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Ethical and Ethical and bioethical bioethical issuesissues

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Bioethics - what is itBioethics - what is it

• Bioethics is a specific discipline that probes the Bioethics is a specific discipline that probes the reasoning behind our moral life within the context reasoning behind our moral life within the context of the life sciences; how we decide what is of the life sciences; how we decide what is morally right or wrong biosciencemorally right or wrong bioscience

• Ethics is different from morals. Ethics tries to Ethics is different from morals. Ethics tries to probe the reasoning behind our moral life, by probe the reasoning behind our moral life, by examining and analyzing the thinking used to examining and analyzing the thinking used to justify our moral choices and actions in particular justify our moral choices and actions in particular situationssituations

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Bioethics – what is itBioethics – what is it

• Bioethics is normative ethics applied to the practice of Bioethics is normative ethics applied to the practice of science and medicine. It falls under the general group of science and medicine. It falls under the general group of applied and professional ethicsapplied and professional ethics

• It is predicated on an assumption that some solutions to the It is predicated on an assumption that some solutions to the ethical problems that arise in science and medicine are ethical problems that arise in science and medicine are more moral than others and that these solutions can be more moral than others and that these solutions can be arrived at by moral reasoning and reflectionsarrived at by moral reasoning and reflections

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Bioethics – what is itBioethics – what is it

• It is a branch of knowledge like mathematics, and thinking It is a branch of knowledge like mathematics, and thinking in this field is not wholly different from thinking in those in this field is not wholly different from thinking in those other fields, however it cannot be reduced to them. other fields, however it cannot be reduced to them.

• Bioethical conclusions cannot be unambiguously proved Bioethical conclusions cannot be unambiguously proved like mathematical theoremslike mathematical theorems

• Research ethics or more specifically health research ethics Research ethics or more specifically health research ethics is the branch of bioethics that deals with issues relating to is the branch of bioethics that deals with issues relating to the ethical conduct of researchthe ethical conduct of research

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History of bioethicsHistory of bioethics

• There was little broad interest in research ethics before the There was little broad interest in research ethics before the Second World WarSecond World War• Smidovich’s The Confessions of a Physician (1901)Smidovich’s The Confessions of a Physician (1901)• Public concern about Walter Reed’s yellow fever research in the Public concern about Walter Reed’s yellow fever research in the

United StatesUnited States

• The Nuremberg trial that followed the evil that was Nazi The Nuremberg trial that followed the evil that was Nazi war experiments which were marked by unprecedented war experiments which were marked by unprecedented cruelty and inferior science, focused attention on the need cruelty and inferior science, focused attention on the need for a code of research ethicsfor a code of research ethics

• Prosecutors argued that the experiments violated Prosecutors argued that the experiments violated fundamental ethical standards of civilized societyfundamental ethical standards of civilized society

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History of bioethicsHistory of bioethics

• The Nazi war experiments were more bizarre given that in The Nazi war experiments were more bizarre given that in 1931, Germany had enacted strict “Richtlinien” to control 1931, Germany had enacted strict “Richtlinien” to control human experimentation and the use of innovative therapies human experimentation and the use of innovative therapies in medicinein medicine

• Two of the 14 provisions of these guidelines concerned Two of the 14 provisions of these guidelines concerned consent requirementsconsent requirements

• Questions about nature of appropriate information, bona Questions about nature of appropriate information, bona fide consent, careful research design, special protections fide consent, careful research design, special protections for vulnerable subjects were all carefully outlinedfor vulnerable subjects were all carefully outlined

• Experimentation on dying patients was completely Experimentation on dying patients was completely forbiddenforbidden

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History of bioethicsHistory of bioethics

• No other nation had such legally and morally advanced No other nation had such legally and morally advanced regulations at this timeregulations at this time

• These regulations were in force and binding throughout These regulations were in force and binding throughout Germany from before and through the duration of the Germany from before and through the duration of the Second World War Second World War

• They were no less comprehensive and adequate than the They were no less comprehensive and adequate than the more popular Nuremberg Codemore popular Nuremberg Code

• Yet, the Nazi experiments comprehensively ignored and Yet, the Nazi experiments comprehensively ignored and violated every one of the regulationsviolated every one of the regulations

