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BU / Philosophy / phil 148 / What are the 3 angles to philosophy?

What are the 3 angles to philosophy?

What are the 3 angles to philosophy?

Description

School: Binghamton University
Department: Philosophy
Course: Medical Ethics
Professor: Anthony preus
Term: Spring 2019
Tags:
Cost: 50
Name: Study Guide
Description: Medical Ethics exam one split up into case presentations, important people, and important concepts by section of Munson's textbook. Combined is discussion notes, lecture notes, and notes from readings.
Uploaded: 02/21/2019
18 Pages 44 Views 3 Unlocks
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Test: Tuesday, February 26th


What are the 3 angles to philosophy?



Medical Ethics Introduction

Main concepts:

● 3 angles to philosophy:

1. Focus on act: “right”

2. Focus on results: “good”

3. Focus on person: “virtue”

● What is medical ethics?

○ It's what doctors think they should do.

● The Hippocratic Oath

○ “Whatever I see or hear, professionally or privately, which ought not be divulged, I will keep it secret and tell no one.”

○ Considered “the benefit of the sick” 


What is medical ethics?



○ Aim is to prevent harm of a patient

○ Confidentiality clause (protecting the privacy of the patient)

○ Dietetic remedies were emphasized, not surgery

○ No abortion (now revised) Don't forget about the age old question of Huntington disease affects what parts of the brain?
We also discuss several other topics like What is an omnipotent being?

○ Nothing is said about client choices

○ Animal rights -> because of pythagoras of samos… reincarnation

● AMA (American Medical Association) principles

○ Competent in medical care with compassion and respect 

○ Honest, report physicians which are deficient

○ Privacy of patients


What are the three formulations of the categorical imperative?



○ No explicit recognition of patient, self-determination, although updated since the Hippocratic oath

● Patient Bill of Rights

○ 2010 Affordable Health Care Act: focuses on health insurance availability ○ Association of American Physicians & Surgeons We also discuss several other topics like What is carbon dioxide used for?

○ NY State, part of regulation

● Basic goods

○ “Life, liberty, pursuit of happiness” 

○ Self-actualization

○ Pleasure (hedonism)

○ Greatest happiness of greatest number of people (utilitarianism)

○ Friendship, community

● Goals of medical practice

○ Health

○ Life

○ Quality of life

○ Evolutionary practice -> importance of religion

■ Divine law 

■ Natural law (God’s law as discovered by reason) We also discuss several other topics like Which part of the brain is the primary site for the receipt of visual input?

○ Legislation

● Two kinds of justice:

1. Legality: following the rules, whatever the rules are

2. Fairness: give everyone what is appropriate to have

● Informed consent

○ Genuine deliberation requires both info and understanding

○ It is voluntary, requires competence of patients

○ On a sliding scale -> as the possible risks of a study become worse, a higher level of competence is need to understand a case Don't forget about the age old question of What is the relationship between density and molar mass?

● FDA

○ 1906: pure food and drug act

○ 1938: food, drug, and cosmetics act: requires testing

○ 1962: Kefauver-Harris Amendment: regulation of clinical trials

■ Thalidomide: drug developed in Europe used to fight headaches. In the U.S. it was prescribed to pregnant women with discomfort but it had

adverse effects -> causing birth effects Don't forget about the age old question of What are the terms pertaining to the different levels of ecological organization?

○ 1987: compassionate use and expanded access

Case Studies:

○ Jeremy Bentham (1748-1832)

■ Main practices: consequentialism (the study of actions based on their consequences), utilitarianism (actions are right when they benefit the

majority)

■ Argued that the only thing good is pleasure and the only thing bad is pain ■ We want to maximize pleasure and minimize pain (cost-benefit analysis) ○ John Stuart Mill (1806-1873)

■ Worked alongside Bentham

■ You can interfere with the will of others to protect yourself or others

{preventing x from hurting y}

■ Argued that freedom of choice (autonomy) is of such importance that it can be justifiably restricted only when it can be shown that unregulated choice would cause harm to other people

■ Wrote a book on what the standard view of utilitarianism is about

■ More in depth analysis than just pleasure and pain -> there are

qualities/levels of pleasure 

■ Pleasure, usefulness {even if it’s painful} and nobility (pursuing beauty)

