You have been appointed Director of Public Relations and Ethics at County Hospital.
The hospital is facing several urgent situations regarding the following issues. Your Stand- Alone Project responses should be both grammatically and mechanically correct and formatted in the same fashion as the project itself. If there is a Part A, your response should identify a Part A, etc.
2. Germline Experimentation
3. Randomized Clinical Research
4. Rationing Health Care
5. Organ transplants
Part A White Papers: You are charged with preparing white papers on these topics. White papers present various positions, explaining the strengths and weaknesses of each; they do not give or defend the authors position. Using the Required Readings, your textbook, and articles and Web sites you find by doing your own research, write a two-page paper on each of the topics listed above. Include a bibliography formatted in APA style.
Part B Questions and Rationales: You must also instruct the hospitals Ethics Committee to discuss these issues in depth and revise the hospitals ethics handbook. As part of your work with the Ethics Committee, you must draft three (3) questions that will guide Ethics Committee deliberations for each of the five (5) topics (15 questions total). For each question provide the rationale for the question.
Part C Press Release Flyers: In aIDition to the white papers, you are charged with preparing 1-page summaries of your own position on each of these topics in the form of a flyer that clearly states hospital policy and the rationale behind it. (In real life, this flyer would state the position and rationale of your ethics committee.) A suggested outline for these summaries is as follows:
1. State the position clearly in one paragraph.
2. Allot one paragraph for each ethical position, giving reasons for and against each of them.
3. Restate your position and give persuasive arguments for it.
4. Indicate that hospital personnel are available to discuss ethical issues with family members.
There was a time not long ago when doctors could offer only limited help, but they dispensed that help generously to their patients. Today, doctors have amazing medical resources, but they are limited in supplying them by scarcity and economics. How, for instance, do they decide whether a patient gets a liver transplant? First, they have to determine if the patient is a good candidate for organ transfer. Then they have to locate a liver donor or apply to an organ
registry. They also have to consider how the surgery will be paid for since they will need approximately $100,000 to cover the expense.
What should doctors do? Should they follow the market approach and allot treatment to those who will pay the most for it? Should they decide on the basis of medical need? Should they depend on a committee to make the decision? Should they depend on a lottery system or an HMO to make decisions regarding allocating treatment? Or should they follow the customary approach, which is a bunch of practices that mask the fact that treatment is being rationed? Each
of these approaches has its advantages and disadvantages.
The market approach is consonant with the free market economy. It simplifies the choice because the transplant goes to those who can pay for it, either with their own money or with insurance. Many libertarians feel comfortable with this idea because people would get the care that they have earned and deserve. Many of us would be troubled if society followed this option exclusively. It is, however, a component of the customary approach discussed below.
The medical-need approach would allot organs by giving priority to patients who most need them to stay alive. It would be supported by a prognosis on the patients likelihood of recuperating to live a healthy life. According to medical need, a 93-year old man who would almost certainly die with a transplant would have priority over a 30-year old woman who could live for six months without a transplant. According to medical prognosis, the woman would receive the transplant.
The lottery approach is another simple approach to rationing transplants that guarantees a kind of fairness because it treats all seekers of expensive and scarce treatment equally. This approach may be too simple because it does not take into account the seriousness of need, the likelihood of success, the length of time on a waiting list, or the persons age or importance to their families and society. On the other hand, everyone would have an equal chance of receiving
The committee approach merely moves the decision making from a doctor to a
committee without dealing with underlying ethical concerns. The committee is likely to reflect the arbitrary biases of its members. It does, however, distribute feelings of guilt and gives its members a feeling of justification because ones judgment is supported by ones peers. The customary approach, on the other hand, offers some comfort to the medical establishment. It conceals the reality that people are denied treatment because of rationing and conceals reasons of
economics and bias that shape the rationing. In short, it does not rock the medical status quo.
