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STATE UNIVERSITY OF MEDICINE AND PHARMACY “NICOLAE TESTEMITANU”

OF THE REPUBLIC OF MOLDOVA

Chair of Philosophy and Bioethics

BIOETHICS

Didactic material for medical students

Collected by
Adriana PALADI

Chisinau, 2011

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Table of content:

1. Morality and ethics: history and general


concepts……………………………………………………….

1.1. Ethics and Morality: general concepts

1.2. Theories of morality

1.3. Study case

2. Bioethics, the origin, the subject-matter and its paths of development. Bioethics’
principles……………………………………………

2.1. The origins and development of Bioethics. Bioethical aspects.

2.2. Bioethics’ principles

2.3. Cases

3. Bioethics as socio-cultural phenomenon. Paternalism and anti - paternalism in


medicine and bioethics…………………………………………

3.1. Paternalism and anti-paternalism

3.2. Inform consent

3.3. Study cases

4. Bioethics in practical medicine. ……………………………………..

4.1. Euthanasia

4.2. Bioethics and reproduction

4.3. Bioethics and genetic

4.4. Study cases

5. Social problems of bioethics: socio-philosophical analysis………………..

5.1. Ethics and sex: transexualism

5.2. Ethical issues in mental disorder patients.

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5.3. Suicide.

5.4. Study cases

6. Medical ethics - compartment of bioethics……………………………

6.1. Medical ethics: patient-doctor relation

6.2. The problem of confidentiality

6.3. Study cases

7. Scientific research and clinical trials in the biomedical world from the perspective
of bioethics………………………………………….

7.1. Ethical issues in human subjects research

7.2. Ethical issues in nonhuman subjects research

7.3. Study cases

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Chapter I

1. Ethics and Morality : general concepts.


After Bernard Gert. The Definition of Morality. Stanford encyclopedia of philosophy.
Principal Editor: Edward N. Zalta. First published Wed Apr 17, 2002; substantive
revision Mon Mar 14, 2011.

http://plato.stanford.edu/entries/morality-definition/

Ethics is the branch of philosophy that involves systematizing, defending, and recommending values
and principles for good human behavior. Or it is the systematical study of morality. Term Morality comes
from the Latin moralitas which means manner, character, and proper behavior. In the widest formula
morality refers to well-founded standards of right and wrong that prescribe what humans ought to do,
usually in terms of rights, obligations, benefits to society, fairness etc. Morality for instance refers to:
standards that impose the reasonable obligations to refrain from rape, stealing, murder, assault, slander, and
fraud; standards that enjoin virtues of honesty, compassion, and loyalty; standards relating to rights, such
as the right to life, the right to freedom from injury, and the right to privacy. Generalizing, morality is a
code of conduct accepted by humans (the members of that society) as a guide to behavior, and the basic
feature of which is avoiding and preventing harm to some others. However, in human society there are
other guides for behavior: etiquette, law, and religion. What is the distinction among morality and that
mentioned above?

Etiquette is usually included as a part of morality, but it applies to norms that are considered less
serious than the kinds of norms for behavior that are part of morality in the basic sense. Hobbes expresses
the distinction between morality and etiquette in this way: “By manners I mean not here decency of
behavior, as how one man should salute another, or how a man should wash his mouth or pick his teeth
before company, and such other points of small morals, but those qualities of mankind that concern their
living together in peace and unity.” (Leviathan, Chapter XI, paragraph 1)

Law or a legal system is distinguished from morality or a moral system by having explicit written
rules, penalties, and officials who interpret the laws and apply the penalties. Although there is often
considerable overlap in the conduct governed by morality and that governed by law, laws are often
evaluated on moral grounds. Moral criticism is often used to support a change in the law. (Dworkin).

Religion differs from morality or a moral system in that it includes stories about events in the past,
usually about supernatural beings, that are used to explain or justify the behavior that it prohibits or requires.
Sometimes there is no distinction made between a moral code and a code of conduct put forward by a
religion, and there is often a considerable overlap in the conduct prohibited or required by religion and that
prohibited or required by morality. But religions may prohibit or require more than is prohibited or required
by guides to behavior that are explicitly labeled as moral guides, and may allow some behavior that is
prohibited by morality. In the same time some religious practices and precepts are criticized on moral
grounds, e.g., discrimination on the basis of race, gender, or sexual orientation. So morality cannot be
confined to religion, nor is it the same as religion, as well as vice versa. While religious guide is applied

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only to religious people, morality applies as much to the behavior of the atheist as to that of the saint.
Nevertheless morality is only a guide to conduct, while religion is always more than this. (1)

2. Ethical theories

After James Fieser. Ethics. Internet enchiclopedia of philosophy. http://www.iep.utm.edu/ethics/

As was mention in previous paragraph ethics is a branch of philosophy studing values relating to human
conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of
the motives and ends of such actions. As moral philosophy ethics consist in a sistem of theories usually
divide into three general subject areas: metaethics, normative ethics, and applied ethics.

A. Metaethics

Metaethics is the study of the origin and meaning of ethical concepts. Dealing with such question as: Where
our ethical principles come from, and what they mean, methaethics arises and covers two basec issues:
(1) metaphysical issues concerning whether morality exists independently of humans, and (2) psychological
issues concerning the underlying mental basis of our moral judgments and conduct.

(1) Metaphysical Issues involves discovering specifically whether moral values are eternal truths that exist
in a spirit-like realm (are objective), or simply human conventions (are relative). There are two general
directions that discussions of this topic take, one other-worldly(objectivism) and one this-worldly
(relativism).

Proponents of the other-worldly view typically hold that moral values are objective in the sense that
they exist in a spirit-like realm beyond subjective human conventions. They also hold that they are absolute,
or eternal, in that they never change, and also that they are universal insofar as they apply to all rational
creatures around the world and throughout time. The most dramatic example of this view is Plato, who was
inspired by the field of mathematics. When we look at numbers and mathematical relations, such as 1+1=2,
they seem to be timeless concepts that never change, and apply everywhere in the universe. Humans do not
invent numbers, and humans cannot alter them. Plato explained the eternal character of mathematics by
stating that they are abstract entities that exist in a spirit-like realm. He noted that moral values also are
absolute truths and thus are also abstract, spirit-like entities. In this sense, for Plato, moral values are
spiritual objects. A different other-worldly approach to the metaphysical status of morality is divine
commands issuing from God’s will. Sometimes called voluntarism (or divine command theory), this view
was inspired by the notion of an all-powerful God who is in control of everything. God simply wills things,
and they become reality. He wills the physical world into existence, he wills human life into existence and,
similarly, he wills all moral values into existence. Proponents of this view, such as medieval philosopher
William of Ockham, believe that God wills moral principles, such as “murder is wrong,” and these exist in
God’s mind as commands. God informs humans of these commands by implanting us with moral intuitions
or revealing these commands in scripture.

The second and more this-worldly approach to the metaphysical status of morality follows in the
skeptical philosophical tradition, such as that articulated by Greek philosopher Sextus Empiricus, and
denies the objective status of moral values. Technically, skeptics did not reject moral values themselves,
but only denied that values exist as spirit-like objects, or as divine commands in the mind of God. Moral
values, they argued, are strictly human inventions, a position that has since been called moral relativism.
There are two distinct forms of moral relativism. The first is individual relativism, which holds that
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individual people create their own moral standards. Friedrich Nietzsche, for example, argued that the
superhuman creates his or her morality distinct from and in reaction to the slave-like value system of the
masses. The second is cultural relativism which maintains that morality is grounded in the approval of one’s
society – and not simply in the preferences of individual people. This view was advocated by Sextus, and
in more recent centuries by Michel Montaigne and William Graham Sumner. In addition to espousing
skepticism and relativism, this-worldly approaches to the metaphysical status of morality deny the absolute
and universal nature of morality and hold instead that moral values in fact change from society to society
throughout time and throughout the world. They frequently attempt to defend their position by citing
examples of values that differ dramatically from one culture to another, such as attitudes about polygamy,
homosexuality and human sacrifice.

(2) Psychological Issues in Metaethics involves the psychological basis of our moral judgments and
conduct, particularly understanding what motivates us to be moral. We might explore this subject by asking
the simple question, “Why be moral?” Even if I am aware of basic moral standards, such as don’t kill and
don’t steal, this does not necessarily mean that I will be psychologically compelled to act on them. Some
answers to the question “Why be moral?” are to avoid punishment, to gain praise, to attain happiness, to be
dignified, or to fit in with society.

i. Egoism and Altruism

One important area of moral psychology concerns the inherent selfishness of humans. 17th century British
philosopher Thomas Hobbes held that many, if not all, of our actions are prompted by selfish desires. Even
if an action seems selfless, such as donating to charity, there are still selfish causes for this, such as
experiencing power over other people. According to Hobbes, for purely selfish reasons, the agent is better
off living in a world with moral rules than one without moral rules. For without moral rules, we are subject
to the whims of other people’s selfish interests. Our property, our families, and even our lives are at
continual risk. Selfishness alone will therefore motivate each agent to adopt a basic set of rules which will
allow for a civilized community. Not surprisingly, these rules would include prohibitions against lying,
stealing and killing. However, these rules will ensure safety for each agent only if the rules are enforced.
As selfish creatures, each of us would plunder our neighbors’ property once their guards were down. Each
agent would then be at risk from his neighbor. Therefore, for selfish reasons alone, we devise a means of
enforcing these rules: we create a policing agency which punishes us if we violate these rules.

This view is called psychological egoism and maintains that self-oriented interests ultimately motivate all
human actions. Closely related to psychological egoism is a view called psychological hedonism which is
the view that pleasure is the specific driving force behind all of our actions. 18th century British philosopher
Joseph Butler agreed that instinctive selfishness and pleasure prompt much of our conduct. However, Butler
argued that we also have an inherent psychological capacity to show benevolence to others. This view is
called psychological altruism and maintains that at least some of our actions are motivated by instinctive
benevolence.

ii. Emotion and Reason

A second area of moral psychology involves a dispute concerning the role of reason in motivating moral
actions. If, for example, I make the statement “abortion is morally wrong,” am I making a rational
assessment or only expressing my feelings? On the one side of the dispute, 18th century British philosopher
David Hume argued that moral assessments involve our emotions, and not our reason. We can amass all

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the reasons we want, but that alone will not constitute a moral assessment. We need a distinctly emotional
reaction in order to make a moral pronouncement. Reason might be of service in giving us the relevant data,
but, in Hume’s words, “reason is, and ought to be, the slave of the passions.” Inspired by Hume’s anti-
rationalist views, some 20th century philosophers, most notably A.J. Ayer, similarly denied that moral
assessments are factual descriptions. For example, although the statement “it is good to donate to charity”
may on the surface look as though it is a factual description about charity, it is not. Instead, a moral utterance
like this involves two things. First, I (the speaker) I am expressing my personal feelings of approval about
charitable donations and I am in essence saying “Hooray for charity!” This is called the emotive element
insofar as I am expressing my emotions about some specific behavior. Second, I (the speaker) am trying to
get you to donate to charity and am essentially giving the command, “Donate to charity!” This is called the
prescriptive element in the sense that I am prescribing some specific behavior.

From Hume’s day forward, more rationally-minded philosophers have opposed these emotive
theories of ethics (see non-cognitivism in ethics) and instead argued that moral assessments are indeed acts
of reason. 18th century German philosopher Immanuel Kant is a case in point. Although emotional factors
often do influence our conduct, he argued, we should nevertheless resist that kind of sway. Instead, true
moral action is motivated only by reason when it is free from emotions and desires. A recent rationalist
approach, offered by Kurt Baier (1958), was proposed in direct opposition to the emotivist and prescriptivist
theories of Ayer and others. Baier focuses more broadly on the reasoning and argumentation process that
takes place when making moral choices. All of our moral choices are, or at least can be, backed by some
reason or justification. If I claim that it is wrong to steal someone’s car, then I should be able to justify my
claim with some kind of argument. For example, I could argue that stealing Smith’s car is wrong since this
would upset her, violate her ownership rights, or put the thief at risk of getting caught. According to Baier,
then, proper moral decision making involves giving the best reasons in support of one course of action
versus another.

B. Normative Ethics

Normative ethics takes on a more practical task, which is to arrive at moral standards that regulate right and
wrong conduct. This may involve articulating the good habits that we should acquire, the duties that we
should follow, or the consequences of our behavior on others. In a sense, it is a search for an ideal litmus
test of proper behavior. The Golden Rule is a classic example of a normative principle: We should do to
others what we would want others to do to us. Since I do not want my neighbor to steal my car, then it is
wrong for me to steal her car. Since I would want people to feed me if I was starving, then I should help
feed starving people. Using this same reasoning, I can theoretically determine whether any possible action
is right or wrong. So, based on the Golden Rule, it would also be wrong for me to lie to, harass, victimize,
assault, or kill others. The Golden Rule is an example of a normative theory that establishes a single
principle against which we judge all actions. Other normative theories focus on a set of foundational
principles, or a set of good character traits. The key assumption in normative ethics is that there is only one
ultimate criterion of moral conduct, whether it is a single rule or a set of principles. Three strategies will be
noted here: (1) virtue theories, (2) duty theories, and (3) consequentialist theories.

a. Virtue Theories

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Many philosophers believe that morality consists of following precisely defined rules of conduct, such
as “don’t kill,” or “don’t steal.” Presumably, I must learn these rules, and then make sure each of my actions
live up to the rules. Virtue ethics, however, places less emphasis on learning rules, and instead stresses the
importance of developing good habits of character, such as benevolence. Once I’ve acquired benevolence,
for example, I will then habitually act in a benevolent manner. Historically, virtue theory is one of the oldest
normative traditions in Western philosophy, having its roots in ancient Greek civilization. Plato emphasized
four virtues in particular, which were later called cardinal virtues: wisdom, courage, temperance and justice.
Other important virtues are fortitude, generosity, self-respect, good temper, and sincerity. In addition to
advocating good habits of character, virtue theorists hold that we should avoid acquiring bad character
traits, or vices, such as cowardice, insensibility, injustice, and vanity. Virtue theory emphasizes moral
education since virtuous character traits are developed in one’s youth. Adults, therefore, are responsible for
instilling virtues in the young.