Important People:

● Kant (1724-1804)

○ 2 premises:

■ People are free

■ People are essentially rational

○ 1 conclusion: UNIVERSAL LAW (Categorical imperative)

○ Categorical imperative: 

■ The fact that we’re free let’s us step out of emotions and desires -> Kant says we’re only free when we’re out there, which means we need

■ The essence of moral is consistency on a very high level of rationality ■ It must affirm the universal system of law

■ treat humanity NOT as a means in itself

■ Respect human beings as equal to yourself -> don’t use a patient for an experiment

○ Rationality: to tell us what to do

■ Everyone in the same situation would do the same thing -> therefore, I should do whatever I would want everyone else to do (CI)

■ System of rationality: “kingdom of ends”

○ Kant cares about reason for acting and public opinion of that act, NOT consequences. Cares about intentions.

○ 3 categorical imperatives:

■ CI: universal law -> personal

● Will to be universal law

● {would i want to live in a world where this is a law}

■ C2: never treat a person merely as a means

● Interpersonal

● {using someone else as a tool}

■ C3: kingdom of ends

● Societal

○ Kantian Moral theory:

■ Act only in the way that you would want to be a universal law

■ Moral justness is split up into three groups, each with different

philosopher associations:

● Good intentions: Kantian

● Avoid harming others: J.S. Mill (utilitarianism)

● Good consequences

○ Application of Kant’s studies:

■ Autonomy 

■ Respect for persons

● W.D. Ross (1877-1971)

○ Tried to bring together utilitarianism and logic 

○ We can derive a set of prime facie duties through:

■ Fidelity

■ Reparation

■ Gratitude

■ Justice

■ Beneficence

■ Self-improvement

■ Non-maleficence

● Robert Nozick (1938-2002)

○ Priority of procedural justice 

● John Rawls (1921-2002)

○ Each person should have the greatest liberty compatible with smaller liberties for everyone else

Munson Chapter 1: Cases and Contexts

1.1

Case Presentation

● Donald (Dax) Cowart Rejects Treatment

○ July, 1973 - Texas

○ He was impaired

○ Lawyers, his mother, and doctors were paternalistic and override his autonomy ○ After the fact he still wishes they’d let him die

○ Dax is unemployed after the airforce, he drives up to the country with his father for the weekend. On the way there, their car caught on fire due to a leak in propane gas transmission line.

○ Don was convinced that physicians at the hospital let his dad die.

○ Mr. cowart had deep burns (65%) of his body and his eyes were removed. ○ His father filed a lawsuit against the owners of the propone transmission line. ○ Don wanted to die but was treated for 10 months

○ When he moved out of the hospital he tried to kill himself with an overdose and then changed his name to Dax

○ Main takeaway: an individual should be able to decide what minimum quality of life is acceptable

○ “Please let me die”

○ Issue of quality of life

○ Lawyers wanted Dex to live because of the monetary benefits

● Kara Neumann

○ Kara Neumann (11) couldn’t walk or speak

○ Parents didn’t get help because they’re religious

○ She was pronounced DOA when she got to the hospital from her T1D ○ Parents are accused for reckless homicide

● Robyn Twitchell (2)

○ But her parents are Christian Scientists

○ His parents were charged with involuntary manslaughter

○ There is a spiritual-healing exemption law in most states that make it hard to arrest Christian Scientists

Important Concepts

● Autism and vaccination

○ The state has the right to requires vaccinations of children because of Jacobson v Commonwealth of MA 1905 (smallpox vaccination)

○ MMR vaccine was correlated with a rise in Autism although this was faulty ■ Wakefield had a conflict of interest because he had a with a competing vaccine for this disease (financial interest)

■ Thimerosal with mercury or vaccination without did not make a difference in autism rates

■ The claim that “vaccines damage the immune system” is ridiculous

○ Most scientists don’t think the increase in the number of reported cases of autism represents a genuine increase in the number of actual cases of autism

● Vaccine injury fund: deal with death and injury claims alleged to be connected with vaccines administered after October, 1988

○ The idea behind any vaccine is that injected proteins will trigger the immune response... But this this is very wrong obviously

● Herd immunity:

○ the greater percent of people in a population who are immunized against a given disease, the less likely that its infectious

○ Serves as a barrier to protect a population from the ravages of infectious diseases ○ When enough people are vaccinated disease spreads less

● Jacobson V. Mass:

○ Addressed the issue of whether the state’s requirement that everyone be vaccinated for smallpox violated Jacobson’s “inherent right” to “care for his own body”

○ Addressed the issue of whether the state’s requirement that everyone be vaccinated for smallpox violated Jacobson’s “inherent right” to “care for his own body”

● HPV Vaccine -> hope or hype?