• The defendants argued that voluntary participation by The defendants argued that voluntary participation by human subjects in medical experimentation was not the human subjects in medical experimentation was not the norm at that timenorm at that time

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Nuremberg code 1948Nuremberg code 1948

• The main components of the code areThe main components of the code are

• Requirement for voluntary participationRequirement for voluntary participation

• Informed consentInformed consent

• Favorable risk/benefit analysisFavorable risk/benefit analysis

• Right to withdraw without penaltyRight to withdraw without penalty

• Criticized for being legalistic Criticized for being legalistic

• Largely ignored by medicineLargely ignored by medicine

• No mention of independent review or fair selection of No mention of independent review or fair selection of participantsparticipants

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1950s Wichita Jury Study 1950s Wichita Jury Study

• Social science researchers from the University of Chicago Social science researchers from the University of Chicago conducted a study involving secret audio taping of jury conducted a study involving secret audio taping of jury deliberations in order to better understand decision making deliberations in order to better understand decision making process of jurors in criminal trialsprocess of jurors in criminal trials

• Their hypothesis was that showmanship on the part of trial Their hypothesis was that showmanship on the part of trial attorneys was affecting the outcome of trialsattorneys was affecting the outcome of trials

• When the results were presented in respectable academic When the results were presented in respectable academic forums, public reaction was markedly negativeforums, public reaction was markedly negative

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1950s Wichita Jury Study1950s Wichita Jury Study

• People objected to deception for research purposes in a People objected to deception for research purposes in a setting where privacy and confidentiality were critically setting where privacy and confidentiality were critically importantimportant

• This prompted the U.S. Congress to pass a law prohibiting This prompted the U.S. Congress to pass a law prohibiting recording of jury deliberations, marking the first time that recording of jury deliberations, marking the first time that actions of well meaning researchers will result in action to actions of well meaning researchers will result in action to protect people from exploitationprotect people from exploitation

• Case highlighted the fact that some research questions Case highlighted the fact that some research questions cannot be answered without compromising the integrity of cannot be answered without compromising the integrity of significant and cherished social institutionssignificant and cherished social institutions

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1960s Thalidomide Study1960s Thalidomide Study

• Thalidomide was introduced for the treatment of Thalidomide was introduced for the treatment of hyperemesis gravidarum hyperemesis gravidarum in Europe and while still in Europe and while still undergoing review in the U.S., an influential group of East undergoing review in the U.S., an influential group of East Coast practitioners started using it before it became clear Coast practitioners started using it before it became clear that it was causing a large number of birth defectsthat it was causing a large number of birth defects

• Public outrage led to legislation that required investigators Public outrage led to legislation that required investigators to obtain informed consent before administering to obtain informed consent before administering investigational medicationsinvestigational medications

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1964 World Medical Council Declaration of 1964 World Medical Council Declaration of HelsinkiHelsinki

• This basically builds on the Nuremberg code and adds two This basically builds on the Nuremberg code and adds two additional pointsadditional points

• That the interests of the subject should always be given That the interests of the subject should always be given a higher priority than those of societya higher priority than those of society

• That every subject in clinical research should get the That every subject in clinical research should get the best known treatmentbest known treatment

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Other seminal eventsOther seminal events

• Henry Beecher’s 1959 Experimentation in Man’s Henry Beecher’s 1959 Experimentation in Man’s monographmonograph

• 1960 – 1963 The Law-Medicine Research Institute of 1960 – 1963 The Law-Medicine Research Institute of Boston University’s survey of researhers attitudes and the Boston University’s survey of researhers attitudes and the anthology “Clinical Investigation in Medicine”anthology “Clinical Investigation in Medicine”

• Henry Beecher’s article in NEJM in 1966 discussing 22 Henry Beecher’s article in NEJM in 1966 discussing 22 out 50 collected cases of unethical research in America’s out 50 collected cases of unethical research in America’s leading universitiesleading universities

• 1966 - Henry Beecher’s editorial in the Journal of the 1966 - Henry Beecher’s editorial in the Journal of the American Medical Association and argument for virtue American Medical Association and argument for virtue ethicsethics

• 1967 - M.H. Papworth – Human Guinea Pigs collected 1967 - M.H. Papworth – Human Guinea Pigs collected more than 500 papers describing unethical experiments more than 500 papers describing unethical experiments

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Other seminal eventsOther seminal events