For these reasons, the customary approach will remain in place with only minor
modifications until situations, interest groups, and individuals mount campaigns for more
transparency. This is the ordinary course of democracy: Elites make decisions for their own benefit until people make them decide for the benefit of ordinary people.
One practical decision-making strategy for allotting organ transplants or other scarce and/or expensive procedures is an explicit or implicit checklist. Using such checklists, doctors, committees, and HMOs automatically disqualify certain groups of people from receiving them.
Such people might be excluded on the basis of: age, criminality, drug or alcohol abuse, mental illness, likelihood of medical failure, quality of life, low social standing, or lack of insurance.
Carl Cohen (as cited in Card, 2004) argues that there are no special reasons that should automatically deprive alcoholics of liver transplants, a position with which many Americans disagree as evidenced by the furor that erupted when Mickey Mantle, an alcoholic, got a liver while those who had not been alcoholics went without. Daniel Callahan (as cited in Card, 2004) argues that scarce treatments should not be allocated to people who have completed their
productive life spans because society owes people a good life, not a long life, and because giving old people those treatments will deprive younger people of opportunities for a full life. He believes that old age is meant to be a time of reflection and making peace with inevitable death.
George Annas (as cited in Card, 2004) considers ideas for deciding between prostitutes, playboys, poets, and other reprobates. He says the process should be fair, efficient, and reflective of important social values (p. 458). He believes that the initial screening should be based exclusively on strict medical criteria. The secondary criteria should minimize social worth criteria and move toward a randomized method of selection, for which he prefers a modified first come, first served procedure. For example, every prospective kidney recipient would first be typed with prospective donated kidneys on the basis of compatibility and likelihood of successful outcomes. After the first selection had been completed, the prospective recipient who had been on the list the longest would be awarded the transplant.
On controversial measures of distributive justice, such as the allocation of medical resources, conflicting moral and economic stances prohibit our assuming any common moral consensus. Rational ethical consensus needs to be constructed with careful attention to all points of view and the details of particular situations. General ethical considerations must be balanced against each other in making such decisions. For these reasons, an ethics committee composed of broadly represented stakeholders should probably be consulted in the allotment of scarce medical resources. In such a committee, political considerations would either be sublimated to ethical ones or, at least, would be balanced among competing interests.
A doctors ethical decision making is more difficult in the United States than it is in the United Kingdom. The British National Health Service provides universal health care to all citizens, but it makes explicit what medical procedures will not be supported. More elaborate xray, MRI, and Cat Scans are not supported, for example, under the justification that their cost would subtract from the care provided to the remainder of the population. In other words, medical resources are rationed. Of course, the miIDle class and wealthy can fly to countries such
as Belgium and receive any treatment they can afford to pay for, so health care is really only rationed for the working class and the poor.
American doctors are pressured on both sides: by their patients to provide treatments of questionable worth and by HMOs and hospital administrators to limit the use of expensive tests and treatments. In the U. S. the cost-containment role is taken over by a number of organizations such as HMOs that pressure hospitals and doctors to limit expensive procedures. A doctor risks his livelihood and practice if he or she continually orders tests and procedures that are discouraged by HMO accountants. Doctors and hospitals are also financially rewarded if they spend less than the amount set by the HMO. Thus by means of operant conditioning, they are taught to provide their patients less service than might be appropriate. Some authors believe that this conditioning turns doctors into double agents who slight their patients in favor of HMOs and other institutions.
In this connection, an Oklahoma study (Khalig, Broyles, & Robertson, 2003) found that insurance status, prospective payment, and the unit of payments make a difference in the length of hospital stays. Medicare-insured, Medicaid-insured, and the uninsured experience significantly shorter episodes of hospitalization than their commercially insured counterparts.
These shorter stays were found to contribute to physician-induced (iatrogenic) injury. This study and many others argue that medicine in the United States needs to find a different method of financing. Whatever happens, however, the chances are that, because of the progress in treating chronic diseases and Americans high expectations, the cost of health care will continue to rise
no matter who pays for it. Another reason that medical costs are high in this country is the American tort system.