Aristotle argued that virtues are good habits that we acquire, which regulate our emotions. For
example, in response to my natural feelings of fear, I should develop the virtue of courage which allows
me to be firm when facing danger. Analyzing 11 specific virtues, Aristotle argued that most virtues fall at
a mean between more extreme character traits. With courage, for example, if I do not have enough courage,
I develop the disposition of cowardice, which is a vice. If I have too much courage I develop the disposition
of rashness which is also a vice. According to Aristotle, it is not an easy task to find the perfect mean
between extreme character traits. In fact, we need assistance from our reason to do this. After Aristotle,
medieval theologians supplemented Greek lists of virtues with three Christian ones, or theological virtues:
faith, hope, and charity. Interest in virtue theory continued through the middle ages and declined in the 19th
century with the rise of alternative moral theories below. In the mid 20th century virtue theory received
special attention from philosophers who believed that more recent approaches ethical theories were
misguided for focusing too heavily on rules and actions, rather than on virtuous character traits. Alasdaire
MacIntyre (1984) defended the central role of virtues in moral theory and argued that virtues are grounded
in and emerge from within social traditions.

b. Duty Theories

Many of us feel that there are clear obligations we have as human beings, such as to care for our children,
and to not commit murder. Duty theories base morality on specific, foundational principles of obligation.
These theories are sometimes called deontological, from the Greek word deon, or duty, in view of the
foundational nature of our duty or obligation. They are also sometimes called nonconsequentialist since
these principles are obligatory, irrespective of the consequences that might follow from our actions. For
example, it is wrong to not care for our children even if it results in some great benefit, such as financial
savings. There are four central duty theories.

The first is that championed by 17th century German philosopher Samuel Pufendorf, who classified dozens
of duties under three headings: duties to God, duties to oneself, and duties to others. Concerning our duties
towards God, he argued that there are two kinds:

- a theoretical duty to know the existence and nature of God, and

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- a practical duty to both inwardly and outwardly worship God.

Concerning our duties towards oneself, these are also of two sorts:

- duties of the soul, which involve developing one’s skills and talents, and

- duties of the body, which involve not harming our bodies, as we might through gluttony or
drunkenness, and not killing oneself.

Concerning our duties towards others, Pufendorf divides these between absolute duties, which are
universally binding on people, and conditional duties, which are the result of contracts between people.
Absolute duties are of three sorts:

- avoid wronging others,

- treat people as equals, and

- promote the good of others.

Conditional duties involve various types of agreements, the principal one of which is the duty is to keep
one’s promises.

A second duty-based approach to ethics is rights theory. Most generally, a “right” is a justified claim
against another person’s behavior – such as my right to not be harmed by you. Rights and duties are related
in such a way that the rights of one person implies the duties of another person. For example, if I have a
right to payment of $10 by Smith, then Smith has a duty to pay me $10. This is called the correlativity of
rights and duties. The most influential early account of rights theory is that of 17th century British
philosopher John Locke, who argued that the laws of nature mandate that we should not harm anyone’s
life, health, liberty or possessions. For Locke, these are our natural rights, given to us by God. Following
Locke, the United States Declaration of Independence authored by Thomas Jefferson recognizes three
foundational rights: life, liberty, and the pursuit of happiness. Jefferson and others rights theorists
maintained that we deduce other more specific rights from these, including the rights of property,
movement, speech, and religious expression. There are four features traditionally associated with moral
rights. First, rights are natural insofar as they are not invented or created by governments. Second, they are
universal insofar as they do not change from country to country. Third, they are equal in the sense that
rights are the same for all people, irrespective of gender, race, or handicap. Fourth, they are inalienable
which means that I ca not hand over my rights to another person, such as by selling myself into slavery.

A third duty-based theory is that by Kant, which emphasizes a single principle of duty. Influenced by
Pufendorf, Kant agreed that we have moral duties to oneself and others, such as developing one’s talents,
and keeping our promises to others. However, Kant argued that there is a more foundational principle of
duty that encompasses our particular duties. It is a single, self-evident principle of reason that he calls the
“categorical imperative.” A categorical imperative, he argued, is fundamentally different from hypothetical
imperatives that hinge on some personal desire that we have, for example, “If you want to get a good job,
then you ought to go to college.” By contrast, a categorical imperative simply mandates an action,
irrespective of one’s personal desires, such as “You ought to do X.” Kant gives at least four versions of the
categorical imperative, but one is especially direct: Treat people as an end, and never as a means to an end.
That is, we should always treat people with dignity, and never use them as mere instruments. For Kant, we
treat people as an end whenever our actions toward someone reflect the inherent value of that person.
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Donating to charity, for example, is morally correct since this acknowledges the inherent value of the
recipient. By contrast, we treat someone as a means to an end whenever we treat that person as a tool to
achieve something else. It is wrong, for example, to steal my neighbor’s car since I would be treating her
as a means to my own happiness. The categorical imperative also regulates the morality of actions that
affect us individually. Suicide, for example, would be wrong since I would be treating my life as a means
to the alleviation of my misery. Kant believes that the morality of all actions can be determined by appealing
to this single principle of duty.

A fourth and more recent duty-based theory is that by British philosopher W.D. Ross, which emphasizes
prima facie duties. Like his 17th and 18th century counterparts, Ross argues that our duties are “part of the
fundamental nature of the universe.” However, Ross’s list of duties is much shorter, which he believes
reflects our actual moral convictions:

- Fidelity: the duty to keep promises

- Reparation: the duty to compensate others when we harm them

- Gratitude: the duty to thank those who help us

- Justice: the duty to recognize merit

- Beneficence: the duty to improve the conditions of others

- Self-improvement: the duty to improve our virtue and intelligence

- Nonmaleficence: the duty to not injure others

Ross recognizes that situations will arise when we must choose between two conflicting duties. In a classic
example, suppose I borrow my neighbor’s gun and promise to return it when he asks for it. One day, in a
fit of rage, my neighbor pounds on my door and asks for the gun so that he can take vengeance on someone.
On the one hand, the duty of fidelity obligates me to return the gun; on the other hand, the duty of
nonmaleficence obligates me to avoid injuring others and thus not return the gun. According to Ross, I will
intuitively know which of these duties is my actual duty, and which is my apparent or prima facie duty. In
this case, my duty of nonmaleficence emerges as my actual duty and I should not return the gun.

c. Consequentialist Theories

It is common for us to determine our moral responsibility by weighing the consequences of our actions.
According to consequentialism, correct moral conduct is determined solely by a cost-benefit analysis of an
action’s consequences: An action is morally right if the consequences of that action are more favorable than
unfavorable. Consequentialist normative principles require that we first tally both the good and bad
consequences of an action. Second, we then determine whether the total good consequences outweigh the
total bad consequences. If the good consequences are greater, then the action is morally proper. If the bad
consequences are greater, then the action is morally improper. Consequentialist theories are sometimes
called teleological theories, from the Greek word telos, or end, since the end result of the action is the sole
determining factor of its morality.

Consequentialist theories became popular in the 18th century by philosophers who wanted a quick
way to morally assess an action by appealing to experience, rather than by appealing to gut intuitions or
long lists of questionable duties. In fact, the most attractive feature of consequentialism is that it appeals to
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publicly observable consequences of actions. Most versions of consequentialism are more precisely
formulated than the general principle above. In particular, competing consequentialist theories specify
which consequences for affected groups of people are relevant. Three subdivisions of consequentialism
emerge:

- Ethical Egoism: an action is morally right if the consequences of that action are more favorable than
unfavorable only to the agent performing the action.

- Ethical Altruism: an action is morally right if the consequences of that action are more favorable
than unfavorable to everyone except the agent.

- Utilitarianism: an action is morally right if the consequences of that action are more favorable than
unfavorable to everyone.

All three of these theories focus on the consequences of actions for different groups of people. But, like
all normative theories, the above three theories are rivals of each other. They also yield different
conclusions. Consider the following example. A woman was traveling through a developing country when
she witnessed a car in front of her run off the road and roll over several times. She asked the hired driver to
pull over to assist, but, to her surprise, the driver accelerated nervously past the scene. A few miles down
the road the driver explained that in his country if someone assists an accident victim, then the police often
hold the assisting person responsible for the accident itself. If the victim dies, then the assisting person
could be held responsible for the death. The driver continued explaining that road accident victims are
therefore usually left unattended and often die from exposure to the country’s harsh desert conditions. On
the principle of ethical egoism, the woman in this illustration would only be concerned with the
consequences of her attempted assistance as she would be affected. Clearly, the decision to drive on would
be the morally proper choice. On the principle of ethical altruism, she would be concerned only with the
consequences of her action as others are affected, particularly the accident victim. Tallying only those
consequences reveals that assisting the victim would be the morally correct choice, irrespective of the
negative consequences that result for her. On the principle of utilitarianism, she must consider the
consequences for both herself and the victim. The outcome here is less clear, and the woman would need
to precisely calculate the overall benefit versus disbenefit of her action.

i. Utilitarianism

Utilitarianism is more famous conception among other conseqventialist conception. Jeremy Bentham
presented one of the earliest fully developed systems of utilitarianism. Two features of his theory are
noteworty. First, Bentham proposed that we tally the consequences of each action we perform and thereby
determine on a case by case basis whether an action is morally right or wrong. This aspect of Bentham’s
theory is known as act-utilitiarianism. Second, Bentham also proposed that we tally the pleasure and pain
which results from our actions. For Bentham, pleasure and pain are the only consequences that matter in
determining whether our conduct is moral. This aspect of Bentham’s theory is known as hedonistic
utilitarianism. Critics point out limitations in both of these aspects.
First, according to act-utilitarianism, it would be morally wrong to waste time on leisure activities such
as watching television, since our time could be spent in ways that produced a greater social benefit, such as
charity work. But prohibiting leisure activities doesn’t seem reasonable. More significantly, according to
act-utilitarianism, specific acts of torture or slavery would be morally permissible if the social benefit of
these actions outweighed the disbenefit. A revised version of utilitarianism called rule-utilitarianism

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addresses these problems. According to rule-utilitarianism, a behavioral code or rule is morally right if the
consequences of adopting that rule are more favorable than unfavorable to everyone. Unlike act
utilitarianism, which weighs the consequences of each particular action, rule-utilitarianism offers a litmus
test only for the morality of moral rules, such as “stealing is wrong.” Adopting a rule against theft clearly
has more favorable consequences than unfavorable consequences for everyone. The same is true for moral
rules against lying or murdering. Rule-utilitarianism, then, offers a three-tiered method for judging conduct.
A particular action, such as stealing my neighbor’s car, is judged wrong since it violates a moral rule against
theft. In turn, the rule against theft is morally binding because adopting this rule produces favorable
consequences for everyone. John Stuart Mill’s version of utilitarianism is rule-oriented.
Second, according to hedonistic utilitarianism, pleasurable consequences are the only factors that
matter, morally speaking. This, though, seems too restrictive since it ignores other morally significant
consequences that are not necessarily pleasing or painful. For example, acts which foster loyalty and
friendship are valued, yet they are not always pleasing. In response to this problem, G.E. Moore proposed
ideal utilitarianism, which involves tallying any consequence that we intuitively recognize as good or bad
(and not simply as pleasurable or painful). Also, R.M. Hare proposed preference utilitarianism, which
involves tallying any consequence that fulfills our preferences.

3. Applied Ethics

Applied ethics is the branch of ethics which consists of the analysis of specific, controversial moral issues
such as abortion, animal rights, or euthanasia. In recent years applied ethical issues have been subdivided
into convenient groups such as medical ethics, business ethics, environmental ethics, and sexual ethics.
(More recently some of this gropes are coverd by bioethics.) Generally speaking, two features are necessary
for an issue to be considered an “applied ethical issue.” First, the issue needs to be controversial in the sense
that there are significant groups of people both for and against the issue at hand. The issue of drive-by
shooting, for example, is not an applied ethical issue, since everyone agrees that this practice is grossly
immoral. By contrast, the issue of gun control would be an applied ethical issue since there are significant
groups of people both for and against gun control.

The second requirement for an issue to be an applied ethical issue is that it must be a distinctly moral
issue. On any given day, the media presents us with an array of sensitive issues such as affirmative action
policies, gays in the military, involuntary commitment of the mentally impaired, capitalistic versus
socialistic business practices, public versus private health care systems, or energy conservation. Although
all of these issues are controversial and have an important impact on society, they are not all moral issues.
Some are only issues of social policy. The aim of social policy is to help make a given society run efficiently
by devising conventions, such as traffic laws, tax laws, and zoning codes. Moral issues, by contrast, concern
more universally obligatory practices, such as our duty to avoid lying, and are not confined to individual
societies. Frequently, issues of social policy and morality overlap, as with murder which is both socially
prohibited and immoral. However, the two groups of issues are often distinct. For example, many people
would argue that sexual promiscuity is immoral, but may not feel that there should be social policies
regulating sexual conduct, or laws punishing us for promiscuity. Similarly, some social policies forbid
residents in certain neighborhoods from having yard sales. But, so long as the neighbors are not offended,
there is nothing immoral in itself about a resident having a yard sale in one of these neighborhoods. Thus,
to qualify as an applied ethical issue, the issue must be more than one of mere social policy: it must be
morally relevant as well.
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In theory, resolving particular applied ethical issues should be easy. With the issue of abortion, for
example, we would simply determine its morality by consulting our normative principle of choice, such as
act-utilitarianism. If a given abortion produces greater benefit than disbenefit, then, according to act-
utilitarianism, it would be morally acceptable to have the abortion. Unfortunately, there are perhaps
hundreds of rival normative principles from which to choose, many of which yield opposite conclusions.
Thus, the stalemate in normative ethics between conflicting theories prevents us from using a single
decisive procedure for determining the morality of a specific issue. The usual solution today to this
stalemate is to consult several representative normative principles on a given issue and see where the weight
of the evidence lies.