• 1972 Jay Katz, Alex Capron and Eleanor Glass 1972 Jay Katz, Alex Capron and Eleanor Glass “Experimentation with Human Beings” “Experimentation with Human Beings”

• 1973 Congressional hearings on quality of health care and 1973 Congressional hearings on quality of health care and human experimentationhuman experimentation• Main catalyst for this was the Tuskegee Study (1932 – 1972), but Main catalyst for this was the Tuskegee Study (1932 – 1972), but

there were others, likethere were others, like• 1950 Willowbrook Hepatitis Study1950 Willowbrook Hepatitis Study• 1960 Jewish Chronic Diseases Hospital Studies1960 Jewish Chronic Diseases Hospital Studies• 1960 Milgram study of obedience1960 Milgram study of obedience• 1970 San Antonio study of contraceptive pills1970 San Antonio study of contraceptive pills• 1970 Humphrey’s Tearoom Trade Study 1970 Humphrey’s Tearoom Trade Study • 1970 Zimbardo’s Mock Prison Research 1970 Zimbardo’s Mock Prison Research

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1974 U. S. National Research Act1974 U. S. National Research Act

• This act established the modern research ethics system. The act This act established the modern research ethics system. The act created U.S. federal regulations that required ethical approval created U.S. federal regulations that required ethical approval before most kinds of research involving human subjects can be before most kinds of research involving human subjects can be conducted, defined policy and procedures that EC must follow conducted, defined policy and procedures that EC must follow when reviewing research, and established the criteria that an when reviewing research, and established the criteria that an EC must use to approve research conductEC must use to approve research conduct

• It also established the National Commission for the Protection It also established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. of Human Subjects of Biomedical and Behavioral Research. The function of the Commission is to issue recommendations The function of the Commission is to issue recommendations when what to do is not clear to researchers.when what to do is not clear to researchers.

• In 1978, the Commission issued the Belmont ReportIn 1978, the Commission issued the Belmont Report

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Other influences on development of bioethicsOther influences on development of bioethics

• The 60s and 70s civil rights movement in the United States The 60s and 70s civil rights movement in the United States with distrust of authority, emphasis on individual rights with distrust of authority, emphasis on individual rights and autonomyand autonomy

• The pace and variety of development of new health care The pace and variety of development of new health care technologytechnology

• The Cold War and fear of any type of socialismThe Cold War and fear of any type of socialism• The allocation, by the NHGRI, of substantial funds to The allocation, by the NHGRI, of substantial funds to

bioethics in 1989 leading to codification of the currently bioethics in 1989 leading to codification of the currently predominant academic mode of discourse for bioethicists: predominant academic mode of discourse for bioethicists: research concerning ethical issues as they are encountered research concerning ethical issues as they are encountered and resolved in society, culminating in data that is subject and resolved in society, culminating in data that is subject to the same rigors of peer review as other social science.to the same rigors of peer review as other social science.

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How bioethical dilemmas are How bioethical dilemmas are resolvedresolved

• Ethical dilemmas continue to arise in researchEthical dilemmas continue to arise in research

• Should we select some people and expose them to an Should we select some people and expose them to an unproven but potentially beneficial treatment so that we unproven but potentially beneficial treatment so that we can know if the rest of the population can benefitcan know if the rest of the population can benefit

• How should we select such peopleHow should we select such people

• Who should we selectWho should we select

• WhyWhy

• Should such research participants be compensated Should such research participants be compensated

• How should they be compensated How should they be compensated

How ethical dilemmas are resolvedHow ethical dilemmas are resolved

• If the questions are clear cut, there is no dilemmaIf the questions are clear cut, there is no dilemma

• Many times they are not and that is where the ethical Many times they are not and that is where the ethical dilemma arises. To resolve this, we look for guidancedilemma arises. To resolve this, we look for guidance

• Guidance are based on Guidance are based on

• The arguments are conducted within an established The arguments are conducted within an established ethical frameworkethical framework

• Arguments that lead to the particular conclusions are Arguments that lead to the particular conclusions are supported by reasonsupported by reason

• A reasonable consensus exists about validity of the A reasonable consensus exists about validity of the conclusions, arising from a process of genuine debateconclusions, arising from a process of genuine debate

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Why not rely on reason aloneWhy not rely on reason alone