○ Cervical cancer is the most common of the cancers caused by HPV

○ Gardasil -> vaccine attacks 4 strains of HPV

○ Meck’s marketing strategy required the company

● Placebos

○ If you believe something is going to work it has a more likely chance of working ○ They can benefit the patient

● Food insecurity aspect

○ Cheaper foods are usually less healthy -> unavailability of good food

Moral topics

● Moral theory: makes people think about ethics

○ Most abstract: metaethics

■ What is the nature of morality?

○ Middle: normative ethics

■ How should I live? Aka choices

○ Least abstract: applied ethics

■ Medical ethics

■ Political, environmental and business

● Branches of medical ethics:

○ Professional ethics:

■ Rule following “is”

○ Philosophical ethics:

■ Which rules should there be?

■ {questions rule following:

■ What “ought” to be

● Autonomy: “self-determination”

○ Testing autonomy:

1. Through administering a test with a large set of data (norm) compared to the individual. BUT this assumes that the average person

2. Observe his values, knowledge, and beliefs to see if he makes morally just decisions BUT this assumes we know what is morally just (we could

advance a moral theory)

○ Three-condition theory:

■ Intentionality- originating your actions

■ Understanding

■ Non-condition: you’re not controlled by someone else

○ Varieties of consent:

■ Explicit: everything is said and informed

■ Implicit: not everything is asked permission

■ Presumed: if you have someone who’s unconscious, assuming they would consent if they could

○ Competence:

■ “Where we draw the line depends on the particular tasks involved” ○ Standards of incompetence:

■ Express a choice

■ Understand a situation and its consequences

■ Understand relevant information

■ Give reason

■ Gave rational reason

■ Give risk/benefit reason

■ Reach a reasonable decision

○ Temporal alteration:

■ Consent can change all the time you can’t assume that consent will continue indefinitely

○ Autonomy is NOT as absolute value because it relies on other people

● When we talk about any action we discuss:

○ Means (action) ---------------> ends (goals)

1.2

Important Concepts

● Paternalism:

○ Inference of a state or individual with another person, against their will (but not necessarily) and defender or motivated by a claim that the person interfered with will be better off

○ acting in a way that is believed to protect/advance the interest of a person, even if acting in this way goes against the person’s own immediate desires or limits the person’s freedom of choice.

○ “Father knows best”

○ “Other determination”

○ Branches:

■ Strong: determining the ends for you

■ Weak: determining the means for you

○ State paternalism:

■ the control exerted by a legislature, agency, or other government body over particular kinds of practices

○ Personal paternalism:

■ an individual’s deciding, on the basis on his own principles or values, that he knows what is best for another person

○ Pure paternalism:

■ Directed internally to the interest of the person acting upon

○ Impure paternalism:

■ Interest of the person exercising the authority {for self-interest}

■ What’s the extent?

● Informed Consent:

○ Several specific conditions must be fulfilled:

■ For consent to be morally and legally meaningful individuals must:

● Competent to understand what they are told about their condition

and capable of exercising judgement

● Provide relevant information about their illness opportunity to ask

about treatment

● Alternative treatments (including no treatment)

● Freedom to make a decision

○ Before 1972, the standard was generally “professional standard of care”

○ Challenges:

■ Battery: unauthorized touching could be charged as a crime

■ Malpractice: unauthorized treatment that turns out badly can lead to a suit for damages

1.3

Case Presentation:

● Tarasoff Case

○ California Supreme Court rules that therapists at the student health services of U.C. Berkeley were negligent in their duty to warn Tarasoff that Prosenjit Poddar had threatened her life.