3.1. Sudy Cases

Case 1

After Caroline Whitbeck. Gender Issues: Should You Find a New Supervisor?

http://www.onlineethics.org/Resources/Cases/gender_issues.aspx

You are nearing the end of your first year of graduate study at Tough Tech and have been working with
Professor Grimm's group within the large Laboratory for Better Technology. You are very interested in the
subject area of your research. However, whenever you make a significant contribution and start feeling
good about yourself and your work, Professor Grimm gives you a lecture about what hard places Tough
Tech and the Laboratory for Better Technology are, and how you really have to keep your nose to the
grindstone if you expect to make it here. You try to make a joke of Grimm's "anti-pep" talks, but they do
demoralize you. It has gotten to the point that whenever you make a contribution to the project, you send
him something in writing and avoid talking to him for several days to avoid hearing his pessimistic
assessment of your abilities.

On several occasions, Grimm has walked into the men's room while having an interesting conversation
with the group. He seems not to notice that this leaves you asking male students to fill you in on what he
said in there.

You are thinking about finding a different supervisor. The trouble is, there is only one other faculty
member who works in this area, which you enjoy very much. From the two women in his group you learn
that this second faculty member opens his group meetings by addressing everyone as "Gentlemen."

What should you do and how should you go about it?

Are there established standards of behavior that are being violated here?

If so, what could be done to get others to help uphold those standards?

Case 2

Female circumcision/genital cutting

13
http://www.bbc.co.uk/ethics/femalecircumcision/femalecirc_1.shtml

Female circumcision usually involves the cutting or removal of the clitoris. This area of the genitals is
very sensitive because it contains the most nerve endings.

Genital cutting is a painful practice that is often poorly carried out, and endangers the health and lives of
millions of girls, particularly in Africa. In some communities the controversial practice is a female rite of
passage and remains an important religious and cultural tradition. In regions where a new religion has
become dominant, the tradition of genital cutting does not necessarily die out. It is seen as the climax of
initiation, something that both boys and girls have to take part in before they are accepted as adults in the
community.

In the Middle East, female circumcision is practised in the Yemen, Saudi Arabia, Iraq, Jordan and Syria.
Even in the United States, 10,000 girls are believed to be at risk from illegal operations within their own
communities. It has also been reported that young women in Australia, Canada, Denmark, France, Italy,
the Netherlands, Sweden and the UK have also undergone similar operations.Genital cutting is widespread
within some African cultures and ethnic groups.

It is certainly a painful process. It is sometimes carried out by a midwife with anaesthetics, but more
often than not there is nothing to ease the pain.The operation involved varies widely from culture to culture.
In its most extreme form (infibulation) it can involve the removal of all external genitalia and the stitching
up of the labia leaving only a very small opening for sex, urination, menstruation and giving birth. This
often makes a later operation necessary to create a larger opening. Many objections to the practice of genital
cutting are concerned with the particular circumstances in which it is done. Amnesty International, a human
rights organisation, reports that the operation is often carried out using blunt tools (penknives, fragments
of glass or tin cans). A particularly brutal operation can leave a woman with haemorrhaging, infections,
abscesses and sometimes a lifelong loss of sensation during sex. The Pan-African Committee on Traditional
Practices estimates that two million girls in Africa each year undergo some kind of genital cutting which
endangers both their health and their lives. Another objection concerns the inability of some young women
to make a choice. Cutting takes place when a girl is young (aged between three and ten), vulnerable and
unable to make an informed decision. In a small village community pressure to take part is enormous.

14
Chapter 2

Bioethics, the origin, the subject-matter and its paths of development.


Bioethics’ principles
2.1. The origins and evolution of bioethics. Bioethical aspects.

Bioethicists is a form of applied ethics concerned with the ethical questions that arise in the relationships
among life sciences, biotechnology, medicine, politics, law, and philosophy. The term Bioethics (Greek
bios, life; ethos, behavior) was coined in 1927 by Fritz Jahr, who "anticipated many of the arguments and
discussions now current in biological research involving animals" in an article about the "bioethical
imperative," as he called it, regarding the scientific use of animals and plants. Aldo Leopold (January 11,
1887 – April 21, 1948) American author, scientist, ecologist, forester, and environmentalist, was
influential in the development of modern bioethics in its environmental aspect and in the movement for
wilderness conservation. His ethics of nature and wildlife preservation had a profound impact on the
environmental movement, with his biocentric or holistic ethics regarding land. Leopold offered frank
criticism of the harm he believed was frequently done to natural systems (such as land) out of a sense of a
culture or society's sovereign ownership over the land base – eclipsing any sense of a community of life to
which humans belong. He felt the security and prosperity resulting from "mechanization" now gives people
the time to reflect on the preciousness of nature and to learn more about what happens there. These ideas
were unfolded in his book published in 1949, shortly after his death. One of the well-known quotes from
the book which clarifies his land ethic is: A thing is right when it tends to preserve the integrity, stability,
and beauty of the biotic community. It is wrong when it tends otherwise.
In 1970, the American biochemist Van Rensselaer Potter used the term Bioethics with a broader meaning
including solidarity towards the biosphere, a discipline representing a link between biology, ecology,
medicine and human values in order to attain the survival of both human beings and other animal species.
Nevertheless later (in 1988) he preferred to call this domain "global ethics".
The field of bioethics first emerged as an academic discipline in Anglophone societies in the 1960s. By
the 1970s, bioethical think tanks and academic bioethics programs had emerged. Among the earliest such
institutions were the Hastings Center, USA (originally known as The Institute of Society, Ethics and the
Life Sciences), founded in 1969 by philosopher Daniel Callahan and psychiatrist Willard Gaylin, and the
Kennedy Institute of Ethics, established at Georgetown University in 1971. The publication of Principles
of Biomedical Ethics by James F. Childress and Tom Beauchamp—the first American textbook of
bioethics—marked a transformative moment in the discipline.

A great contribution of evolution of bioethics in its medical aspect had scandals concerning involvement
of human subject in scientific research, among which Nazi experiments conducted during World War II,
Tuskegee syphilis experiment conducted between 1932 and 1972 in Tuskegee, Alabama by the U.S. Public
Health Service to study the natural progression of untreated syphilis in poor, rural black men who thought
they were receiving free health care from the U.S. government, Willowbrook State School case, where
mentally handicapped were infected with hepatitis for research objectives etc. These and other case
contributed to formulation of a set of moral norms for researchers in biomedical aria while involving human
subjects in experiments. These norms are written in international documents like: Nuremberg code,
declaration of Helsinki, CIOMS Guides etc.

15
Bioethical issues gained widespread attention also through the court cased caused by technological
advances in such diverse areas as organ transplantation and end-of-life care, including the development of
kidney dialysis and respirators, which posed novel ethical questions, for instants question regarding when
and how care might be withdrawn. The very famous case in this respect is the case surrounding the deaths
of Karen Ann Quinlan. Karen Ann Quinlan (March 29, 1954 – June 11, 1985) was an important figure in
the history of the right to die controversy in the United States. When she was 21, Quinlan became
unconscious after arriving home from a party. She had consumed diazepam, dextropropoxyphene, and
alcohol. After she collapsed and stopped breathing twice for 15 minutes or more, the paramedics arrived
and took her to hospital, where she lapsed into a persistent vegetative state. After she was kept alive on a
ventilator for several months without improvement, her parents requested the hospital to discontinue active
care and allow her to die. The hospital refused, and the subsequent legal battles made newspaper headlines
and set significant precedents. The tribunal eventually ruled in her parents' favor. Although Quinlan was
removed from mechanical ventilation during 1976, she lived on in a persistent vegetative state for almost a
decade until her death from pneumonia in 1985.
Quinlan's case continues to raise important questions in moral theology, bioethics, euthanasia, legal
guardianship and civil rights. Her case has affected the practice of medicine and law around the world. Two
significant outcomes of her case were the development of formal ethics committees in hospitals, nursing
homes and hospices, and the development of advance health directives.

Bioethical aspects
Bioethics appeared as a result of problems brought about by advances in science and technologies,
especially that in biology and medicine. It is an interdisciplinary area dealing with a collection on ethical
issues related to health care, biomedical research, biotechnology, and the environment. As complex area
bioethics has several aspects: philosophical, legal, environmental and medical aspects.
Philosophical aspect of bioethics is related to elaboration and arguing in favor of a system of values
and principles applicable in different aria of human activity so that to assure good results in condition of
morally correct action or agency. The normative theories mentioned in the first Chapter are relevant in this
context. Legal aspect refers to the mandatory documents formulated on the base of ethical principles
mentioned above and which consist in set of compulsory rules. In this context is relevant UNESCO
Universal Declaration on Bioethics and Human Rights.
Environmental aspect refers to the problem of necessity biosphere, for the protection of the integrity of
a certain ecosystem. In this aspect bioethics entry covers: (1) the challenge to the anthropocentrism (i.e.,
human-centeredness) embedded in traditional western ethical thinking; (2) the connection of deep ecology
and social ecology to politics; (3) the attempt to apply traditional ethical theories, including
consequentialism, deontology, and virtue ethics, to support contemporary environmental concerns.
Medical aspect of bioethics has addressed a broad swath of human inquiry, ranging from debates over
the boundaries of life (e.g. abortion, euthanasia), surrogacy to the allocation of scarce health care resources
(e.g. organ donation, health care rationing) to the right to refuse medical care for religious or cultural
reasons. It includes the study of the more commonplace questions of values which arise in primary care and
other branches of medicine. Issues arise about the morality of surrogate mothering, genetic manipulation
of fetuses, the status of unused frozen embryos, and abortion. Other issues arise about patient rights and
physician’s responsibilities, such as the confidentiality of the patient’s records and the physician’s
responsibility to tell the truth to dying patients. The AIDS crisis has raised the specific issues of the
mandatory screening of all patients for AIDS, and whether physicians can refuse to treat AIDS patients.

16
Additional issues concern medical experimentation on humans, the morality of involuntary commitment,
and the rights of the mentally disabled.

2.2. Bioethics’ principles

Bioethicists often disagree among themselves over the precise limits of their discipline, debating
whether the field should concern itself with the ethical evaluation of all questions involving biology and
medicine, or only a subset of these questions. Some bioethicists would narrow ethical evaluation only to
the morality of medical treatments or technological innovations, and the timing of medical treatment of
humans. Others would broaden the scope of ethical evaluation to include the morality of all actions that
might help or harm organisms capable of feeling fear. Accordingly nowadays is spoken about two paths of
bioethics evolution or of two types of bioethics: a) bioethics in widest sense covering issues of
environmental ethics as well as that biomedical; b) bioethics in narrow sense dealing with issues arise in
medical context. Thus, the moral principles, used in these two directions, differ one from other, even though
the overlapping of them is not excluded as well. Also it is important to say that the principles in both cases
represent a spectrum of traditional normative principles and are derived from consequentialist and duty-
based approaches.

a. Normative Principles of bioethics in widest sense

 Principle of biospherocentrism: acknowledge the extent to which an action produces beneficial


consequences for both nature and society. It emphasizes the necessity of co evolution between
nature and society.

 Principle of social benefit: acknowledge the extent to which an action produces beneficial
consequences for society.

 Principle of benevolence: acknowledge the importance to help those in need (not only human but
also inhuman beings).

 Principle of harm: do not harm others beings.

 Principle of honesty: do not deceive others.

 Principle of responsibility and lawfulness: do your duties and do not violate the law.

 Principle of autonomy: acknowledge a person’s freedom over his/her actions or physical body.

 Principle of justice: acknowledge a person’s right to due process, fair compensation for harm done,
and fair distribution of benefits.

 Rights: acknowledge a person’s rights to life, information, privacy, free expression, and safety.

b) Principles of Bioethics in narrow sense

After Thomas R. McCormick, D Min Faculty, Medical History and Ethics. Principles of Bioethics.
University of Washington School of Medicine. http://depts.washington.edu/bioethx/tools/princpl.html
17
In the realm of health care it is difficult to hold rules or principles that are absolute. This is due to the
many variables that exist in the context of clinical cases as well as the fact that in health care there are
several principles that seem to be applicable in many situations. Even though they are not considered
absolute, these rules and principles serve as powerful action guides in clinical medicine. Over the years,
these moral principles have won a general acceptance as applicable in the moral analysis of ethical issues
in medicine. The commonly accepted principles of health care ethics include:
 the principle of respect for autonomy,
 the principle of nonmaleficency,

 the principle of beneficence, and

 the principle of justice.

1. Respect for Autonomy

Any notion of moral decision making assumes that rational agents are involved in making informed and
voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common
parlance, mean that the patient has the capacity to act intentionally, with understanding, and without
controlling influences that would mitigate against a free and voluntary act. This principle is the basis for
the practice of "informed consent" in the physician/patient transaction regarding health care.

2. The Principle of Nonmaleficence

The principle of nonmaleficence requires of us that we not intentionally create a needless harm or injury
to the patient, either through acts of commission or omission. In common language, we consider it
negligence if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard
of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral
convictions, but by the laws of society as well. In a professional model of care one may be morally and
legally blameworthy if one fails to meet the standards of due care. The legal criteria for determining
negligence are as follows:

 the professional must have a duty to the affected party


 the professional must breach that duty
 the affected party must experience a harm; and
 the harm must be caused by the breach of duty.

This principle affirms the need for medical competence. It is clear that medical mistakes occur, however,
this principle articulates a fundamental commitment on the part of health care professionals to protect their
patients from harm.

3. The Principle of Beneficence

The ordinary meaning of this principle is the duty of health care providers to be of a benefit to the patient,
as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed
as self-evident and are widely accepted as the proper goals of medicine. These goals are applied both to
individual patients, and to the good of society as a whole. For example, the good health of a particular
patient is an appropriate goal of medicine, and the prevention of disease through research and the
employment of vaccines is the same goal expanded to the population at large.
18
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another
individual. Whereas, beneficence is a limited duty. A physician has a duty to seek the benefit of any or all
of her patients, however, the physician may also choose whom to admit into his or her practice, and does
not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two
patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some
principle of first come first served, to decide who should be helped at the moment.