• Reason alone is insufficient as there is no single Reason alone is insufficient as there is no single universally accepted reason-based framework within universally accepted reason-based framework within which ethical questions can be resolvedwhich ethical questions can be resolved

• Nor is one likely in the futureNor is one likely in the future• E.g., reason alone cannot decide between an ethical E.g., reason alone cannot decide between an ethical

framework that looks only at consequences and one that framework that looks only at consequences and one that considers intrinsic rightness or wrongness of actions considers intrinsic rightness or wrongness of actions regardless of the consequencesregardless of the consequences

• The history of discrimination against women for example The history of discrimination against women for example provides strong arguments against reliance on reason aloneprovides strong arguments against reliance on reason alone

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The need for ethical frameworksThe need for ethical frameworks

• The insufficiency of reason justifies the need for The insufficiency of reason justifies the need for established ethical frameworksestablished ethical frameworks

• The most widely accepted ethical frameworks in most The most widely accepted ethical frameworks in most cultures arose within systems of religious belief but these cultures arose within systems of religious belief but these have limitations such as:have limitations such as:• A significant number of people do not accept scripture A significant number of people do not accept scripture

as the source of moral thinkingas the source of moral thinking• Human plurality is associated with scriptural pluralityHuman plurality is associated with scriptural plurality• Many modern biotechnological issues are not addressed Many modern biotechnological issues are not addressed

in the scripturesin the scriptures

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Ethical frameworksEthical frameworks

• Despite these limitations, it is still necessary to consider Despite these limitations, it is still necessary to consider the ethical frameworks becausethe ethical frameworks because

• Lives are not lived in isolation. We all grow up within Lives are not lived in isolation. We all grow up within certain mores and traditionscertain mores and traditions

• None of us derives our ethical thinking from first None of us derives our ethical thinking from first principlesprinciples

• Alternative ethical traditions are already accumulating, Alternative ethical traditions are already accumulating, for example about biotechnologyfor example about biotechnology

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How then should we resolve bioethical How then should we resolve bioethical dilemmas?dilemmas?

• The simplest way to decide whether an action is right or The simplest way to decide whether an action is right or wrong is to look at the consequenceswrong is to look at the consequences

• No one can argue that we should ignore consequences of No one can argue that we should ignore consequences of an action before deciding whether it is right or wrongan action before deciding whether it is right or wrong

• But we can consider the consequences of our response and But we can consider the consequences of our response and that of alternative responsesthat of alternative responses

• How far can we or should we go in consideration of How far can we or should we go in consideration of consequences of specific actions?consequences of specific actions?

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Bioethical dilemmasBioethical dilemmas

• Even when we are in complete agreement about a moral Even when we are in complete agreement about a moral question, consequences still have to be consideredquestion, consequences still have to be considered

• The deeper question is not whether to take consequences The deeper question is not whether to take consequences into account when making ethical decisions but whether into account when making ethical decisions but whether that is all we need to dothat is all we need to do

• Are certain actions morally required, regardless of their Are certain actions morally required, regardless of their consequences?consequences?

• It would appear that the answer to these questions are It would appear that the answer to these questions are obvious, but this is not the caseobvious, but this is not the case

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ConsequentialistConsequentialist

• Consequentialists believe that consequences alone are Consequentialists believe that consequences alone are sufficient to determine a course of action. Example is sufficient to determine a course of action. Example is utilitarianismutilitarianism

• Utilitarianism begins with the assumption that most Utilitarianism begins with the assumption that most actions lead to pleasure or to happinessactions lead to pleasure or to happiness

• Its earliest origins can be found in the work of Mo Tzu in Its earliest origins can be found in the work of Mo Tzu in 55thth Century BC, but the most popular exponent is Epicurus Century BC, but the most popular exponent is Epicurus (341 – 271 BC) who combined consequentialism with (341 – 271 BC) who combined consequentialism with hedonistic theory of value hedonistic theory of value

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UtilitarianismUtilitarianism

• There are many versions of utilitarianism, for example There are many versions of utilitarianism, for example preference utilitarians argue for a subjective understanding preference utilitarians argue for a subjective understanding of pleasure in terms of an individual’s own perception of of pleasure in terms of an individual’s own perception of his/her well-beinghis/her well-being

• Utilitarians have no moral absolutes beyond maximization Utilitarians have no moral absolutes beyond maximization of the pleasure principleof the pleasure principle