Premiums got so high in West Virginia because of the thousands of law suits against doctors that physicians staged a 1-day strike to protest. Worse, so many physicians have moved out of that state that people in some areas have to drive two or more hours to see a doctor. Two issues are important here. The first is the many unnecessary lawsuits that people bring against doctors, lawsuits that frequently cost insurance companies millions of dollars.
On the other hand, doctors, like the rest of us, make mistakes. For example, if a doctor sews up after an operation and leaves a clamp inside the patient, what should he or she do?
Ignore it and hope for the best? Wait until the patient reacts badly and then reopen? Cover up the incident? Confer with lawyers to design a defense strategy? Consult with accountants to see if his or her insurance premiums will skyrocket? Tell the patient and relatives what happened, apologize, reopen, and correct the mistake?
Thurman (as cited in Card, 2004) says that the barriers to admitting mistakes are:
1. The providers difficulty in confessing mistakes.
2. The fear of implicating other providers.
3. The possibility of liability exposure. (p. 484)
The first barrier has psychological force but no ethical force. We all make mistakes, but ethical
people admit and correct them as quickly as possible. Honest admission of mistakes is cheaper
than cover-up because cover-up aIDs fraud to mere malpractice and angers the patient or family,
who might then sue the doctor or hospital. Doctors are discouraged from speculating about the
behaviors and intentions of other providers. Instead, they should relate only their present
observations of a patient and not assign guilt to anyone. Both the national and state legislatures
are currently struggling to find a solution to medical liability that is fair to both doctors and to
patients who have truly been harmed. Some states, like New York and Pennsylvania, exempt
mere medical malpractice from punitive damages.
Knowing right and wrong was simple when we were kids. Right was what we were told
to do. Wrong was thinking on our own. As adults and professionals, however, we often find that
knowing right from wrong is more problematic because we are called upon to think for ourselves
and because many of the decisions we are forced to make are complex and emotionally charged.
In aIDition, we find that other adults and professionals do not always agree with our
moral opinions about controversial situations. In medical ethics, we face conflicting arguments
on real-life procedures like abortion, assisted suicide, euthanasia, genetic testing, germline
therapy, stem-cell therapy, research on human subjects, and rationing health care. We move from
a world of black and white into a world of grays. We inhabit a world of competing cultural
imperatives and moral entanglements.
Nevertheless, ideal rules for morality are part of every culture and tend to be universal.
We are all familiar with some of them:
1. First, do no harm.
2. Do unto others as you would have them do unto you.
3. The Ten Commandments
4. Mens sano in corpore sano (a sound mind in a healthy body)
Interpretations of these general sentiments, however, vary widely from culture to culture.
These variations can and do lead to conflicts as societies become more complex.
In ancient Greece 2500 years ago, Socrates insisted on questioning people about their
moral assumptions and was eventually asked to commit suicide for being irreligious. His
insistence on asking questions to get to a philosophical truth came to be known as the Socratic
Method. The method is skeptical, conversational, conceptual or definitional, empirical or
inductive, and deductive. Socrates was skeptical of common sense and tested it in conversations
that tried to define key terms. Each proposed definition was tested by applying it to real-life
situations using deduction in the form that says, if that is true, then the following should also be
true. Good examples of the Socratic Method are Euthypro, discussed in your textbook, and
Crito, in which Socrates decides not to escape his death sentence. His method of questioning has
been the driving force of Western ethics, philosophy, and science. His method and arguments
enter into present-day controversies such as voluntary assisted suicide. This method in various
forms underlies most of the research in this course.