4. The Principle of Justice

Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that
which is his due." This implies the fair distribution of goods in society and requires that we look at the role
of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and
services are in short supply, there is not enough to go around, thus some fair means of allocating scarce
resources must be determined. It is generally held that persons who are equals should qualify for equal
treatment. This is borne out in the application of Medicare, which is available to all persons over the age of
65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen
says nothing about need or other noteworthy factors about the persons in this category. In fact, our society
uses a variety of factors as a criteria for distributive justice, including the following:

 to each person an equal share


 to each person according to need
 to each person according to effort
 to each person according to contribution
 to each person according to merit
 to each person according to free-market exchanges
John Rawls and others claim that many of the inequalities we experience are a result of a "natural lottery"
or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even
the playing field by providing resources to help overcome the disadvantaged situation. One of the most
controversial issues in modern health care is the question pertaining to "who has the right to health care?"
Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent
minimum level of health care for all citizens, regardless of ability to pay.

How do principles "apply" to a certain case?

Principles in current usage in health care ethics seem to be of self-evident value. For example, the notion
that the physician "ought not to harm" any patient appears to be convincing to rational persons. Or, the idea
that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms
of other competing alternatives, seems self-evident. Further, before implementing the medical care plan, it
is now commonly accepted that the patient must indicate a willingness to accept the proposed treatment, if
the patient is cognitively capable of doing so. Finally, medical benefits should be dispensed fairly, so that
people with similar needs and in similar circumstances will be treated with fairness.
One might argue that we are required to take all of the above principles into account when they are
applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find
that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our
medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery.
On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy
19
patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient
is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical
procedure and anesthesia if we proceed quickly to surgery. In other words, we have a "prima facie" duty
to both benefit the patient and to "avoid harming" the patient. However, in the actual situation, we must
balance the demands of these principles by determining which carries more weight in the particular case.
Moral philosopher W.D. Ross claims that prima facie duties are always binding unless they are in conflict
with stronger or more stringent duties. A moral person's actual duty is determined by weighing and
balancing all competing prima facie duties in any particular case.

2. 3. Study cases

Case 1

Baby Doe

The case illustrates the function of principles in an applied ethical discussion.

In 1982, a couple from Bloomington, Indiana gave birth to a baby with severe mental and physical
disabilities. Among other complications, the infant, known as Baby Doe, had its stomach disconnected from
its throat and was thus unable to receive nourishment. Although this stomach deformity was correctable
through surgery, the couple did not want to raise a severely disabled child and therefore chose to deny
surgery, food, and water for the infant. Local courts supported the parents’ decision, and six days later Baby
Doe died. Should corrective surgery have been performed for Baby Doe? Arguments in favor of corrective
surgery derive from the infant’s right to life and the principle of paternalism which stipulates that we should
pursue the best interests of others when they are incapable of doing so themselves. Arguments against
corrective surgery derive from the personal and social disbenefit which would result from such surgery. If
Baby Doe survived, its quality of life would have been poor and in any case it probably would have died at
an early age. Also, from the parent’s perspective, Baby Doe’s survival would have been a significant
emotional and financial burden. When examining both sides of the issue, the parents and the courts
concluded that the arguments against surgery were stronger than the arguments for surgery. First, foregoing
surgery appeared to be in the best interests of the infant, given the poor quality of life it would endure.
Second, the status of Baby Doe’s right to life was not clear given the severity of the infant’s mental
impairment. For, to possess moral rights, it takes more than merely having a human body: certain cognitive
functions must also be present. The issue here involves what is often referred to as moral personhood, and
is central to many applied ethical discussions.

Moral issue:

Do you consider that the decision of parents (court) is right or not? Justified your opinion!

Case 2

Don't Goose me!

A role-play case study on animal protection


20
Authors: Kinchel Doerner (Dep. Biology, Western Kentucky Univ., USA), Bonnie Furman (Dep.
Biology, Western Kentucky Univ., USA), Deborah Power (Centro de Ciências Marinhas, Univ.
Algarve, Portugal), Adelino Canário (Centro de Ciências Marinhas, Univ. Algarve, Portugal),
Terri Klinger (School Marine Affairs, Univ. Washington, USA) Copyright © 2003, Iowa State
University. http://www.bioethics.iastate.edu/classroom/dontgooseme.html

Factual background
Canada Geese historically have bred in the Arctic in summer and migrated south only in winter. With
increasing urbanization in northern cities, food and nest sites have become widely available, and predation
rates are low. Consequently, the geese have become year round residents in cities, and their population
numbers have greatly expanded. In many northern cities (Seattle, Chicago, London, Vancouver) the Canada
geese are a nuisance and create potential public health problems by defecating in parks, on golf courses,
and in public waterways (ponds, lakes), where they can foul local water supplies. However, no incidences
of goose-borne illness have been reported. Their abundance now exceeds that at any time in the recent past.
As a consequence of the perceived threat to public health and well-being, management strategies have been
proposed that would lethally remove the geese by collecting and gassing them with carbon dioxide. The
resulting goose meat would be provided to the starving homeless.

A public meeting in which all stakeholders are present has been called for the Mayor to take a final decision
on the proposed course of action.

Stakeholders and concerns


Decision-making
The Mayor will take the final decision after the hearing.

Municipal Services
Municipal Services are responsible for animal population control. Alternative methods of removing the
birds have been considered (e.g hormone control, egg removal) but the urgency in resolving the problem
and anticipated costs led to the proposal that gassing by carbon dioxide is the most efficient method.
Because the meat will be of excellent quality, there is a proposal to sell it for public consumption and the
proceeds would cover some of the costs of the operation. Alternatively, there is a proposal from the Social
Services to distribute the meat to the homeless through charitable service organizations.

Public Health Bureau


The Department of Public Health favors’ lethal removal of Canada geese for the following reasons:
Goose excrement fouls both land and water resources within the city. These droppings can contain high
levels of bacteria and avian parasites. The bacteria and parasites both potentially threaten public health,
especially that of children and the elderly.
Other animal pests associated with Canada geese are increasing within the city. For example, rats that prey
on goose eggs and chicks are more numerous now than before.

Parents Against Geese


This is a popular movement that aims to wrest the control of local parks from geese. The group professes
to be animal lovers (most members have dogs, cats and other pets). When geese were present in low
numbers they were a popular attraction for parents and children. However, there are now so many geese
that they are perceived as a serious problem. They defecate everywhere, they destroy lawns and gardens,
21
and the park is out of bounds for children. There is fear of a health risk. Presence of geese on roadways
makes driving more dangerous. In addition, some people have claimed an increase in allergies perhaps
attributable to the geese, and their honking disturbs the peace.

CRAP - Citizens Responsible for Animal Protection


CRAP is an activist group for animal rights that is currently involved in many issues where animal welfare
is under consideration such as farm animal production, animal research and traditional hunting. This group
will not allow the geese to be molested in any way. They believe that in this case humans unfairly modified
the environment, which as it turns out, now is favourable for the geese. The geese should be left alone and
instead, humans should modify their behaviour to accommodate the geese. In the past CRAP has allegedly
committed acts of violence against those who don´t agree with them.

Social Services
The Department of Social Services is responsible for providing care and assistance to the large population
of homeless individuals within the city. In general, the department is understaffed and under funded and
has difficulty providing sufficient support for the homeless. Social Services strongly support the proposed
method of culling and gassing the geese. This will provide an affordable source of protein for distribution
to the homeless.

Chamber of Commerce
The Chamber of Commerce favours removal of the geese. The geese foul local parks and shopping areas
driving away both tourists and shoppers. However, the Chamber of Commerce is STRONGLY OPPOSED
to the free distribution of goose meat to the homeless because of potential negative effects on retailers´
profits.

Moral issues
Should we proceed with lethal removal?
If yes, should the carcasses be sold, given to the homeless, or otherwise disposed of?
If not, propose and defend alternative management strategies.

Classroom Procedure

1. Students will divide into groups of five.

a. A chairperson will be identified by determination of who is born first in the year. (instructor will explain)

b. The chairperson will chair the discussions and appoint a:

i. Recorder- will write down in a coherent manner all pertinent arguments

ii. Proactive Student- will develop the arguments to convince the city council to adopt their group´s position

iii. Reactive Student #1 and #2 these two students will anticipate the positions of other groups and develop
counter arguments.

2. The groups will have 5 minutes to formulate their arguments.

22
3. At the end of these 5 minutes the students will sign up (as individuals) in the order they wish to speak at
the public meeting.

4. The public meeting will convene with the instructor acting as the mayor.

a. The format will be that of a typical public meeting.

b. The floor will be opened and each individual will be allowed 1 minute to present their comment(s).

c. Individuals will be allowed to speak only once.

d. After all that are signed up have spoken, the mayor will retire to consider public comment and will return
with a final decision.

Chapter 3

Bioethics as socio-cultural phenomenon. Paternalism and anti-paternalism in


medicine and bioethics
23
3.1.Paternalism and anti-paternalism

Cultural pluralism is one of the characters of contemporary world. People from disparate cultural
backgrounds can make disparate moral judges on an act, taking place under the same circumstances. Culture
and tradition have a great impact on how bioethical issues are approach. Nowadays is even spoken about
different cultural models of bioethics: pragmatic model – approach to ethical problem in the key of
utilitarian ethics, liberal model - approach ethical problems in the scope of deontological theories,
personality model – approach the ethical problems in religious manner. Studies on cultural anthropology
suggest that there are cultural variations in attitudes toward truth telling, pain relief, and planning for end-
of-life, care and person autonomy. In what will follow in focus will be two different culturally approaches
to person autonomy: paternalistic - anti paternalistic approaches.

Paternalism

After Dworkin, Gerald, "Paternalism", The Stanford Encyclopedia of Philosophy (Summer 2010 Edition),
Edward N. Zalta (ed.), http://plato.stanford.edu/entries/paternalism/

Paternalism refers to attitudes or states of affairs that exemplify a traditional relationship between father
(pater) and child. Two conditions of paternalism are usually identified: interference with liberty and a
beneficent intention towards those whose liberty is interfered with. Paternalism is the interference of a state
or an individual with another person, against their will, and defended or motivated by a claim that the person
interfered with will be better off or protected from harm.
The issue of paternalism is in concern when:
- The government requires people to contribute to a pension system (Social Security). It requires
motorcyclists to wear helmets. It forbids people from swimming at a public beach when lifeguards
are not present. It forbids the sale of various drugs deemed to be ineffective. It forbids the sale of
various drugs believed to be harmful. It does not allow consent to certain forms of assault to be a
defense against prosecution for that assault.
- Doctors do not tell their patients the truth about their medical condition. A physician may tell the
wife of a man whose car went off a bridge into the water and drowned that he died instantly when
in fact he died a rather ghastly death.

- A husband may hide the sleeping pills from a depressed wife. A psychiatrist confiscating sharp
objects from someone who is suicidally depressed. A parent forbidding their children to engage in
dangerous activities,

- A teacher may be less than honest about telling a student that he has little philosophical
(Mathematical etc. ) ability.

As the examples indicate the question of paternalism is one that arises in many different areas of our
personal and public life. All of these rules, policies, and actions may be done for various reasons; may be
justified by various considerations. When they are justified solely on the grounds that the person affected
would be better off, or would be less harmed, as a result of the rule, policy, etc., and the person in question
would prefer not to be treated this way, we have an instance of paternalism.

The analysis of paternalism involves at least the following elements. It involves some kind of limitation on
the freedom or autonomy of some agent and it does so for a particular class of reasons. Condition one is the
trickiest to capture. Clear cases include threatening bodily compulsion, lying, withholding information that

24
the person has a right to have, or imposing requirements or conditions. So being it is raised certain
theoretical issues. Perhaps the most important is: what powers it is legitimate for a state, operating both
coercively and in terms of incentives, to possess. It also raises questions about the proper ways in which
individuals, either in an institutional or purely personal setting, should relate to one another. How should
we think about individual autonomy and its limits? What is it to respect the personhood of others? What is
the trade-off, if any, between regard for the welfare of another and respect for their right to make their own
decisions? Or when paternalism is justified?
There are various views about when paternalism is justified. The following terminology is useful.
Hard vs. soft paternalism
Soft paternalism is the view that the only conditions under which state paternalism is justified is when it is
necessary to determine whether the person being interfered with is acting voluntarily and knowledgeably.
To use Mill's famous example of the person about to walk across a damaged bridge, if we could not
communicate the danger (he speaks only Japanese) a soft paternalist would justify forcibly preventing him
from crossing the bridge in order to determine whether he knows about its condition. If he knows, and
wants to, say, commit suicide he must be allowed to proceed. A hard paternalist says that, at least
sometimes, it may be permissible to prevent him from crossing the bridge even if he knows of its condition.
We are entitled to prevent voluntary suicide.
Broad vs. narrow paternalism
A narrow paternalist is only concerned with the question of state coercion, i.e. the use of legal coercion. A
broad paternalist is concerned with any paternalistic action: state, institutional (hospital policy), or
individual.
Weak vs. strong paternalism
A weak paternalist believes that it is legitimate to interfere with the means that agents choose to achieve
their ends, if those means are likely to defeat those ends. So if a person really prefers safety to convenience
then it is legitimate to force them to wear seatbelts. A strong paternalist believes that people may be
mistaken or confused about their ends and it is legitimate to interfere to prevent them from achieving those
ends. If a person really prefers the wind rustling through their hair to increased safety it is legitimate to
make them wear helmets while motorcycling because their ends are irrational or mistaken. Another way of
putting this: we may interfere with mistakes about the facts but not mistakes about values. So if a person
tries to jump out of a window believing he will float gently to the ground we may restrain him. If he jumps
because he believes that it is important to be spontaneous we may not.
Moral vs. welfare paternalism
The usual justification for paternalism refers to the interests of the person being interfered with. These
interests are defined in terms of the things that make a person's life go better; in particular their physical
and psychological condition. It is things like death or misery or painful emotional states which are in
question. Sometimes, however, advocates of state intervention seek to protect the moral welfare of the
person. So, for example, it may be argued that prostitutes are better off being prevented from plying their
trade even if they make a decent living and their health is protected against disease. They are better off
because it is morally corrupting to sell one's sexual services. The interference is justified, therefore, to
promote the moral well-being of the person. This then can be called moral paternalism. Still another
distinction within moral paternalism is between interferences to improve a person's moral character, and
hence her well-being, and interferences to make someone a better person—even if her life does not go better
for her as a result.
Normative Issues
Normatively spiking the question is: is paternalism justified at all or not?