• Rather they examine particular cases in detail to see Rather they examine particular cases in detail to see whether it would lead to greatest whether it would lead to greatest netnet increase in pleasure increase in pleasure

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UtilitarianismUtilitarianism

• This system has 2 great strengths:This system has 2 great strengths:• It provides a single ethical framework for all questionsIt provides a single ethical framework for all questions• Pleasure and Happiness are taken seriouslyPleasure and Happiness are taken seriously

• LimitationsLimitations• Not always practicable. Detailed examination of every Not always practicable. Detailed examination of every

action will soon bring all actions to a haltaction will soon bring all actions to a halt• How do we measure pleasure? How do we measure pleasure?

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Intrinsic Ethical PrinciplesIntrinsic Ethical Principles

• Considers intrinsic nature of the action, whether, it is right Considers intrinsic nature of the action, whether, it is right or wrongor wrong

• There are a number of possible intrinsic ethical principles There are a number of possible intrinsic ethical principles depending on the rights and obligations to which they are depending on the rights and obligations to which they are concernedconcerned

• This approach to ethics is called This approach to ethics is called deontologicaldeontological (rights (rights discourse)discourse)

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DeontologyDeontology

• Deontology considers the intrinsic value of actions rather Deontology considers the intrinsic value of actions rather than their consequencesthan their consequences

• Immanuel Kant – German philosopher held that an act is Immanuel Kant – German philosopher held that an act is moral only if it springs from a “good will” not because it moral only if it springs from a “good will” not because it gives us pleasure or leads to good consequencesgives us pleasure or leads to good consequences

• He constructed a formal “Categorical Imperative” as the He constructed a formal “Categorical Imperative” as the ultimate test of morality – “I ought never to act except in ultimate test of morality – “I ought never to act except in such a way that I can also will that my maxim should such a way that I can also will that my maxim should become universal law”become universal law”

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DeontologyDeontology

• Kant said a moral rule is one that can serve as a guide for Kant said a moral rule is one that can serve as a guide for everyone’s conducteveryone’s conduct

• It allows people to treat others as ends in themselves and It allows people to treat others as ends in themselves and not solely as a means to someone else’s endsnot solely as a means to someone else’s ends

• It is a rule that one can impose on oneself by one’s will It is a rule that one can impose on oneself by one’s will and not by the imposition of anotherand not by the imposition of another

• It embodies the principles of autonomy (individual rights) It embodies the principles of autonomy (individual rights) and justice (fair distribution of resources and and justice (fair distribution of resources and opportunities), and is the basis for social contract approach opportunities), and is the basis for social contract approach in bioethicsin bioethics

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DeontologyDeontology

• Justice is a broader conceptJustice is a broader concept• It is about fair treatment, fair distribution of resources or It is about fair treatment, fair distribution of resources or

opportunitiesopportunities• But this is associated with considerable disagreementsBut this is associated with considerable disagreements• For examples, a lot of people accept that unequal For examples, a lot of people accept that unequal

distribution of certain resources (e.g. educational distribution of certain resources (e.g. educational opportunities) may be fair provided certain other criteria opportunities) may be fair provided certain other criteria are satisfied (e.g. educational opportunities are purchased are satisfied (e.g. educational opportunities are purchased with money earned or inherited)with money earned or inherited)

• Others have argued that we should all be altruisticOthers have argued that we should all be altruistic

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Natural Law approachNatural Law approach

• First developed by Thomas Aquinas, it states that actions First developed by Thomas Aquinas, it states that actions are morally right if they accord with our nature as human are morally right if they accord with our nature as human beings. The attribute that is distinctively human is our beings. The attribute that is distinctively human is our ability to reason and exercise intelligence. The theory thus ability to reason and exercise intelligence. The theory thus argues that we can know what is morally right through argues that we can know what is morally right through reasonreason

• Theory of virtue stresses the disposition of individuals to Theory of virtue stresses the disposition of individuals to act virtuouslyact virtuously

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Virtues of a researcherVirtues of a researcher

• Temperance in personal lifeTemperance in personal life

• JusticeJustice

• HonestyHonesty

• CourageCourage

• CompassionCompassion

• Professional competenceProfessional competence

• Practical judgmentPractical judgment

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Consensus?Consensus?