Robert Card (2004) describes the relationship between morality and ethics as follows:
Ethics consists in the construction of a critically reflective morality. Ethics is
critical since it leaves itself open to examining and reexamining reasons from all
sources and disciplines. Ethics is reflective in that a conscientious moral agent is
constantly trying to achieve a delicate balance that takes into account the effect of
these reasons on his or her deepest values. By contrast, a morality, or set of mores,
is a set of rules, norms, or understandings that may be followed even by a nonreflective
person. So, while ethics is a form of morality, a morality is not
necessarily ethical. To consider ethics as a critically reflective morality highlights
the fact that ethics is a method of discovery and not strictly a body of knowledge.
Ethics does not consist of knowing the answers but instead of knowing how to
inquire. (pp. 44-45)
Your textbook describes major theories that try to systematize ethical decision-making,
including relativism, divine command, psychological egoism, utilitarianism, Kantianism, virtuebased,
and Rawls theory of justice. Each of these theories sheds some light on the playing field
of right and wrong, but none of them enlighten the whole field. We have to use all of these lights
to see clearly the relevant aspects of a particular moral controversy.
Seeing many aspects of a problematic situation is the first stage of sound ethical thinking
that sets up a dialogue among contrasting views. In this distance learning course, this ethical
dialogue will be mainly within your own head as you listen and respond to various arguments
presented in the Required Readings. In your life, the dialogues will also be with family, friends,
and co-workers. The work you do in this course should help you to dialogue effectively in real
The second stage of sound ethical thinking for us as individuals and as groups seeking
guidance in problematic situations is critical thinking. Just gathering conflicting information in a
controversy will only confuse us unless we can think clearly about that information. Questions
about euthanasia, for example, will remain confusing unless many distinctions are made and
thinking is directed toward every aspect of a particular situation.
How then do we make practical personal and communal ethical decisions?
In the past, we could trust our conscience, gut, or common sense. This is the timehonored
strategy of the human race that operates at a mostly subconscious level. This strategy
works for us personally because it reflects what we have been taught and our previous
experiences. It used to work socially because the people around us shared our common-sense
values. When they consulted their consciences, they could be expected to agree with us. This
manner of decision-making has the great virtues of authenticity, clarity, and resolve; in aIDition,
it primes us for action.
In the present, this strategy is more troublesome in the social arena because the people
around us are likely to disagree with us. When they consult their consciences, they may
advocate courses of action that we see as bad, or conversely, they may see our desired actions as
evil. They might, for example, decide to abort a fetus that has been diagnosed with a crippling
hereditary disease, whereas we might think their decision is wrong. We might decide to
experiment on human subjects, while they might think we are being immoral. In the
controversies that arise in such situations, we need to listen respectfully to one another and
reason our way to a practicalnot necessarily a theoreticalconsensus. The kind of thinking
required is critical thinking.
When we are thinking critically, we even-handedly evaluate arguments and their
conclusions on the basis of the truth of their premises and the validity of their logic. Robert Card
(2004) says that critical thinking [i]nvolves learning how to monitor your own thought process.
More particularly, it involves learning the standards for evaluating your own thinking and then
attempting to internalize certain tools to improve your thinking by constantly engaging in
reflection and self-assessment. It is important to note that thinking well is hard work!
There are two basic forms of argument: deductive and inductive. Deductive arguments
start with premises, which are accepted as true, and, using formal logic, derive conclusions,
which then also have to be accepted as true. (Ex: Major premise: All men die. Minor premise:
John is a man. Conclusion: John will die.) Deductive arguments can be opposed by questioning
the truth of the premises or pointing out flaws of logic. If the major premise or the minor premise
is false, then the conclusion will be false, but if both are true, then the conclusion must be true.
Card (2004) spells out the relationships between the following basic terms that are used
in analyzing arguments:
1. Description, inference, and normative statements
2. Propositions, premises, and conclusions
3. Assumptions, facts, opinions, and ideas
4. Meaning of and and or
5. Validity and soundness. (47-53)
Inductive arguments do not observe the criteria of validity and soundness as do deductive
ones. They make the more modest claim that the truth of their premises makes it likely that their
conclusions are true. We tend to use inductive arguments often to discern how we are to proceed
in novel situations. They can be based on statistics, probability, analogy, or cause and effect.