25
The normative options seem to be just two. Either we are never permitted to do good for others against their
wishes, and in ways which limit their liberty, or we are permitted to do so.
Why might one think that at least the state may never do so? One might think so because of various beliefs
about the impossibility of in fact doing good for people against their will or because one thinks that although
possible to do good it is in fact inconsistent with some normative standard which ought to prevail. With
respect to the impossibility question one might believe either that it is not possible to do any good by acting
paternalistically or that although it is possible to do some good the process will (almost) always produce
bads which outweigh the good.
If one thought that almost)always more harm than good is done by the state when it acts paternalistically
this raises the question of whether we can distinguish the conditions in which (rarely) more good than harm
is done and build that into our guidelines. If this is possible, and so distinguishing does not create further
harms which outweigh the good produced, and we think, the only issue is good promotion we should
sometimes be paternalists. If it is impossible to distinguish the “good” from the “bad” cases then, at least if
we are rule consequentialists, we ought not to have such a rule; and we ought not to try and make the
distinctions on a case by case basis.
But one might believe that the question of whether more good than harm is produced is not simply an
empirical one. It depends on our understanding of the good of persons. If the good simply included items
such as longer life, greater health, more income, or less depression, then it makes it look like an empirical
issue. But if we conceive of the good of individuals as including items such as being respected as an
independent agent, having a right to make decisions for oneself, or having one's autonomy not infringed,
then the issue of whether the agent is better off after being paternalised is partly a normative matter. One
might believe that one cannot make people better off by infringing their autonomy in the same way that
some people believe one cannot make a person better off by putting them in a Nozickian experience
machine (one in which they are floating in a tank but seem to be having all kinds of wonderful experiences).
Compare Mill's statement that “…a man's mode of laying out his own existence is best not because it is the
best in itself, but because it is his own mode…” (1859, Chapter III).
Kantian views are frequently absolutistic in their objections to paternalism. On these views we must always
respect the rational agency of other persons. To deny an adult the right to make their own decisions,
however mistaken from some standpoint they are, is to treat them as simply means to their own good, rather
than as ends in themselves. In a way anti-paternalism is already incorporated into Kantian theories by their
prohibition against lying and force—the main instruments of paternalistic interference. Since these
instrumentalities are already denied even to prevent individuals from harming others, they will certainly be
forbidden to prevent them from harming themselves. Of course, one may object to the former absolutism
while accepting the latter.

If one believes that sometimes paternalism is justifiable one may do so for various kinds of theoretical
reasons. The broadest is simply consequentialist, i.e. more good than harm is produced. A narrower
justification is that sometimes the individuals (long-run) autonomy is advanced by restricting his autonomy
(short-run). So one might prevent people from taking mind-destroying drugs on the grounds that allowing
them to do so destroys their autonomy and preventing them from doing so preserves it. This is essentially
Mill's argument against allowing people to contract into slavery. Note that if the theory of the good
associated with a particular consequentialism is broad enough, i.e., includes autonomy as one of the goods,
it can be equivalent to the autonomy theory (assuming that the structure of the autonomy view is a
maximizing one).
A different theoretical basis is (moral) contractualism. On this view if there are cases of justified
paternalism they are justified on the basis that we (all of us) would agree to such interference, given suitable
26
knowledge and suitable motivation. So, for instance, it might be argued that since we know we are subject
to depression we all would agree, at least, to short-term anti-suicide interventions, to determine whether we
are suffering from such a condition, and to attempt to cure it. More generally, we might accept what
Feinberg called “soft paternalism.” This is the view that when we are not acting fully voluntarily it is
permissible to intervene to provide information, or to point out defects in our rationality, but that if we then
do make a voluntary choice it must be respected. Or we might agree to being forced to wear seat-belts
knowing our disposition to discount future benefits for present ones. The justification here is neither
consequentialist nor based simply on the preservation of autonomy. Rather either kind of consideration may
be taken into account, as well as others, in determining what we would reasonably agree to.

Anti - paternalism

After Buss, Sarah, "Personal Autonomy", The Stanford Encyclopedia of Philosophy (Fall 2008 Edition),
Edward N. Zalta (ed.), http://plato.stanford.edu/cgi-bin/encyclopedia/archinfo.cgi?entry=personal-
autonomy

Christman, John, "Autonomy in Moral and Political Philosophy", The Stanford Encyclopedia of Philosophy
(Spring 2011 Edition), Edward N. Zalta (ed.), http://plato.stanford.edu/entries/autonomy-moral/

Ant - paternalism is opposite to paternalism. It is the liberal view interfere with the idea of human
autonomy.

Individual autonomy is an idea that is generally understood to refer to the capacity to be one's own person,
to live one's life according to reasons and motives that are taken as one's own and not the product of
manipulative or distorting external forces. To be autonomous is to be a law to oneself; autonomous agents
are self-governing agents.
What conditions must be satisfied in order to ensure that we govern ourselves when we act? To govern
oneself one must be in a position to act competently and from desires (values, conditions, etc.) that are in
some sense one's own. This picks out the two families of conditions often proffered in conceptions of
autonomy: competency conditions and authenticity conditions. Competency includes various capacities for
rational thought, self-control, and freedom from debilitating pathologies, systematic self-deception, and so
on. Authenticity conditions often include the capacity to reflect upon and endorse (or identify with) one's
desires, values, and so on. The most influential models of authenticity in this vein claim that autonomy
requires second-order identification with first order desires.
Thus, when an individual makes declaration that has the right to live autonomously, she is denying that
anyone else has the authority to control her activity within this sphere; she is saying that any exercise of
power over this activity is illegitimate unless she authorizes it herself.
Most of us want to be autonomous because we want to be accountable for what we do, and because it seems
that if we are not the ones calling the shots, then we cannot be accountable. More importantly, perhaps, the
value of autonomy is tied to the value of self-integration. We don't want to be alien to, or at war with,
ourselves; and it seems that when our intentions are not under our own control, we suffer from self-
alienation. Of course, no one can govern herself without being subject to influences whose power does not
derive from her own authority: everything we do is a response to past and present circumstances over which
we have no control. But some of the forces that move us to act do not merely affect which actions we choose
to perform, nor how we govern ourselves in making these choices. They influence us in a way that makes
a mockery of our authority to determine our own actions. They undermine our autonomy. What
27
distinguishes autonomy-undermining influences on a person's decision, intention, or will from those
motivating forces that merely play a role in the self-governing process? This is the question that all accounts
of autonomy try to answer. As the number and variety of these accounts indicate, the distinction is extremely
elusive. There is certainly widespread agreement about the paradigm threats to personal autonomy:
brainwashing and addiction are the favorite examples in the philosophical literature. If an agent fails to
govern herself when she acts, this must be because what she does is independent of her power to determine
how she will act.

3.2. Inform consent

After Kelly A. Edwards, M.A. Informed Consent. 1998, University of Washington.


http://depts.washington.edu/bioethx/topics/consent.html

Gail Van Norman, MD. Informed Consent in the Operating Room. niversity of Washington School of
Medicine. http://depts.washington.edu/bioethx/topics/infc.html

The paternalistic - non paternalistic quarrel is especially hot in medical context. In same eastern cultural
traditions the paternalism is the dominant approach to patient. In western world the physician can
justifiably apply the principle of paternalism in a particular case only after he has determined both that there
are no alternate non-paternalistic courses of action which will have the same results. Concluding it is to say
that in western culture medical paternalism is justified only when utilitarian considerations apply and when
they do not violate personal rights. This occurs only when the subject of paternalism is not fully competent,
when he has explicitly or by implication given consent, or when it can be reasonably concluded, from the
knowledge of his emotional and cognitive make up, that he would approve of such treatment.
The practical form of anti paternalism is informed consent.
Informed consent is the process by which a fully informed patient can participate in choices about her health
care. It originates from the legal and ethical right the patient has to direct what happens to her body and
from the ethical duty of the physician to involve the patient in her health care. It is originate in idea of
autonomy , analised above. The most important goal of informed consent is that the patient have an
opportunity to be an informed participant in his health care decisions. It is generally accepted that complete
informed consent includes a discussion of the following elements:
- the nature of the decision/procedure
- reasonable alternatives to the proposed intervention
- the relevant risks, benefits, and uncertainties related to each alternative
- assessment of patient understanding
- the acceptance of the intervention by the patient

In order for the patient's consent to be valid, he must be considered competent to make the decision at hand
and his consent must be voluntary. It is easy for coercive situations to arise in medicine. Patients often feel
powerless and vulnerable. To encourage voluntariness, the physician can make clear to the patient that he
is participating in a decision, not merely signing a form. With this understanding, the informed consent
process should be seen as an invitation to him to participate in his health care decisions. The physician is
also generally obligated to provide a recommendation and share her reasoning process with the patient.
Comprehension on the part of the patient is equally as important as the information provided. Consequently,
the discussion should be carried on in layperson's terms and the patient's understanding should be assessed
along the way.
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How do you know when you have said enough about a certain decision? Most of the literature and law
in this area suggest one of three approaches:
- reasonable physician standard: what would a typical physician say about this intervention? This
standard allows the physician to determine what information is appropriate to disclose. However, it
is probably not enough, since most research in this area shows that the typical physician tells the
patient very little. This standard is also generally considered inconsistent with the goals of informed
consent as the focus is on the physician rather than on what the patient needs to know.

- reasonable patient standard: what would the average patient need to know in order to be an informed
participant in the decision? This standard focuses on considering what a patient would need to know
in order to understand the decision at hand.

- subjective standard: what would this patient need to know and understand in order to make an
informed decision? This standard is the most challenging to incorporate into practice, since it
requires tailoring information to each patient.

Most states have legislation or legal cases that determine the required standard for informed consent. In
the state of Washington, we use the "reasonable patient standard." The best approach to the question of how
much information is enough is one that meets both your professional obligation to provide the best care and
respects the patient as a person with the right to a voice in health care decisions.
Most health care institutions, must have policies that state which health interventions require a signed
consent form. For example, surgery, anesthesia, and other invasive procedures are usually in this category.
These signed forms are really the culmination of a dialogue required to foster the patient's informed
participation in the clinical decision. For a wide range of decisions, written consent is neither required or
needed, but some meaningful discussion is needed. For instance, a man contemplating having a prostate-
specific antigen screen for prostate cancer should know the relevant arguments for and against this
screening test, discussed in layman's terms.
In most cases, it is clear whether or not patients are competent to make their own decisions. Occasionally,
it is not so clear. Patients are under an unusual amount of stress during illness and can experience anxiety,
fear, and depression. The stress associated with illness should not necessarily preclude one from
participating in one's own care. However, precautions should be taken to ensure the patient does have the
capacity to make good decisions. There are several different standards of decision making capacity.
Generally you should assess the patient's ability to:

- understand his or her situation,

- understand the risks associated with the decision at hand, and

- communicate a decision based on that understanding.

When this is unclear, a psychiatric consultation can be helpful. Of course, just because a patient refuses a
treatment does not in itself mean the patient is incompetent. Competent patients have the right to refuse
treatment, even those treatments that may be life-saving. Treatment refusal may, however, be a flag to
pursue further the patient's beliefs and understanding about the decision, as well as your own.
Patients can move in and out of a coherent state as their medications or underlying disease processes ebb
and flow. You should do what you can to catch a patient in a lucid state - even lightening up on the
medications if necessary - in order to include him in the decision making process.

29
If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate
decision maker must speak for her. There is a specific hierarchy of appropriate decision makers defined by
state law (also see the DNR topic page). If no appropriate surrogate decision maker is available, the
physicians are expected to act in the best interest of the patient until a surrogate is found or appointed.
The patient's consent should only be "presumed", rather than obtained, in emergency situations when
the patient is unconscious or incompetent and no surrogate decision maker is available. In general, the
patient's presence in the hospital ward, ICU or clinic does not represent implied consent to all treatment
and procedures. The patient's wishes and values may be quite different than the values of the physician's.
While the principle of respect for person obligates you to do your best to include the patient in the health
care decisions that affect his life and body, the principle of beneficence may require you to act on the
patient's behalf when his life is at stake.

Influence can be applied to the information given to patients, and generally falls into three categories:
- coercion
- manipulation
- persuasion
Coercion is the application of a credible threat to the patient, and is always unethical. Manipulation
involves incomplete or nontruthful presentation of information, such as lying, omitting vital information,
or deliberately deceiving. Manipulation is always ethically suspected. Persuasion involves the presentation
of a rational argument for a choice, and is permissible, even desirable during the consent process. Patients
recognize that physicians have expertise and advice to offer about their care, and expect physicians to be
forthright with recommendations. The idea that information may harm patients is often cited as a reason to
curtail the discussion of risks with patients about to undergo treatment/care. (anesthesia and surgery).
Multiple studies have failed to demonstrate differences in the way patients and observers rate the stress
levels of patients who receive detailed information when compared with patients who received little or no
information about risks.
Patients have the right to refuse information, but the request must originate from the patient and not the
physician.

3.3. Study cases

Case 1
Mrs. R, a 29-year old mother, is admitted into hospital with abdominal pain. The medical examination
shows that she is suffering from an incurable cancer with few months to live and with great suffering before
her. Despite the fact that the woman has specifically asked to be told exactly what she is facing, the
physician informs her that the results of the examination are not conclusive and that he will see her weekly
as an outpatient. Mrs. R. feels better after the appointment.
Is the decision of doctor correct one?

Case 2
Mrs. B is about to have a life-or-death operation as a result of a car accident, in which one of her children
has died. Mrs. B asks the physician about her children and he lies to her, saying that “the children are
worried about her”. The physician decides to hide this information from her because he thinks that, in her
condition, knowing the truth could kill her.
Is the decision of doctor good one?
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Case 3

informed Consent: http://depts.washington.edu/bioethx/topics/consntd1.html

A 64-year-old woman with MS (Multiple sclerosis (MS) is a demyelinating disease of the central nervous
system, causing impairment in sensation, movement, cognition, or other functions depending on which
nerves are involved.) is hospitalized. The team feels she may need to be placed on a feeding tube soon to
assure adequate nourishment. They ask the patient about this in the morning and she agrees. However, in
the evening (before the tube has been placed), the patient becomes disoriented and seems confused about
her decision to have the feeding tube placed. She tells the team she doesn't want it in. They revisit the
question in the morning, when the patient is again lucid. Unable to recall her state of mind from the previous
evening, the patient again agrees to the procedure.