• Much heat and little motion when proponents of one Much heat and little motion when proponents of one theory or the other arguetheory or the other argue

• It has been argued that a middle level of ethics discussion It has been argued that a middle level of ethics discussion between the abstractions of ethical theories and specifics between the abstractions of ethical theories and specifics of moral judgments are neededof moral judgments are needed

• While ethicists are needed, there is a far greater need for While ethicists are needed, there is a far greater need for scientists, sociologist, psychologist, policy makers and scientists, sociologist, psychologist, policy makers and politicians in setting ethical policy and standardspoliticians in setting ethical policy and standards

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Belmont principlesBelmont principles

• Respect for persons Respect for persons • Persons should be treated as autonomous agentsPersons should be treated as autonomous agents• Individuals with diminished autonomy deserve special Individuals with diminished autonomy deserve special

protectionprotection• Derived moral principlesDerived moral principles

• Informed consent; incorporating information, comprehension Informed consent; incorporating information, comprehension and voluntarinessand voluntariness

• Truth telling. In Kant’s “The supposed right to tell lies from Truth telling. In Kant’s “The supposed right to tell lies from benevolent motives”, he wrote that “If then, we define a lie benevolent motives”, he wrote that “If then, we define a lie merely as an intentionally false declaration towards another merely as an intentionally false declaration towards another man, we need not add that it must injure another … for it man, we need not add that it must injure another … for it always injures another; if not another individual, yet mankind always injures another; if not another individual, yet mankind generallygenerally

• ConfidentialityConfidentiality• PrivacyPrivacy

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Belmont principlesBelmont principles

• BeneficenceBeneficence• Most well known principle to physician from the oft Most well known principle to physician from the oft

quoted dictum “quoted dictum “Primum non nocerePrimum non nocere” What Hippocrates ” What Hippocrates actually said is “I will keep (patients) from harm and actually said is “I will keep (patients) from harm and injustice; I will … remain free from intentional injustice; I will … remain free from intentional injusticeinjustice

• Frankena arranged the components of this principle in Frankena arranged the components of this principle in the following hierarchical orderthe following hierarchical order

• I ought not to do evil or inflict harm (non-maleficence)I ought not to do evil or inflict harm (non-maleficence)• I ought to prevent evil or harm (beneficence)I ought to prevent evil or harm (beneficence)• I ought to remove evil or harm (beneficence)I ought to remove evil or harm (beneficence)• I ought to do or promote good (beneficence)I ought to do or promote good (beneficence)

• This ordering is not universally acceptedThis ordering is not universally accepted

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Belmont principlesBelmont principles

• Justice – in the sense of what is fair and what is Justice – in the sense of what is fair and what is deserveddeserved• An injustice occurs when an entitlement is denied An injustice occurs when an entitlement is denied

without good reason or burden imposed undulywithout good reason or burden imposed unduly• Another conception is that equals must be treated Another conception is that equals must be treated

equally.equally.• This plays a role in resource allocation, ensuring that This plays a role in resource allocation, ensuring that

no particular group bears excessive burden on behalf of no particular group bears excessive burden on behalf of others others

• The emphasis on rights in bioethics is another The emphasis on rights in bioethics is another derivative of this principlederivative of this principle

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When principles conflictWhen principles conflict

• Conflict of principles creates a weighting or priority Conflict of principles creates a weighting or priority problemproblem

• Ross proposed finding the greatest duty in any Ross proposed finding the greatest duty in any circumstance of conflict by finding the greatest balance of circumstance of conflict by finding the greatest balance of right over wrong in that particular contextright over wrong in that particular context

• He proposed a distinction between He proposed a distinction between prima facieprima facie and and actualactual dutiesduties

• Prima faciePrima facie duties are those that must always be acted duties are those that must always be acted upon except they conflict with equal or stronger duties in upon except they conflict with equal or stronger duties in that particular occasion. They are always right and always that particular occasion. They are always right and always bindingbinding

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When principles conflictWhen principles conflict

• So, though firm, they are conditional on not being So, though firm, they are conditional on not being overridden or outweighed by competing moral demandsoverridden or outweighed by competing moral demands

• Actual dutyActual duty is therefore determined by a balance of the is therefore determined by a balance of the respective weights of the competing respective weights of the competing prima facieprima facie duties duties