For example, if you lent Robert money on two different occasions, and he never paid the money
back, you might conclude, based on the evidence, that Robert doesnt pay loans back.
Spotting the informal logical fallacies in arguments is both fun and torture during
controversial times such as election campaigns. How often do we hear one person assert a point
and his or her opponent avoid that point by attacking (ad hominem) the asserters personality?
How often do we hear parties appeal to common belief as being the truth when ample evidence
shows that the common belief is unfounded? How often do people invoke the authority of some
well-known person who has no expertise concerning the controversy under discussion? How
many hasty generalizations do we hear? How many ways are statistics spun? How many false
dilemmas are hurled about? How many times do politicians beg a question by assuming exactly
what they are trying to prove? How many times do politicians drop in a red herring to divert
attention from an embarrassing situation? How many times do we argue against change on the
basis that going just one step would put us on a slippery slope to disaster? How often do we
twist the meaning of an opponents words (equivocation) in order to gain advantage? And how
often do we argue that the way things are is obviously the way they should be? While we laugh
and gnash our teeth at the blatant use of fallacies in political discourse, we also realize how
effective these fallacies can beif they are not pointed out.
People get elected partially because they convince us with faulty arguments. Similar
misuses of logic occur in medical systems. What we learn in this course will enable us to point
out these abuses of logic when they come up in our lives and workplaces. Ideally, the clarity of
our thinking should lead to constructive changes and personal promotions to more responsible
positions. In reality, we have to learn patience and sharpen our political skills. We need to
remember that a big ship can be turned only a degree at a time.
Using the ethical perspective discussed in Chapter One of the text and the critical
thinking tools of Chapter Two, you should be able to work your way to reasoned conclusions on
many medical controversies. In the following assignments, you read examples of critical
thinking and construct arguments for your own conclusions. With practice you will master the
tough art of critical thinking and gain moral independence for your own opinions.
Couples hope to have healthy babies with an opportunity for a good life. Unfortunately,
approximately 10% of couples in the United States are infertile. Other couples face the
likelihood of birthing children with grave physical disabilities. Still other couples may want to
design a certain kind of offspring. Today and tomorrow, these couples, with the aid of new
medical advances, can achieve their desires. But, what are the ethical concerns in the
development and use of these medical technologies? Are the advances ethical? Which ones?
What are the personal and societal consequences of the different procedures? What are their
The earlier forms of assisted reproductive technologies (artificial insemination, in vitro
fertilization, and different forms of ovarian stimulation, implantation of ova and zygotes) have
been debated and have generally passed medical ethical approval. In this assignment, we explore
the ethics of:
1. Prenatal diagnosis for disease and sex.
2. Whether information should be open to parents and the public, especially insurance
3. Whether abortions should be performed on the basis of the babies sex or health.
4. What genetics can do and should do to produce healthy and/or exceptional children.
In its broadest terms, the controversies over genetic intervention pit conservatives who
value prenatal life and traditional and natural processes against progressives who envision a new
and more humane future with less suffering. Historically, new methods of reproduction raise
fear and condemnation that gradually lessen as they prove to be reliable and produce healthy
babies. There may well come a day when cloning and eugenics are accepted practices, but we
must first evaluate the ethics of these and other procedures.
The general benefits of the new medical technologies are that:
1. They enable couples to have children.
2. They enable disease-free children.
3. They promise revolutionary cures for many intractable diseases.
The possible downsides of these new technologies are that they may:
1. Weaken peoples reverence for life.
2. Weaken respect for religious authority.
3. Encourage women to have abortions.
4. Put society on the slippery slope to horrors such as eugenics.
If new medical advances in human reproduction are permitted, they raise new questions
in medical ethics:
1. For what situations are they ethical?
2. How can we avoid abuses and slippery slopes?
3. How should applications of these technologies be regulated and/or monitored?
When a prenatal diagnosis is performed, important, sensitive information such as genetic
predispositions to certain diseases is generated. Some argue that this information should not be
generated or at least not be revealed to either the childs parents or the public. They believe that
this information will tempt parents and doctors to play God, to try to design the perfect child, and
to have abortions. Others argue that the sex of the fetus should be withheld because of possible
parental sexist preferences. Still others would say that this sensitive information should not be
made public because it could influence the childs employment possibilities and his or her ability
to obtain affordable insurance later in life.