○ Duty to warn

○ Poddar thought him and Tarasoff were engaged, when Tatiana rejected him and he shot her. Someone should have warned Poddar was after her or keep

confidentiality. The university had to pay.

● The vegan baby

○ Iice Swinton was fed pureed vegetables not breast fed

○ When she 1.5 child protective intervened and took her to the hospital

○ She recovered but with neurological problems

● Jehovah’s witness emergency blood

○ JW refuses surgery, goes unconscious, surgeon operates and gives blood ○ The problem here is adherence to the consent given by the patient

○ Using experimental artificial a blood may be an option

Important Concepts:

● Psychiatrists are mandated reporters BUT only for one who takes care of the child so, they’re encouraged to, but not required

● Christian scientists

○ Typically, physicians will seek the assistance of social services to be authorized to treat

○ Parents need to show that the child has been “harmed” and that’s not all here ● Transparency model

○ “A reasonably informed patient is allowed to participate in the medical decision to the extent that the patient wishes”

● Reasonably informed

○ Basis on which the proposed treatment has been chosen

○ Asking questions on that treatment

● Right to suicide

○ Lots of extensive suffering -> you have a right to end this suffering -> therefore, if the only way is to end your life, that’s what should happen

Court cases:

● Cobbs V. Grant:

○ 1972

○ Rejected the “customary professional practice” standard

○ Denormalized the medical practices that everyone is doing must show that someone consented

○ Started protection against malpractice through consent forms, informed, and voluntary

● Canterbury v. Spence

○ Battery -> negligence

○ “All risks potentially affecting the decision must be revealed”

○ Consent must include this

● AMA has a list for informed consent including:

○ Patient’s diagnosis

○ Nature and purpose of treatment

○ Risks and benefits

○ Alternatives

○ Risks and benefits of not receiving/undergoing a treatment/ procedure ● Since lawsuits are triggered when patients suffer harm, disclosure of benefits ● MDs consider it more important to document what they said to the patient than how the doctor used or thought about the information

Munson Chapter 2

Case Presentation:

● First face transplant

○ Isabelle Dinoire (38)

○ Most common criticism: Dubernard’s group had rushed the transplant and she would have to take immunosuppressive drugs for the rest of her life and Dubernard’s group had selected the wrong sort of patient for a transplant ● Abigail Alliance v. FDA

○ Supreme Court 2008: terminally ill patients have NO right to gain access to exp. Drugs. This upheld FDA legislation.

○ Abigail 19, cell cancer she could not be included in a clinical trial of a 3rd drug. She died.

○ He father founded the Abigail Alliance for Better Access to Developmental Drugs in Nov. 2011

■ The alliance’s aim was to change FDA policies to give terminally ill people easier access to investigational drugs that might benefit them

○ Right to try law:

■ Abigail alliance persuaded a majority of states to adopt these laws, signed 2018 by Congress and Trump

■ Opposition:

● Weakens enforcement power of FDA

● For new medications for rare diseases, “right to try” makes it hard

to carry out a scientific test, because few want to risk being on

“placebo” or “alternative” arm

● Dr. Klingman and his test subjects

○ Dr. Kingman 1966 clinical trials at Holmesburg state prison, PA

○ 70 prisoners were exposed to dioxin, a major component of Agent Orange ○ Informed consent at Holmesburg seemed more a formal ritual than a genuine process for protecting autonomy and showing respect for persons

● Tuskegee syphilis study

○ Revelations about the deception, exploitation, and harm caused to individuals in this federally sponsored study produced a public and political furor

● Patrick Harison, 2015

○ 41 volunteer firefighter, Mississippi now lives with the face of a 26 year old ○ The most extensive face treatment in history

● Baby Fae

○ Baboon heart implant -> 1st infant subject

○ Hypoplastic left heart syndrome

○ Died 21 days after transplant from kidney infection

○ Consent doctor did not include the possibility of searching for a human donor ○ Possible benefits were extremely overstated

● Hans Jonas

○ Scholar of ancient philosophy

○ Had an issue on how the individual relates to society

○ Cannot afford to let epidemic range unchecked

○ Excess of birth

○ Low life expectancy

○ Progress as supererogatory vs conscription of consent

○ Fundamental privilege of the sick: no research on unrelated items

○ Double blind issues

● Rawls

○ The difficulty with utilitarianism with respect to human experimentation is that the principle of utility would permit the exploitation of some groups for the sake of others

