roughly half of those waiting will die ○ Each year, 57000 people die who could donate but don’t. ○ Why? Under 20% of american adults sign organ donor forms ● Checking the box on your driver’s license is not enough ● Doctors are cautious about harvesting ● It is hard to approach grieving families ● Families are hoping for a miracle ● Uncertainty about when death occurs. ● Ethical Perspective ○ Many people are needlessly dying. ○ How can we increase the supply ● Possibilities ○ 1. Forced donation ■ Freedom to bury organs after death vs. human life ○ 2. Presumed consent ■ You’re a donor unless you indicate otherwise ○ Organ Donor ■ Denmark 4% ■ Germany 12% ■ U.K 17% ■ The Netherlands 28% ■ Sweden 86% ■ Belgium 98% ■ Austria, Poland, France, Portugal 100% ○ Why? Not cultural ■ People go for thdefault option ■ “Check the box if you want to be an organ donor” ■ “Check the box if you DON’T want to be an organ donor” ○ 3. Commercial Market for Organs ■ “Some things should not be bought or sold” Why not? ■ Exploitation of poor? (danger with living donors only) ■ Even if you think I shouldn’t sell my organs don’t I have the right to? ■ Is selling one’s organs so stupid that we shouldn’t allow it, as with slavery? Of course not. ○ Drawback of 13: ■ Increased distrust in doctors ■ Which leads to more death ○ 4. Stem Cell Research may allow us to clone organs ■ The God Committee: ● About first dialysis machines ● Dialysis cleans the blood and return it to the body; a kidney substitute. ■ Purpose of sleep is to clean the brain. ■ Dialysis machine: invented in 1943. Willem Kolff (Dutch) ■ 1960, Belding Scribner invented the “Scribner Shunt” ■ 1962, Scribner’s hospital could serve 17 dialysis patients ■ 1961, the “God Committee” was set up to decide who to accept. ● They limited candidates to those under 45 that could pay ● Considered if they were employed ● Educated ● Had dependent children ● Had achievements ● Could potentially help others ■ Were they “playing God?” ■ Well some choice had to be made. ● The EndStage Renal Disease Act (1972): ○ The government funds all dialysis ○ Lives were saved, but it was too much money. ● Animal Research ● How many birds and mammals are used for research in the U.S.? ○ Roughly 25 million per year ○ Most are rodents, with very similar genomes ● Animal care and use committees (required since 1986) ○ Must be a committee that researchers have to go through ○ Because of monkeys ● 3 approaches to assessing animal research: ○ 1) Any research on animals is ok. ■ It’s just an animal ○ 2) No research on animals is ok. ■ They’re not ours to use/animal rights must be protected ○ 3) Research is judged in terms of harms and benefits ■ How many animals? ■ How much pain? ■ To what end is the research? ■ Likelihood of success? ■ Are there alternatives? ● Position is too extreme. ● Immoral research done on animals: ○ LD 50 Test ○ “Lethal Dosage” 50% ○ Products are force fed to animals until 50% die ■ Ex. paint thinner, floor wax, motor oil. ● Shopping is like voting. ● Company can do harm: ○ Mistreatment of own workers ○ Treatment of animals ○ Treatment of environment ● Another Immoral research: ○ Draize Test: ■ Mostly done on shampoo ■ Chemicals are applied to rabbits eyes ■ Rabbit’s arms are restrained and eyelids slit (rabbits don’t have tears) ● Why are these tests wrong? ○ Because animals feel pain ● Why is it bad for animals to feel pain? ○ Pain is bad because it hurts. ● Animal pain, if it hurts as much as human pain, is just as bad. So thesevery s are wrong. ● What is human equality? ○ Humans are not equal in intelligence, beauty, moral virtue, wit, grace, speed, memory, age, height, the ability to hold one’s breath, etc. ○ Human equality is amoral idea. It is abequal consideration of interests ○ The Equality Principle: Everyone’s interests should count equally ■ Exception! Maybe your interests should count more if they are good, not bad. ○ Ways to violate the Equality Principle (forms of discrimination) ● A Group The belief that their interests matter less ● African Americans Racism ● Jews Antisemitism ● Women Sexism ● The Elderly Ageism ● Everyone but you Seflism (selfishness) ● Foreigners Nationalism ● Nonhumans Speciesism ● Most people are speciests: they favor human interestssimila non human interests. ● Factory Farms (CAFO) ○ concentrated animal feeding operations ○ 10 billion animals suffer horribly each year in US ○ Cramped, unsanitary conditions, disease, stress, mutilation. ● Overuse of antibiotics disease evolved and becomes resistant ○ Most antibodies use on animals in feed ● Pigs: gestation grates, castration, and tail docking with anesthesia. ● Cows: hot iron branded, castrated, tail docked, dehorned, ears cut, all without pain relief ● Chickens and turkeys: 9 billion; debeaking, forced molting, ammonia ● Meat industry does more global warming than transportation. ● The reason for all this suffering: ○ Cheap, tasty food ● Why does this happen? ○ Green revolution ○ We buy meat ○ It’s legal, tax supported ○ It’s profitable ○ Animals can’t fight back ○ Long history of speciesism ○ Influence of money in american politics. ● The Tuskegee Syphilis Study: ○ Syphilis is acquired through bacterium and transmitted sexually ○ The three stages of acquired syphilis: ■ 1. Primary Syphilis: ● Starts up about 2 weeks after having sex ● Lasts about 46 weeks ● Painless lesion appears (chancres, visible spots on the skin) ● Highly infectious period ■ 2. Secondary Syphilis: ● Last 130 years ● Very vague ● Chancres on skin subside/fade, but often internal lesions will rise (medically dangerous) ● Various symptoms ■ 3. Tertiary