Is this patient competent to decide? Which preference should be honored?

Case 4

A 55-year-old man has a 3-month history of chest pain and fainting spells. You feel his symptoms merit
cardiac catheterization (Cardiac catheterization is the insertion of a catheter into a chamber or vessel of
the heart.). You explain the risks and potential benefits to him, and include your assessment of his likely
prognosis without the intervention. He is able to demonstrate that he understands all of this, but refuses
the intervention.

Can he do that, legally? Should you leave it at that?

Chapter 4

Bioethics in practical medicine


Practical Medicine is the art and science of healing (the word medicine is derived from the Latin
ars medicina, meaning the art of healing) It encompasses a range of health care practices evolved to
maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies
health science, biomedical research, and medical technology to diagnose and treat injury and disease,
31
typically through medication, surgery, or some other form of therapy. Though medical technology and
clinical expertise are pivotal to contemporary medicine, successful face-to-face relief of actual suffering
continues to require the application of ordinary human feeling and compassion, known in English as bedside
manner.
Any tip of practice (including Medical, Bioethical etc.) is a coherent and complex set of activities,
socially constructed. It has distinctive goals and standards of excellence that help make the practice what it
is, and that cannot be fully under stood apart from it. These defining goals and standards develop through
time. This development is not plain and easy, it consists of many periods and moments of uncertainly.
Nowadays in medical practice also there are some issues on which the consensus is not achieved. These
issues are bioethical problems related to life and death (euthanasia), problems of reproduction, and moral
problems of genetic.

4.1. Euthanasia

Euthanasia : http://www.bbc.co.uk/ethics/euthanasia/infavour/infavour_1.shtml#h8

Euthanasia (literally "good death" in Old Greek) refers to the practice of ending a life in a painless
manner. Euthanasia can be several types.

A. Euthanasia by consent
Euthanasia may be conducted with consent (voluntary euthanasia) or without consent (involuntary
euthanasia). Involuntary euthanasia is conducted where an individual makes a decision for another person
incapable of doing so. The decision can be made based on what the incapacitated individual would have
wanted, or it could be made on substituted judgment of what the decision maker would want were he or she
in the incapacitated person's place, or finally, the decision could be made by assessing objectively whether
euthanasia is the most beneficial course of treatment. In any case, euthanasia by proxy consent is highly
controversial, especially because multiple proxies may claim the authority to decide for the patient and may
or may not have explicit consent from the patient to make that decision.
B. Euthanasia by means
Euthanasia may be conducted passively, non-actively, and actively. Passive euthanasia entails the
withholding of common treatments (such as antibiotics, pain medications, or surgery) or the distribution of
a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double
effect). Passive euthanasia is the most accepted form, and it is a common practice in most hospitals. Non-
active euthanasia entails the withdrawing of life. Active euthanasia entails the use of lethal substances or
forces to kill and is the most controversial means.
Assisted suicide is the process by which an individual, who may otherwise be incapable, is provided
with the means (drugs or equipment) to commit suicide. In some cases, the terms aid in dying or death
with dignity are preferred. These terms are often used to draw a distinction from suicide; in some legal
jurisdictions, "suicide" (whether assisted or not) remains illegal, while "aid in dying" is permitted.

History

The term euthanasia comes from the Greek words "eu"-meaning good and "thanatos"-meaning
death, which combined means “well-death” or "dying well". Hippocrates mentions euthanasia in the
Hippocratic Oath, which was written between 400 and 300 B.C. The original Oath states: “To please no

32
one will I prescribe a deadly drug nor give advice which may cause his death.” Despite this, the ancient
Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in
consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the
Stoics and Epicureans, where a person no longer cared for his life.
English Common Law from the 1300s until the middle of the last century made suicide a criminal
act in England and Wales. Assisting others to kill themselves remains illegal in that jurisdiction. However,
in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that
would facilitate the death of those whose lives had become burdensome as a result of "torturing and
lingering pain".

A. Modern history

Since the 19th Century, euthanasia has sparked intermittent debates and activism in North America
and Europe. According to medical historian Ezekiel Emanuel, it was the availability of anesthesia that
ushered in the modern era of euthanasia. In 1828, the first known anti-euthanasia law in the United States
was passed in the state of New York, with many other localities and states following suit over a period of
several years. The first major effort to legalize euthanasia in the United States arose as part of the eugenics
movement in the early years of the twentieth century. In an article in the Bulletin of the History of Medicine,
Brown University historian Jacob M. Appel documented extensive political debate over legislation to
legalize physician-assisted suicide in both Iowa and Ohio in 1906. Appel indicates social activist Anna S.
Hall was the driving force behind this movement. In his book A Merciful End, Ian Dowbiggen has revealed
the role that leading public figures, including Clarence Darrow and Jack London, played in advocating for
the legalization of euthanasia.
Euthanasia societies were formed in England in 1935 and in the U.S.A. in 1938 to promote
aggressive euthanasia. Although euthanasia legislation did not pass in the U.S. or England, in 1937, doctor-
assisted euthanasia was declared legal in Switzerland as long as the person ending the life has nothing to
gain. During this period, euthanasia proposals were sometimes mixed with eugenics. While some
proponents focused on voluntary euthanasia for the terminally ill, others expressed interest in involuntary
euthanasia for certain eugenic motivations (e.g., mentally "defective"). During this same era, meanwhile,
U.S. court trials tackled cases involving critically ill people who requested physician assistance in dying as
well as “mercy killings”, such as by parents of their severely disabled children.
Prior to and during World War II, the Nazis carried out an involuntary euthanasia program, largely
in secret. In 1939, Nazis, in what was code-named Action T4, killed children under three who exhibited
mental retardation, physical deformity or other debilitating problems which they considered gave the
disabled child "life unworthy of life”. This program was later extended to include older children and adults..
Inmates of mental asylums in Germany and Austria would be transported to an intermediate facility, from
where they would be retransported to one of six killing centres at Brandenburg near Berlin (January 1940
- September 1940), Grafeneck near Stuttgart (January 1940 - December 1940), Hartheim near Linz in
Austria (January 1940 - December 1944), Sonnenstein/Pirna near Dresden (April 1940 - August 1943),
Bernburg near Magdeburg (September 1940 - April 1943), Hadamar near Koblenz (January 1941 - August
1941). Religious protest especially but not limited to Catholic prelates caused Hitler to order the official
cancellation of T4 but postwar investigation made it clear that the practice continued in institutes where
personnel were sympathetic to eugenic policies.

33
The T4 program of the Nazis was extended to killing of concentration camp inmates when Philipp
Bouhler,the head of the T4 program, allowed Heinrich Himmler to utilize T4 doctors, staff and facilities to
kill concentration camp prisoners who were "most seriously ill" in a program designated "14f13".

B. Post-War history

Due to outrage over Nazi euthanasia, in the 1940s and 1950s there was very little public support for
euthanasia, especially for any involuntary, eugenics-based proposals. Catholic church leaders, among
others, continued speaking against euthanasia as a violation of the sanctity of life. (Nevertheless, owing to
its principle of double effect, Roman Catholic moral theology did leave room for shortening life with pain-
killers and what could be characterized as passive euthanasia.) On the other hand, judges were often lenient
in mercy-killing cases. By the 1960s, advocacy for a right-to-die approach to voluntary euthanasia
increased. A key turning point in the debate over voluntary euthanasia (and physician assisted dying), at
least in the United States, was the public furor over the case of Karen Ann Quinlan. The Quinlan case paved
the way for legal protection of voluntary passive euthanasia. In 1977, California legalized living wills and
other states soon followed suit.
In 1994, Oregon voters approved the Death with Dignity Act, permitting doctors to assist terminal
patients with six months or less to live to end their lives. The U.S. Supreme Court allowed such laws in
1997. The Bush administration failed in its attempt to use drug law to stop Oregon in 2001, in the case
Gonzales v. Oregon. In 1999, non-aggressive euthanasia was permitted in Texas.
In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were
loosened. During that year, physician-assisted suicide was approved in Belgium. Belgium's at the time most
famous author Hugo Claus, suffering from Alzheimer's disease, was among those that asked for euthanasia.
He died in March 2008, assisted by an Antwerp doctor. Australia's Northern Territory approved a
euthanasia bill in 1995, but that was overturned by Australia’s Federal Parliament in 1997.
In November 2008, Washington Initiative 1000 made Washington the second U.S. state to legalize
physician-assisted suicide.
As of 2008, some forms of euthanasia are legal in Belgium, Luxembourg, The Netherlands,
Switzerland, the U.S. states of Oregon and Washington the Autonomous Community of Andalusia (Spain),
and Thailand.
Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration
of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route
is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain
euthanasia: Intravenous administration is the most reliable and rapid way to accomplish euthanasia and
therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg
sodium thiopental (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous
dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide
(Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given
intravenously, in order to ensure optimal availability. Only for pancuronium bromide (Pavulon) are there
substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.

Arguments for and against voluntary euthanasia

Since World War II, the debate over euthanasia in Western countries has centered on voluntary
euthanasia (VE) within regulated health care systems. In some cases, judicial decisions, legislation, and
regulations have made VE an explicit option for patients and their guardians. Proponents and critics of such
VE policies offer the following reasons for and against official voluntary euthanasia policies:

34
Reasons given for voluntary euthanasia:

 Choice: Proponents of VE emphasize that choice is a fundamental principle for liberal democracies
and free market systems.
 Quality of Life: The pain and suffering a person feels during a disease, even with pain relievers, can
be incomprehensible to a person who has not gone through it. Even without considering the physical
pain, it is often difficult for patients to overcome the emotional pain of losing their independence.
 Economic costs and human resources: Today in many countries there is a shortage of hospital space.
The energy of doctors and hospital beds could be used for people whose lives could be saved instead
of continuing the life of those who want to die which increases the general quality of care and
shortens hospital waiting lists. It is a burden to keep people alive past the point they can contribute
to society, especially if the resources used could be spent on a curable ailment.

Reasons given against voluntary euthanasia:

 Professional role: Critics argue that voluntary euthanasia could unduly compromise the professional
roles of health care employees, especially doctors. They point out that European physicians of
previous centuries traditionally swore some variation of the Hippocratic Oath, which in its ancient
form excluded euthanasia: "To please no one will I prescribe a deadly drug nor give advice which
may cause his death." However, since the 1970s, this oath has largely fallen out of use.
 Moral: Some people consider euthanasia of some or all types to be morally unacceptable. This view
usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the
morality of which is the subject of active debate.
 Theological: Voluntary euthanasia has often been rejected as a violation of the sanctity of human
life. Specifically, some Christians argue that human life ultimately belongs to God, so that humans
should not be the ones to make the choice to end life. Orthodox Judaism takes basically the same
approach, however, it is more open minded, and does, given certain circumstances, allow for
euthanasia to be exercised under passive or non-aggressive means. Accordingly, some theologians
and other religious thinkers consider voluntary euthanasia (and suicide generally) as sinful acts, i.e.
unjustified killings.
 Feasibility of implementation: Euthanasia can only be considered "voluntary" if a patient is mentally
competent to make the decision, i.e., has a rational understanding of options and consequences.
Competence can be difficult to determine or even define.
 Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will
soon be curable, the correct action is sometimes considered to attempt to bring about a cure or
engage in palliative care.
 Wishes of Family: Family members often desire to spend as much time with their loved ones as
possible before they die.
 Consent under pressure: Given the economic grounds for voluntary euthanasia (VE), critics of VE
are concerned that patients may experience psychological pressure to consent to voluntary
euthanasia rather than be a financial burden on their families. Even where health costs are mostly
covered by public money, as in various European countries, VE critics are concerned that hospital
personnel would have an economic incentive to advise or pressure people toward euthanasia
consent.

Euthanasia and religion

Catholic teaching condemns euthanasia as a "crime against life". The teaching of the Catholic
Church on euthanasia rests on several core principles of Catholic ethics, including the sanctity of human
life, the dignity of the human person, concomitant human rights, due proportionality in casuistic remedies,
the unavoidability of death, and the importance of charity. The Church's official position is the 1980
35
Declaration on Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith. In Catholic
medical ethics official pronouncements strongly oppose active euthanasia, whether voluntary or not, while
allowing dying to proceed without medical interventions that would be considered "extraordinary" or
"disproportionate." The Declaration on Euthanasia states that:

"When inevitable death is imminent... it is permitted in conscience to take the decision to refuse
forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the
normal care due to a sick person in similar cases is not interrupted." The Declaration concludes that doctors,
beyond providing medical skill, must above all provide patients "with the comfort of boundless kindness
and heartfelt charity". Although the Declaration allows people to decline heroic medical treatment when
death is imminently inevitable, it unequivocably prohibits the hastening of death and restates Vatican II's
condemnation of "crimes against life 'such as any type of murder, genocide, abortion, euthanasia, or
willful suicide'".

Jewish medical ethics have become divided, partly on denominational lines, over euthanasia and
end of life treatment since the 1970s. Generally, Jewish thinkers oppose voluntary euthanasia, often
vigorously, though there is some backing for voluntary passive euthanasia in limited circumstances.
Likewise, within the Conservative Judaism movement, there has been increasing support for passive
euthanasia (PAD) In Reform Judaism response, the preponderance of anti-euthanasia sentiment has shifted
in recent years to increasing support for certain passive euthanasia (PAD) options.

Islam categorically forbids all forms of suicide and any action that may help another to kill
themselves. It is forbidden for a Muslim to plan, or come to know through self-will, the time of his own
death in advance. The precedent for this comes from the Islamic prophet Muhammad having refused to
bless the body of a person who had committed suicide. If an individual is suffering from a terminal illness,
it is permissible for the individual to refuse medication and/or resuscitation. Other examples include
individuals suffering from kidney failure who refuse dialysis treatments and cancer patients who refuse
chemotherapy.