Important concepts

● Richard Brandt

○ Justifying what it is good not through intuition/theories about moral words mean but by the explanation of moral psych

● Norman Daniels

○ Studied Brandt and Rawls to one theory

○ Health care research

○ Reflective equilibrium

○ Concerned about:

■ Nutrition

■ Exercise, rest, lifestyle

■ Non-medical

■ Sanitation and safe living/working conditions

■ Medical services

■ Support systems

● IRBS

○ Were established to review human research projects and rules to protect confidentiality and enable informed consent were introduced

○ Required to gain FDA approval

● “Presumed consent”

○ The patient would have consented to the intervention if, under the condition to make a decision

● Medical neglect vs medical abuse

○ When persons fail to take reasonable steps to secure the welfare of their children, doing so becomes a matter of interest to the state

● Fetal neglect vs fetal abuse

○ Alcohol and drug consumption during pregnancy by giving her an inactive substance in the guise of an effective medication

● Information privacy

○ Confidentiality

○ Secrecy

○ Anonymity

○ Accountability

○ Data protection and security

○ Professional norms

● Physical privacy

○ Solitude

○ Bodily modesty

○ Bodily integrity

○ Associational privacy

○ Proprietary property

● Privileged communication

○ Cannot be used as evidence in court

● HIPAA regulations

○ Patients have the right to examine their records.

○ Medical information cannot be disclosed to an employer without explicit authorization.

○ To use medical records for research can be against confidentiality. ● Utilitarianism

○ Autonomy justifiably restricted only if choices would harm others ○ “The greatest Happiness Principle:” those actions are right that produce the greatest happiness for the greatest number of people

○ Types:

■ Classical: vacations produce most happiness= right

● happiness= pleasure > pain

● no action is inherently wrong

● thus anything can be justified if it provides more pleasure than

pain

■ Act: principles of utilitarianism should be applied to acts, an act is right if there’s no other act that can produce better consequences

● benefit: sensitive to circumstances

● costs: no real way to know the cost of an act, can lead to the

collapse of rules/social institutions

■ Rule: a rule is a right if there is no other rule that would produce more pleasure.

● Looks at matters in the long term, so rules should not sacrifice us. ● Benefit: more plausible, long term solution.

● Costs: best option may not equal most pleasure who defines rules

■ Preference: people have a plurality of preferences -> values change from person to person

● We can rank pleasurable things

● Benefits: everyone gets a say

● Costs: too many options leads to paralysis, not all desires are good, people have bad preferences, preferences always change, along

with life

● Consequentialism

○ Whether an act is morally right depends only on consequences

○ rightness/wrongness is based on consequences

○ Is it the ACTUAL or EXPECTED

○ Consequences that make an action right?

○ If actual: can easily by very wrong

○ If expected: you can be wrong also, but in a different way

○ Motives?

○ Utilitarianism seems to lack a principle of justice

○ Mill tried to derive justice from utility, but many feel that he and subsequent writers, have failed

● Deontological ethical theories

○ Divide command

○ Natural law

○ Kant

○ Russ

○ Advantages: acord with institutions

○ Disadvantages: duties to make world worse

● Contractarian theories:

○ Interpersonal relationships create an agreement of what’s right. I.e. marriage ● “Agent”- centered vs “patient”-center theories

● Hedonism:

○ Value of consequences depends on pleasure or pain

● What makes clinical research ethical?

○ Value -> what we’re hoping for unity, respect for persons

○ Scientific validity -> takes a certain care and attention to get a positive result ○ Fair subject selection -> not taking people of “lesser value”

○ Favorable risk-benefit ratio -> side affects vs how much good can be done ○ Independent review

○ Informed consent

○ Respect for enrolled subjects

● Belmont Report 1978

○ Principles:

■ Respect for persons

■ Beneficence -> good > bad

■ Justice

○ Applications:

■ Informed consent

■ Assessment of risks and benefits

■ Fair selection of subjects

● Nuremberg 1947

○ Nazis carried out unethical research on their subjects in concentration camps ○ Buchenwald