• Therefore duties and rights are not absolutes but rather Therefore duties and rights are not absolutes but rather strong prima facie moral demands that may validly be strong prima facie moral demands that may validly be overiden in circumstances where stringent opposing overiden in circumstances where stringent opposing demands are presented by a competing moral principle demands are presented by a competing moral principle

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When principle conflictWhen principle conflict

• These ideas also apply where a single principle is leading These ideas also apply where a single principle is leading us to two equally attractive alternatives, only one of which us to two equally attractive alternatives, only one of which can be pursuedcan be pursued

• They also allow us to see that there is no basis for always They also allow us to see that there is no basis for always reifying one principle – particularly autonomy – as is wont reifying one principle – particularly autonomy – as is wont to be the case in many writings on research ethicsto be the case in many writings on research ethics

• Justice and beneficence can override respect for autonomy Justice and beneficence can override respect for autonomy under certain circumstances – some of which are more under certain circumstances – some of which are more common in developing countries such as issues relating common in developing countries such as issues relating rights during epidemics and disasters, community benefit, rights during epidemics and disasters, community benefit, consent in certain diseases/research and sharing of consent in certain diseases/research and sharing of informationinformation

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When principles conflictWhen principles conflict

• This does not diminish the value of autonomy but let us This does not diminish the value of autonomy but let us ask with Daniel Callahan “What would it be like to live in ask with Daniel Callahan “What would it be like to live in a community for which autonomy was the central value”a community for which autonomy was the central value”

• The arguments about duties applies to rights tooThe arguments about duties applies to rights too• Many philosophers no longer submit to a thesis of absolute Many philosophers no longer submit to a thesis of absolute

right to life irrespective of competing claims or social right to life irrespective of competing claims or social conditionsconditions

• It is now commonly agreed that we have an It is now commonly agreed that we have an exercisable exercisable rightright not to have our life taken only if there is not a not to have our life taken only if there is not a sufficient moral justificationsufficient moral justification to override this right to override this right

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When principles conflictWhen principles conflict

• The right toThe right to• LifeLife• Make autonomous decisionsMake autonomous decisions• Give informed consentGive informed consent• Decide for a childDecide for a child

• Is legitimately exercisable and created duties on Is legitimately exercisable and created duties on others others if and only ifif and only if the right has an overriding the right has an overriding status in the situationstatus in the situation

• Therefore rights compete in many situations, Therefore rights compete in many situations, producing controversies and need for balance producing controversies and need for balance

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When principles conflictWhen principles conflict

• The burden of moral proof lies with those who seek to The burden of moral proof lies with those who seek to intervene in another’s choice, because as the need to intervene in another’s choice, because as the need to protect persons from harm becomes more compelling, the protect persons from harm becomes more compelling, the weight of other principles rise and may validly override weight of other principles rise and may validly override demands to respect autonomydemands to respect autonomy

• The challenge is to conceptually analyze the ethical The challenge is to conceptually analyze the ethical dilemmas and establish the relationship between principlesdilemmas and establish the relationship between principles

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Consensus?Consensus?

• Consensus?Consensus?• Based on reasonBased on reason• Genuine debateGenuine debate• Takes ethical traditions into accountTakes ethical traditions into account• Open to criticism, refutation and the possibility Open to criticism, refutation and the possibility

of changeof change• It is not majority opinion as it often needs to It is not majority opinion as it often needs to

protect the minorityprotect the minority• Takes timeTakes time

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Levels of ethical discussionLevels of ethical discussion

• Should research be allowed? Should research be allowed? • Lesson of historyLesson of history

• Certain things used to be banned but are now Certain things used to be banned but are now considered appropriate, for example, allowing women considered appropriate, for example, allowing women to voteto vote

• Alternatively certain things that were allowed are now Alternatively certain things that were allowed are now banned e.g. slaverybanned e.g. slavery

• Scientist right to autonomy of actionScientist right to autonomy of action• Research provides the information needed for decision Research provides the information needed for decision

making because there is a reasonable chance that research making because there is a reasonable chance that research will lead to increase in public goodswill lead to increase in public goods

Bioethical dilemmasBioethical dilemmas

• Should we select some people and expose them to an Should we select some people and expose them to an unproven but potentially beneficial treatment so that we unproven but potentially beneficial treatment so that we can know if the rest of the population can benefitcan know if the rest of the population can benefit