Palliative care

Many think palliative care as a proper alternative to euthanasia. Palliative care is physical, emotional
and spiritual care for a dying person when cure is not possible. It includes compassion and support for
family and friends. Competent palliative care may well be enough to prevent a person feeling any need to
contemplate euthanasia. You matter because you are you. You matter to the last moment of your life and
we will do all we can to help you die peacefully, but also to live until you die. The key to successful
palliative care is to treat the patient as a person, not as a set of symptoms, or medical problems. The World
Health Organization states that palliative care affirms life and regards dying as a normal process; it neither
hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and
spiritual aspects of the patient. Making things better for patient, family and friends.

4. 2. Bioethics and reproduction

Within the framework of WHO's definition of health as a state of complete physical, mental and
social well-being, and not merely the absence of disease or infirmity. And reproductive health, or sexual
36
health/hygiene, is a component of this state of well being. It addresses the reproductive processes,
functions and system at all stages of life. Reproductive health, therefore, implies that people are able to
have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the
freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be
informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation
of their choice, and the right of access to appropriate health care services. The freedom to decide coupled
with technological advance in reproductive sphere give rise of some ethical debates concerning forms of
(A) reproducing on one hand and (B) abortion on the other hands.

A. Advanced methods of reproduction and ethical debates

Children are flowers of life and appearance of a new life is the motive of happiness while infertility
is a cause of distress. Today’s technologies offer the chance to reduce this distress by means In vitro
fertilization (IVF) and Surrogacy
In vitro fertilization (IVF) is a process by which egg cells are fertilized by sperm outside of the
womb, in vitro. The term in vitro, from the Latin root meaning in glass, is used, because early biological
experiments involving cultivation of tissues outside the living organism from which they came, were carried
out in glass containers such as beakers, test tubes, or petri dishes. Today, the term in vitro is used to refer
to any biological procedure that is performed outside the organism it would normally be occurring in, to
distinguish it from an in vivo procedure, where the tissue remains inside the living organism within which
it is normally found. Initially IVF was developed to overcome infertility due to problems of the fallopian
tube, but it turned out that it was successful in many other infertility situations as well. The introduction of
intracytoplasmic sperm injection (ICSI) addresses the problem of male infertility to a large extent.
For IVF to be successful it may be easier to say that it requires healthy ova, sperm that can fertilize, and a
uterus that can maintain a pregnancy. In the simplest case, a woman is given a course of hormone treatments
to cause her ovaries to produce multiple eggs. The eggs are surgically removed just prior to ovulation, either
under general anesthesia through the abdomen (laparoscopy) or under local anesthesia through the wall of
the vagina (transvaginal retrieval). They are then placed in a culture dish with the father’s sperm. During
the next few days, the dish is periodically examined to see if fertilization has occurred. In approximately
48 hours, when the embryos reach the eight-cell stage, those that appear healthy and that are growing
normally are transferred into the uterus, where, it is hoped, some will implant and develop full term. A
woman may have to undergo several treatment cycles before she becomes pregnant.
Surrogacy is a method of reproduction whereby a woman agrees to become pregnant and deliver a child
for a contracted party. A surrogate mother is the woman who is pregnant with the child and intends to
relinquish it after birth. The word surrogate, from Latin subrŏgare (to substitute), means appointed to act
in the place of. The intended parent(s) is the individual or couple who intends to rear the child after its birth.
In traditional surrogacy (aka the Straight method) the surrogate is pregnant with her own biological
child, but this child was conceived with the intention of relinquishing the child to be raised by others; by
the biological father and possibly his spouse or partner, either male or female. The child may be conceived
via home artificial insemination using fresh or frozen sperm or impregnated via IUI (intrauterine
insemination) which is performed at a fertility clinic.
In gestational surrogacy the surrogate becomes pregnant via embryo transfer with a child of which
she is not the biological mother. She may have made an arrangement to relinquish it to the biological mother
or father to raise, or to a parent who is themselves unrelated to the child (e. g. because the child was

37
conceived using egg donation, sperm donation or is the result of a donated embryo). The surrogate mother
may be called the gestational carrier.
Altruistic surrogacy is a situation where the surrogate receives no financial reward for her pregnancy
or the relinquishment of the child (although usually all expenses related to the pregnancy and birth are paid
by the intended parents such as medical expenses, maternity clothing, and other related expenses).
Commercial surrogacy is a form of surrogacy in which a gestational carrier is paid to carry a child to
maturity in her womb and is usually resorted to by well off infertile couples who can afford the cost involved
or people who save and borrow in order to complete their dream of being parents. This procedure is legal
in several countries including in India where due to excellent medical infrastructure, high international
demand and ready availability of poor surrogates it is reaching industry proportions. Commercial surrogacy
is sometimes referred to by the emotionally charged and potentially offensive terms "wombs for rent",
"outsourced pregnancies" or "baby farms".

Ethical problems of reproduction

After Mary Carrington Coutts. Ethical Issues in In Vitro Fertilization http://bioethics.georgetown.edu


Sue A. Meinke. Surrogate Motherhood: Ethical and Legal Issues
http://bioethics.georgetown.edu/publications/scopenotes/sn6.pdf

Infertility may have profound psychological effects. Partners may become more anxious to
conceive, ironically increasing sexual dysfunction. Marital discord often develops in infertile couples,
especially when they are under pressure to make medical decisions. Women trying to conceive often have
clinical depression rates similar to women who have heart disease or cancer. Even couples undertaking IVF
face considerable stress. Emotional stress and marital difficulties are greater in couples where the infertility
lies with the man. In many cultures, inability to conceive bears a stigma. In closed social groups, a degree
of rejection (or a sense of being rejected by the couple) may cause considerable anxiety and disappointment.
Some respond by actively avoiding the issue altogether; middle-class men are the most likely to respond in
this way.

If the infertility arise the social, psychological and health problems the advanced methods of
reproduction arise ethical issues.

 At a basic level, some believe that society should not allow any of the reproductive technologies
(artificial insemination, surrogate motherhood, sex preselection, in vitro fertilization, etc.) because
they separate the conjugal act from the procreative act. This is seen as both unnatural and a threat
to the unity of the family and the dignity of the human person.

 Others would argue that the world is already overpopulated, and that those unfortunate couples not
able to conceive naturally should adopt a child rather than struggle to conceive their own biological
child.
 A related question is whether it is right to expend the significant economic resources required to
create just one child through IVF when our health care resources are already overburdened.
 High-cost treatments are out of financial reach for some couples.
 At a more specific level, there are ethical quandaries surrounding the retrieval of the eggs, and their
subsequent treatment. The doctors involved in the IVF procedure must strike a delicate balance
between retrieving and fertilizing enough eggs to establish a pregnancy, but not implanting so many
preembryos that they are faced with a high occurrence of multiple pregnancies; these usually result
in low birth weight babies, which have a statistically higher risk of neonatal problems and death.

38
When doctors do have too many fertilized embryos to transfer back to the mother, they must decide
what to do with the “spare embryos.” There are several possible alternatives: 1) discard them; 2)
donate them to a recipient who is either unable to produce eggs, or whose genetic background makes
it inadvisable for her to use her own egg, 3) freeze the embryos for later transfer, should no
pregnancy occur in the current cycle; or 4) donate the embryos to a research project. All of these
options have stimulated the debate on the significance of the human embryo. For some people
involved in IVF, the decision to discard a spare embryo is a pragmatic one; the embryos discarded
are usually those that are not developing properly in the culture dish, and thus may not be healthy
enough to implant themselves if they were transferred to the womb. The early disposal of these
embryos is merely carrying out what nature would probably do herself. For others, the moral
significance of the embryo is much too important to permit its disposal. They make anti-abortion
opposition to the destruction of embryos not transferred in vivo.

Ethical issues abound surrogacy:


 Many argue that surrogate arrangements depersonalize reproduction and create a separation of
genetic, gestational, and social parenthood.
 Others argue that there is a change in motives for creating children: children are not conceived for
their own sakes, but for another’s benefit. Much is unknown.
 Other says that nobody know: What is the degree of stress on the couple and especially on the
surrogate mother? What are the possible adverse psychological effects on the child? What identity
crisis might ensue, and will there be a desire on the part of the child to know his/her gestational
mother? Will surrogate arrangements be used not only by infertile couples but also for the sake of
convenience, or by single men or women? Should the surrogate be paid? Would this lead to
commercialization of surrogacy and expose the surrogate mother to possible exploitation? What
happens when no one wants a handicapped newborn?

Legal Questions

Many countries have special frameworks for dealing with the ethical and social issues around fertility
treatment.

 One of the best known is the HFEA - The UK's regulator for fertility treatment and embryo research.
This was set up on 1 August 1991 following a detailed commission of enquiry led by Mary Warnock
in the 1980s

 A similar model to the HFEA has been adopted by the rest of the countries in the European Union.
Each country has its own body or bodies responsible for the inspection and licensing of fertility
treatment under the EU Tissues and Cells directive

 Regulatory bodies are also found in Canada and in the state of Victoria in Australia

B. Abortion

http://en.wikipedia.org/wiki/Abortion_debate

An abortion is the termination of a pregnancy by the removal or expulsion of an embryo or fetus from
the uterus, resulting in or caused by its death. An abortion can occur spontaneously due to complications
during pregnancy or can be induced. Abortion as a term most commonly refers to the induced abortion of
a human pregnancy, while spontaneous abortions are usually termed miscarriages. A pregnancy can be
intentionally aborted in many ways. The manner selected depends chiefly upon the gestational age of the
embryo or fetus, in addition to the legality, regional availability, and doctor-patient preference for specific
39
procedures. Reasons for procuring induced abortions are typically characterized as either therapeutic or
elective. An abortion is medically referred to as therapeutic when it is performed to:

 save the life of the pregnant woman;


 preserve the woman's physical or mental health;
 terminate pregnancy that would result in a child born with a congenital disorder that would be fatal
or associated with significant morbidity; or
 selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.
 Any abortion that is not therapeutic is by definition elective.

Abortion debate

In the history of abortion, induced abortion has been the source of considerable debate. Abortion
debates, especially pertaining to abortion laws, are often spearheaded by advocacy groups belonging to one
of two camps. Most often those in favor of greater legal restrictions on, or even complete prohibition of
abortion, describe themselves as pro-life while those against legal restrictions on abortion describe
themselves as pro-choice. Generally, the pro-life position argues that a human fetus is a human being with
the right to live making abortion tantamount to murder. The pro-choice position argues that a woman has
certain reproductive rights, especially the choice whether or not to carry a pregnancy to term. In both public
and private debate, arguments presented in favor of or against abortion focus on either the moral
permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Mare
famous debates are as fellow:
 Fetal pain debate. Many researchers in the area of fetal development believe that a fetus is
unlikely to feel pain until after the sixth month of pregnancy. Developmental neurobiologists suspect that
the establishment of thalamocortical connections (at about 26 weeks) may be critical to fetal perception of
pain. However, legislation has been proposed by anti-abortion advocates requiring abortion providers to
tell a woman that the fetus may feel pain during an abortion procedure. Wendy Savage Press officer,
Doctors for a Woman’s Choice on Abortion, considers the question to be irrelevant. She noted that the
majority of surgical abortions in Britain are already performed under general anesthesia which affects the
fetus, and considers the discussion "to be unhelpful to women and to the scientific debate."
 Fetal personhood debate. Although the two main sides of the abortion debate tend to agree
that fetuses are biologically and genetically human (that is, of the human species), they often differ in their
view on whether or not a fetus is, in any of various ways, a person. Pro-life supporters argue that abortion
is morally wrong on the basis that a fetus is an innocent human person or because a fetus is a potential life
that will, in most cases, develop into a fully functional human being. Others reject this position by drawing
a distinction between human being and human person, arguing that while the fetus is innocent and
biologically human, it is not a person with a right to life. In support of this distinction, some propose a list
of criteria as markers of personhood. For example, Mary Ann Warren suggests consciousness (at least the
capacity to feel pain), reasoning, self-motivation, the ability to communicate, and self-awareness.
According to Warren, a being need not exhibit all of these criteria to qualify as a person with a right to life,
but if a being exhibits none of them (or perhaps only one), then it is certainly not a person. Warren concludes
that as the fetus satisfies only one criterion, consciousness (and this only after it becomes susceptible to
pain), the fetus is not a person and abortion is therefore morally permissible. Critics of this typically argue
that the proposed criteria for personhood would disqualify two classes of born human beings – reversibly
comatose patients, and human infants – from having a right to life, since they, like fetuses, are not self-

40
conscious, do not communicate, and so on. Critics may see such concessions as an indication that the right
to life cannot be adequately defined by reference to developed psychological features.
 Arguments in favor of the right to abortion. An argument first presented by Judith Jarvis
Thomson states that even if the fetus has a right to life, abortion is morally permissible because a woman
has a right to control her own body. Thomson's variant of this argument draws an analogy between forcing
a woman to continue an unwanted pregnancy and forcing a person's body to be used as a dialysis machine
for another person suffering from kidney failure. It is argued that just as it would be permissible to "unplug"
and thereby cause the death of the person who is using one's kidneys, so it is permissible to abort the fetus
(who similarly, it is said, has no right to use one's body against one's will). Critics of this argument generally
argue that there are morally relevant disanalogies between abortion and the kidney failure scenario. For
example, it is argued that the fetus is the woman's child as opposed to a mere stranger; that abortion kills
the fetus rather than merely letting it die; and that in the case of pregnancy arising from voluntary
intercourse, the woman has either tacitly consented to the fetus using her body, or has a duty to allow it to
use her body since she herself is responsible for its need to use her body. Some writers defend the analogy
against these objections, arguing that the disanalogies are morally irrelevant or do not apply to abortion in
the way critics have claimed.
 Sexual emancipation and equality. Some argue that women's freedoms are limited until they
can have the right to abortion on demand and to walk away from parenthood like men can. Governments
that ban abortion arguably burden women with certain duties that men (who, too, are responsible for the
pregnancy) are not also held accountable to, therefore, creating a double standard. Margaret Sanger wrote:
"No woman can call herself free until she can choose consciously whether she will or will not be a mother."
Denying the right to abortion can be construed from this perspective as a form of female oppression under
a patriarchal system, perpetuating inequality between the sexes. Among pro-choice advocates, sexual-
equality discussion often involves the additional debate regarding to what degree the potential father should
have a choice in deciding whether or not to abort the developing child.
 Arguments against the right to abortion. Argument of Discrimination. According to this
argument, those who deny that fetuses have a right to life do not value all human life, but instead select
arbitrary characteristics (such as particular levels of physical or psychological development) as giving some
human beings more value or rights than others. In contrast, philosophers who define the right to life by
reference to particular levels of physical or psychological development typically maintain that such
characteristics are morally relevant, and reject the assumption that all human life necessarily has value (or
that membership in the species Homo sapiens is in itself morally relevant).