■ 1000 prisoners were infected with typhus. Tried to cure homosexuals with hormone shots, had inmates shot to study gunshot wounds

○ Ravensbruck

○ Dachau

○ Joseph Mengele

■ Experiments on children

■ “Angel of death”

■ Infected people with Malaria

■ Sigmund Rascher, M.D. experiments with freezing in icy sea water ○ Nuremberg code

■ Came up with principles of ethical research: studies must be based on animal experimentation and avoiding unnecessary physical and mental suffering and injury

● Helsinki declaration

○ World medical association 1964

○ Revised 1975 to include the idea of IRB

○ Subsequent revisions addressed placebo arms and especially international biomedical research

○ IRB must look at certain criteria:

■ Risks are minimized

■ Selection of subjects are equitable

■ Informed consent

■ Documentation

■ Data is monitored for safety

■ Privacy and confidentiality

● Vulnerable subjects

○ Children, prisoners, anyone who is naturally coerced, mentally disabled, pregnant ● Therapeutic vs non-therapeutic research

○ Therapeutic: involves patients who have a specific diagnosis and their medication specifically benefits them

○ Non-therapeutic: finding out effects without specific reason for testing a certain subject

● Phases of trials

○ Phase one: researchers determine a drug’s interaction with the human system ○ Phase two: controlled tests that help determine a drug’s effects on a person ○ Phase three: confirm the results of earlier efficacy tests and further identify any adverse reaction

○ Phase four: frequency of prescription, basically a follow-up, no longer in control of a clinical setting, keeping tabs on things

● Jesse Gelsinger

○ Had a mutation on x chromosomes, he underwent a phase 1 clinical trial at penn ○ Was the 18th person, thus the largest dose

○ Investigators failed to report liver toxicity in 4 patients prior to Jesse ○ Failed to acknowledge the death of 2 rhesus monkeys injected with a similar high dose “adverse event’ reports

● Radiation experiments

○ 1945: Manhattan project injection of plutonium into soldiers at oak ridge and patients at 4 of Chicago hospital

○ 1946-1953: AEC sponsored study conducted at the Fernald and Wrentham schools in MA. residents were fed quaker oats breakfast cereal containing radioactive tracers

○ 1997: clinton anti-secret tests. Radiation studies were clearly unethical on both factual and value grounds

● Willowbrook

○ Hepatitis studies in 1956

○ Questions of coercion, consent, and deliberate infection

● Pheniramine study

○ Boys exposed to substantial risk with no chance of benefits

○ Autism, treating institutionalized individuals

○ Parents did not get proper consent

● Letrozole trial

○ Ethical overkill?

○ Stopping the trial because letrozole worked, and the benefit should be extended to the women on the placebo arm (alternative to tamoxifen)

○ FDA approved for treatment to breast cancer

Court cases

● Griswold v. CT (1965)

○ There used to be laws preventing types of birth control

○ Yale law students took it to the supreme court and said women are allowed to use whatever birth control they wanted

● Role v. Wade (1973)

○ Abortion rights for women were legalized

● Bowers v Hardwick (1986)

○ Outruled homosexual activity, BUT was outlawed by Lawrence v. Texas (2003) who said anti-sodomy laws are unconstitutional

Important people

● Imhotep

○ Founder of Egyptian medicine

● Hammurabi

○ Set fees for how much surgery cost on a sliding scale

○ Consumer and patient’s rights were to be publicized

○ Explained, and made known to add

● Hippocrates

○ Father of Greek medicine

○ Epidemics (book) -> case studies of symptoms and outcomes

○ Empirical medicine

● Aristotle

○ Parts of animals

● Liasistratus

○ Alexandria in Egypt

○ Worked on the significance of the nervous and circulatory systems -> nervous system development

● Gallen

○ Massive corpus

○ Synthesis of ancient medicine and a fair amount of experimental investigation ● Ibn Sina

○ Canon of medicine, muslim

○ Suggests clinical trials of medication

● Maimonides

○ Poisons, hemorrhoids, cohabitation

○ Commentary on the Aphorisms of Hippocrates

○ Medical aphorisms ○ Three treaties of health ○ Treatise on Asthma ○ Glossary of Drug Names

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