• Research must be conducted on humans at some point Research must be conducted on humans at some point in their development cycle because their results are in their development cycle because their results are ultimately to be used by humans and humans differ ultimately to be used by humans and humans differ from animalsfrom animals

• They can be done only in a subset of the population for They can be done only in a subset of the population for economic and ethical reasonseconomic and ethical reasons

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Bioethical dilemmasBioethical dilemmas

• How should we select such peopleHow should we select such people

• We must ensure that the people who bear the burden of We must ensure that the people who bear the burden of research are drawn from those who most likely to research are drawn from those who most likely to benefit from itbenefit from it

• We must ensure that participants are adequately We must ensure that participants are adequately informed about the risks of researchinformed about the risks of research

• We must ensure that participants know that they can We must ensure that participants know that they can voluntarily withdraw and the procedure for such voluntarily withdraw and the procedure for such withdrawal is set outwithdrawal is set out

• We must ensure that participants know the benefits in We must ensure that participants know the benefits in research and how these will be sharedresearch and how these will be shared

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Bioethical dilemmasBioethical dilemmas

• Who should we selectWho should we select

• Avoid individuals who cannot comprehend the researchAvoid individuals who cannot comprehend the research

• Justify and ensure adequate information where Justify and ensure adequate information where vulnerable participants are being recruited into researchvulnerable participants are being recruited into research

• Ensure adequate community engagement Ensure adequate community engagement

• Respect real and potential participants in researchRespect real and potential participants in research

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Bioethical dilemmasBioethical dilemmas

• Why select these peopleWhy select these people

• Research must be relevant to the health needs of the Research must be relevant to the health needs of the communitycommunity

• It must have social or scientific values It must have social or scientific values

• Should such research participants be compensatedShould such research participants be compensated

• Participation in research should be based on altruismParticipation in research should be based on altruism

• Participation should be cost-free to participants Participation should be cost-free to participants (including opportunity costs)(including opportunity costs)

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Bioethical dilemmasBioethical dilemmas

• How should they be compensatedHow should they be compensated

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Bioethical dilemmaBioethical dilemma

• Avoid undue compensation that can compromise an Avoid undue compensation that can compromise an individuals ability to make rational choiceindividuals ability to make rational choice

• Avoid coercionAvoid coercion

• Avoid deceptionAvoid deception

• Avoid perpetuation of injusticesAvoid perpetuation of injustices

• Avoid disadvantageous exploitationAvoid disadvantageous exploitation

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Resolving ethical dilemmasResolving ethical dilemmas

• No single way exists for resolving ethical debatesNo single way exists for resolving ethical debates• However, we can arrive at valid ethical positionsHowever, we can arrive at valid ethical positions• Requires education and vigorous debate as this Requires education and vigorous debate as this

allows expression of opinions, clarification of allows expression of opinions, clarification of thoughts and participationthoughts and participation

• All moral, legal, social and cultural approaches All moral, legal, social and cultural approaches must be considered must be considered

• Some issues require extensive debates that may Some issues require extensive debates that may take timetake time

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What we must not doWhat we must not do

• Use inappropriate tools to examine moral issuesUse inappropriate tools to examine moral issues• Fail to recognize legitimate diversityFail to recognize legitimate diversity• Disparage or reproach others who reach different Disparage or reproach others who reach different

decisions/conclusionsdecisions/conclusions• Assume that we can always judge the right of Assume that we can always judge the right of

individuals, societies and governments to individuals, societies and governments to construct different requirements that comprise part construct different requirements that comprise part of moral lifeof moral life

• Become skeptical about morality and moral Become skeptical about morality and moral thinkingthinking

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Caution about perceived ethical conflictsCaution about perceived ethical conflicts

• Factual disagreementsFactual disagreements• Scope of disagreements about who should be Scope of disagreements about who should be

protected by moral normsprotected by moral norms• Which norms are relevant in particular Which norms are relevant in particular

circumstancescircumstances• Appropriate specificationAppropriate specification• Weight of relevant normsWeight of relevant norms• Appropriate forms of balancingAppropriate forms of balancing• Presence of genuine moral dilemmaPresence of genuine moral dilemma• Sufficiency of information or evidenceSufficiency of information or evidence