It should be granted that detailed prenatal diagnosis may result in a higher percentage of
healthy babies and fulfillment for childbearing couples. It should also be granted that this kind
of diagnosis will lead to inevitable abuses in a free society interested in knowledge and profit. It
will be practically impossible to keep this kind of knowledge secret for ordinary people. The
ethical question is, How can we foster good uses of prenatal diagnosis and discourage its abuses?
Somatic cell therapy extracts a population of cells from an individual; removes a
defective gene from that population, replacing it with a healthy gene; and returns the geneengineered
cells to the patient. This process should render treatable many genetic diseases that
are caused by a defect in a single gene. This therapy would seem to be ethical because it is
supported by the fundamental moral principle of beneficence: it would relieve human suffering.
Should the same ethical approval be extended to germline gene therapy, which replaces
genes in sperm, ova, and cells that give rise to sperm and ova? This kind of therapy could ensure
that later generations would not inherit a particular disorder, yet some people argue that this
process is unethical because we would be playing God. It would, they argue, be a prelude to
eugenics, not only to removing disease, but also to genetic engineering in the service of creating
super people. (Most people are aware of Hitlers desire to create the Aryan race, but few are
aware that Charles Darwins cousin, Francis Galton, introduced the scientific argument for
eugenics or that mentally handicapped adults were sterilized in the United States in an attempt to
keep them from having handicapped children of their own.) Still others argue that the process is
too dangerous. In our present state of knowledge, we could alter the course of embryonic
development, for example, by interfering with the work of natures time-tested housekeeping
genes and produce severely handicapped children.
Advocates of germline gene therapy argue that we have always tried eugenics in some
form, as by seeking a desirable mate, and that we have always resisted more aggressive eugenic
efforts in the past. They also argue that our understanding of genetic processes is somewhat
intelligent, and our ability to treat unexpected consequences is somewhat developed. Therefore,
they say, any unforeseen results can be taken care of. Moreover, these advocates argue that
medicine itself has a prima facie duty to pursue and employ germline gene therapy because it
offers us the chance to rid ourselves completely of many serious genetic diseases for which there
is no effective treatment.
Cloning humans was once the stuff of science fiction. It is now a real probability. This
probability is proof for many that science has gone too far in its God-playing. The idea of
creating replicas of ourselves raises in our imaginations nightmarish possibilities. How could a
person raise his or her identical twin? Would people use their clones as part shops that they
could dismember at will when their own body parts wear out? Would we sell clones of gifted
people to the highest biIDers? How many cloned embryos will have to be discarded because of
serious defects? How do we know that the clones would not have major defects? Wouldnt
cloning lessen the worth of individuals and diminish respect for life?
Much of the fear of cloning lies in a misperception that persons with the same DNA will
be identical. This is not even true of natural identical twins. It would be less true of a clone
because of the different uterine environment, mitochondrial differences, a different growth
environment, and a different will to live. A clone of Michael Jordan might face pressure to be
good at basketball, but he would not be Michael Jordan; he would be himself.
In certain circumstances, a couple might decide upon cloning to have offspring that are
biologically similar to them. Do they have a right to clone? Cloning might allow couples to
have offspring that are free from hereditary diseases. Cloning might also allow a person to
obtain needed organs or tissue for transplantation. Cloning might allow the duplication of
individuals with great talent. It might also make possible important advances in scientific
knowledge. These are all, arguably, human goods, mostly minor, that could be provided by