Syphilis: ● Can go in different directions medically ● Some people may heal, asymptomatic ● But lesions can cause major damage to cardiac and/or neurological system which can result in paralysis, blindness, death. ● Tuskegee Timeline: ○ 1909→Erich (German) and Hata (Japanese) invented salvarsan (arsphenamine) h eavy metals to treat syphilis. ○ 1912→Neosalvarsan (newsalvarsan) newly absorbed into the skin, “less toxic” but really more toxic ○ 1929→Boeck & Bruusgaard (Norwegian) questioned whether it’s better than no treatment. ○ 19311937→The Scottsboro trials happened in northern AL ■ Supreme Court Decisions that came out of these trials: ● A) Defendants have a right to a lawyer (representation). Don’t assume that they’re always guilty. Is it OK for you to be put on trial if you aren’t guilty and can’t afford it? (Giddeon v Wainwright) ● B) Right to a fair trial with jury by peers. African Americans were never allowed to sit on jury. During the Scottsboro trials it was an all white jury. ■ A time of enormous racism in AL. ■ But the role of racism in the study is unclear. ○ 1932: ■ Tuskegee experiment begins ■ Economic Depression ■ WWI, Great War ■ Tuskegee experiment→ “An experiment in nature” of 399 men in Macon County, AL ■ Experiment to take a look at how the disease acts over time if it’s untreated. ■ Macon County: 82% black; today: 85% black, 40% live below the poverty line ■ At the time, Macon County had a syphilis rate of 20% ■ Subjects had early secondary syphilis, not contagious. ■ Research by United States Public Health Services in cooperation with the Tuskegee Institue. ○ 19411943: ■ Penicillin mass produced for soldiers in WWII (for bacterial infection) ■ Discovered by Fleming in 1928 ○ 19411945→Scientists ensured that drafted subjects (from experiment) won’t get penicillin. ○ 1946→ penicillin becomes widely available, but tuskegee subjects aren’t given it. ○ 1969: ■ Neil Armstrong walks on the moon ■ CDC committee votes to continue the syphilis study ■ Tuskegee physicians, almost all black, agree to never give antibiotics to the subjects. ○ 1972: ■ America wins chess championship (Bobby xyz) ■ Nixon is president and Watergate scandal is coming up ■ Popular Press reports on the study, and it was ended ■ Tuskegee Study went on for 40 years using public’s money ■ 28 of 399 subjects had died ■ Publicity creates mistrust of doctors among blacks ● Institutions that experiment on humans are required to have IRBs (Institutional Review Boards) ○ 1974: ■ A legal settlement, subjects sued the government. ■ the government paid 10 million dollars which mainly covered medical costs ○ 1988: ■ President Clinton apologizes to 4 of the 8 living subject ■ the youngest Survivor was 97 years old and the oldest Survivor was about 104 years old ● Bad Science: ○ No central supervision and no written protocols ○ years would pass between visits with researchers from Washington DC and Tuskegee subjects ○ There was a period where they didn’t see subjects and went 9 years without knowing anything ○ There was poor recordkeeping and subjects got mixed up with controls who didn't have syphilis ○ some subjects got neosalvarsan or penicillin outside of Macon County ○ the upshot was basically that it was useless and nothing was learned ● Ethics: the “no one was harmed” defense ○ Kampmeier: The subjects were not worse off for being in the study ■ A) Neosalvarsan was probably worse than no treatment ■ B) Penicillin was the most effective for primary syphilis ■ C) Many poor African Americans in Alabama would not have gotten penicillin anyways ● Responses: ○ As A and B were true the researchers didn't know it ■ They should have been given penicillin ○ 12.5% of subjects could have been held by penicillin ○ Doctors agreed to never treat subjects with antibiotics ○ They were lied to and told it was “treatment” for “bad blood” ○ No informed consent until after 1960s. ● Genetic Disease ○ The Human Genome Project: 19902003 AGCT ■ Located most of the 25,000 genes ○ 15 million Americans have genetic diseases ○ 2009: the Genetic Information Nondiscrimination Act became law ● Huntington’s Disease ○ A fatal neurological disorder ○ Huntington discovered it, used to be ccorea ○ Purely genetic ○ Onset: 3544 ○ There’s no treatment or cure ○ About 25,000 Americans have it ○ Many more are at risk ○ 1983→ genetic marker was found ○ 1993→ gene was found; 60%80% of people at risk said they would take test ○ Only 1% took it ● Involuntary Psychiatric Commitment: ○ In 1970s, over half of the mental patients in the US were released ■ Many became homeless ○ 1953: 75% in mental institutions; 25% in prisons ○ 2007: 3% in mental institutions; 97% in prisons ○ Why were so many people released? ■ O’Connor vs. Donaldson (1975): the Supreme Court ruled that to be involuntarily confined, you must: 1) Have a mental illness. 2) Be dangerous to yourself or others ■ This now applies to sex offenders ○ Most states also say: ■ 3) facilities must be as unrestrictive as possible ○ More reasons for release: ■ New antipsychotic drug made people better, thorazine ■ But these are only temporary treatments. ● Schizophrenia: ○ A form of psychosis; varying degrees of severity ○ 1%2% of the population has it ○ NOT Dissociative Identity Disorder ○ Onset: late 20s ○ $65 billion to treat it per year ○ Symptoms of Schizophrenia: ■ Auditory (and other) hallucinations ■ Delusions ■ 10% suicide rate ○ John Nash “A Beautiful Mind” ● Prudy→against reproducing if you have the disease ● McMahan→bad to have disabled child instead of healthy, genetic testing is good.
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