Public opinion

An individual's position on the complex ethical, moral, philosophical, biological, and legal issues
of abortion is often related to his or her value system. Opinions of abortion may be best described as being
a combination of beliefs on its morality, and beliefs on the responsibility, ethical scope, and proper extent
of governmental authorities in public policy. Religious ethics also has an influence upon both personal
opinion and the greater debate over abortion.
A number of opinion polls around the world have explored public opinion regarding the issue of
abortion. Results have varied from poll to poll, country to country, and region to region, while varying with
regard to different aspects of the issue.
A May 2005 survey examined attitudes toward abortion in 10 European countries, asking polltakers
whether they agreed with the statement, "If a woman doesn't want children, she should be allowed to have

41
an abortion". The highest level of approval was 81% (in the Czech Republic); the lowest was 47% (in
Poland).
In North America, a December 2001 poll surveyed Canadian opinion on abortion, asking Canadians
in what circumstances they believe abortion should be permitted; 32% responded that they believe abortion
should be legal in all circumstances, 52% that it should be legal in certain circumstances, and 14% that it
should be legal in no circumstances. A similar poll in January 2006 surveyed people in the United States
about U.S. opinion on abortion; 33% said that abortion should be "permitted only in cases such as rape,
incest or to save the woman's life", 27% said that abortion should be "permitted in all cases", 15% that it
should be "permitted, but subject to greater restrictions than it is now", 17% said that it should "only be
permitted to save the woman's life", and 5% said that it should "never" be permitted. A November 2005
poll in Mexico found that 73.4% think abortion should not be legalized while 11.2% think it should.
Of attitudes in South and Central America, a December 2003 survey found that 30% of Argentines
thought that abortion in Argentina should be allowed "regardless of situation", 47% that it should be allowed
"under some circumstances", and 23% that it should not be allowed "regardless of situation". A March 2007
poll regarding the abortion law in Brazil found that 65% of Brazilians believe that it "should not be
modified", 16% that it should be expanded "to allow abortion in other cases", 10% that abortion should be
"decriminalized", and 5% were "not sure". A July 2005 poll in Colombia found that 65.6% said they thought
that abortion should remain illegal, 26.9% that it should be made legal, and 7.5% that they were unsure.

Abortion law

Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to
influence abortion laws throughout the world. The right to life, the right to liberty, the right to security of
person, and the right to reproductive health are major issues of human rights that are sometimes used as
justification for the existence or absence of laws controlling abortion. Many countries in which abortion is
legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using
a trimester-based system to regulate the window of legality:

 In the United States, some states impose a 24-hour waiting period before the procedure, prescribe
the distribution of information on fetal development, or require that parents be contacted if their
minor daughter requests an abortion.
 In the United Kingdom, as in some other countries, two doctors must first certify that an abortion is
medically or socially necessary before it can be performed.
Other countries, in which abortion is normally illegal, will allow one to be performed in the case of
rape, incest, or danger to the pregnant woman's life or health. A few nations ban abortion entirely: Chile,
El Salvador, Malta, Ireland and Nicaragua, although in 2006 the Chilean government began the free
distribution of emergency contraception. In Bangladesh, abortion is illegal, but the government has long
supported a network of "menstrual regulation clinics", where menstrual extraction (manual vacuum
aspiration) can be performed as menstrual hygiene.
In places where abortion is illegal or carries heavy social stigma, pregnant women may engage in
medical tourism and travel to countries where they can terminate their pregnancy. In the USA, it is not
unusual for women to travel from one state to another for reasons of termination of pregnancy.

4.3. Bioethics and genetic


42
GeneticEngineeringDebates http://library.thinkquest.org/C004367/be10.shtml

Nowadays significant advanced is done in genetics or in genetic engineering. Application of them in


practice is the subject of large debates. Some of them are related with following subjects.

Genetically Modified Foods

One major application of genetic engineering techniques is in the realm of food production. With the world
population expanding and synthetic pesticides decreasing in effectiveness, novel solutions are increasingly
in demand. Genetically modified foods are one such solution. Genetic modification of organism involves
the insertion or deletion of genes. In the process of cisgenesis, genes are artificially transferred between
organisms that could be conventionally bred (genes are only transferred between closely related organisms).
In the process of transgenesis, genes from a different species are inserted, which is a form of horizontal
gene transfer. Transgenesis is the process of introducing an exogenous gene – called a transgene – into a
living organism so that the organism will exhibit a new property and transmit that property to its offspring.
This techniques can: increase plants' resistance to pesticides and herbicides, thereby decreasing the need
for these pollutant chemicals; allow plants to manufacture their own pesticides to ward off insects; increase
the yields of many staple crops and thereby ward off starvation in many areas of the world; and allow plants
to grow under adverse weather conditions or in poor soil, thereby increasing the amount of arable land on
the planet.
However, despite these undeniable benefits, critics argue that genetically engineered crops might transmit
their novel genes to wild populations, possibly creating organisms against which humans have no defense.
Critics also argue that genetic diversity of plant populations could decrease, thus making crops more
susceptible to decimation by as-yet-unknown pathogens. A third argument centers on food consumption,
and states that people with food allergies or dietary restrictions might inadvertently eat foods that contain
a dangerous compound due to modification.
The debate also is concerning to label or not genetically modified food. According to the US Food and
Drug Administration, food coming from cloned animals is safe to eat. In addition the FDA stated that cloned
food does not require special labeling. Both meat and milk from cloned animals such as swine, goats and
cattle have no differences from the conventionally bred animals. Joseph Mendelson, legal director of the
Center for Food Safety, said that cloned food still should be labeled due to the fact that safety and ethical
issues of it remain questionable.

Gene Therapy

Another application of genetic engineering techniques is in the area of gene therapy, or treatment of genetic
diseases through genetic modifications. Gene therapy is the insertion of genes into an individual's cells
and tissues to treat a disease. For example, if a person had a disease caused by a defective gene, a healthy
gene could be added to the affected cells to treat the disorder. The technique researchers are currently
experimenting is viruses. Viruses are good at injecting their DNA payload into human cells and reproducing
it. By adding the desired DNA to the DNA of non-pathogenic virus, a small amount of virus will reproduce
the desired DNA and spread it all over the body.
Proponents of this method argue that gene therapy is the most reasonable and cost-effective way to treat
most genetic diseases, because the ideal treatment would only need to be administered once - after that, the
modification would be incorporated into the person's genome. Gene therapy techniques promise to end or

43
at least curb a vast amount of human suffering due to painful, debilitating, and sometimes fatal genetic
diseases.

Opponents of gene therapy cite the unknown and unpredictable results of inserting genes at random into
the genes in a person's cells. They argue that playing with the genome could cause, or at least be a
contributing factor, to many types of cancer; they state that curing a person of a genetic disease only to give
him terminal cancer is unthinkably inhumane. They also maintain that gene therapy on humans, especially
at this stage when we know so little about gene regulation, would amount to unethical experimentation on
human subjects.

Some of the problems of gene therapy mentioned is as following:

 Immune response - Anytime a foreign object is introduced into human tissues, the immune system
has evolved to attack the invader. The risk of stimulating the immune system in a way that reduces
gene therapy effectiveness is always a possibility. Furthermore, the immune system's enhanced
response to invaders it has seen before makes it difficult for gene therapy to be repeated in patients.
 Problems with viral vectors - Viruses, while the carrier of choice in most gene therapy studies,
present a variety of potential problems to the patient --toxicity, immune and inflammatory
responses, and gene control and targeting issues. In addition, there is always the fear that the viral
vector, once inside the patient, may recover its ability to cause disease.
 Multigene disorders - Conditions or disorders that arise from mutations in a single gene are the best
candidates for gene therapy. Unfortunately, some of the most commonly occurring disorders, such
as heart disease, high blood pressure, Alzheimer's disease, arthritis, and diabetes, are caused by the
combined effects of variations in many genes. Multigene or multifactorial disorders such as these
would be especially difficult to treat effectively using gene therapy.
 Chance of inducing a tumor (insertional mutagenesis) - If the DNA is integrated in the wrong place
in the genome, for example in a tumor suppressor gene, it could induce a tumor. This has occurred
in clinical trials for X-linked severe combined immunodeficiency (X-SCID) patients, in which
hematopoietic stem cells were transduced with a corrective transgene using a retrovirus, and this
led to the development of T cell leukemia in 3 of 20 patients.
 Religious concerns - Religious groups and creationists may consider the alteration of an individual's
genes as tampering or corrupting God's work.

Germ-Line Therapy

An even more controversial subset of gene therapy is germ-line therapy, or the removal or
replacement of faulty genes, not in a person's body cells, but in his gametes. The distinguishing
characteristic of somatic engineering mention in previous pharagrapf is that it is non-inheritable, e.g. the
new gene would not be passed to the recipient’s offspring. Germline engineering would change genes in
eggs, sperm, or very early embryos. This type of engineering is inheritable, meaning that the modified genes
would appear not only in any children that resulted from the procedure, but in all succeeding generations.
Proponents argue that germ-line therapy would be a great boon to mankind because it would eliminate
destructive and costly genetic diseases. They often state that it would be inhuman to allow children to be
born with fatal genetic diseases when the capability exists to remove those genes from the population once
and for all. They generally see it as an extremely effective way to curb human suffering, as well as a
practical measure against the high costs of conventional treatment for generations of people afflicted with
a given disease.

44
The potential of genetic engineering to cure medical conditions opens the question of exactly what
such a condition is. Some view aging and death as medical conditions and therefore potential targets for
engineering solutions. They see human genetic engineering potentially as a key tool in this. The difference
between cure and enhancement from this perspective is merely one of degree. Theoretically genetic
engineering could be used to drastically change people's genomes, which could enable people to regrow
limbs and other organs, perhaps even extremely complex ones such as the spine. It could also be used to
make people stronger, faster, smarter, or to increase the capacity of the lungs, among other things. Strength,
speed, endurance and so on can be enhanced. The baby can be made taller, more beautiful; the changes
possible are really up to the imagination, and the ability of the techniques employed by future gene
manipulators. If a gene exists in nature, it could be brought over to a human cell. In this view, there is no
qualitative difference (only a quantitative one) between, for instance, a genetic intervention to cure
muscular dystrophy, and a genetic intervention to improve muscle function even when those muscles are
functioning at or around the human average (since there is also an average muscle function for those with
a particular type of dystrophy, which the treatment would improve upon).
Opponents of germ-line gene therapy generally argue that it would be extremely inadvisable at this
time, when so little is known about gene regulation or the mechanisms of embryological development; they
claim that the premature use of such techniques could have results even worse than the diseases they were
trying to cure. Opponents also express concern that not only diseases will be culled from the population,
but also relatively insignificant problems like myopia, racial variations like skin color, and even normal
variations like height; they generally argue that germ-line therapy is a slippery slope that will plunge
humanity into eugenic policies and practices. Individuals may benefit from non-therapeutic genetic
engineering, but some claim that there may be adverse social implications. Few resources – particularly
those related to medicine and health care – are available to everyone, and allowing the most privileged to
engineer themselves or their children to have special capabilities could lead to what some call a genetic
aristocracy. Numerous enhancements via genetic engineering have been proposed, including increased
memory, intelligence, and less need for sleep, in addition to some peoples’ desires to alter their physical
appearance. The advantages created by genetic engineering, either real or perceived, could lead to new
forms of inequality between those with genetic enhancements and those without while also exacerbating
current inequalities between the rich and poor. Others feel that there is an important distinction between
using genetic technologies to treat those who are suffering and to make those who are already healthy
superior to the average. Though theory and speculation suggest that genetic engineering could be used to
make people stronger, faster, smarter, or to increase lung capacity, opponents say there is little evidence
that this can currently be done without very unsafe and therefore unethical human experiments. Because
different cells have different tasks, changing one cell to do a different job will not only affect that one task,
it can affect many others too.
In addition, opponents claim that reduction of genetic diversity in the human gene pool could increase our
collective susceptibility to newly emerging diseases. Some people also cite religious or ethical objections
to this particular method of "playing God".

Cloning

Cloning in biology is the process of producing populations of genetically-identical individuals that


occurs in nature when organisms such as bacteria, insects or plants reproduce asexually. Cloning in
biotechnology refers to processes used to create copies of DNA fragments (molecular cloning), cells (cell

45
cloning), or organisms. The term clone is derived from κλών, the Greek word for "twig, branch", referring
to the process whereby a new plant can be created from a twig.
Organism cloning refers to the procedure of creating a new multicellular organism, genetically
identical to another. Reproductive cloning of organism uses "somatic cell nuclear transfer" (SCNT). This
process entails the transfer of a nucleus from a donor adult cell (somatic cell) to an egg which has no
nucleus. If the egg begins to divide normally it is transferred into the uterus of the surrogate mother. Dolly
(1996-07-05 – 2003-02-14), a Finn Dorsett ewe, was the first mammal to have been successfully cloned
from an adult cell, though the first actual thing to be cloned, was a tadpole in 1952. She was cloned at the
Roslin Institute in Scotland and lived there until her death when she was six. Dolly was publicly significant
because the effort showed that the genetic material from a specific adult cell, programmed to express only
a distinct subset of its genes, could be reprogrammed to grow an entire new organism. Before this
demonstration, there was no proof for the widely spread hypothesis that differentiated animal cells can give
rise to entire new organisms. Cloning Dolly the sheep had a low success rate per fertilized egg; she was
born after 277 eggs were used to create 29 embryos, which only produced three lambs at birth, only one of
which lived. Seventy calves have been created from 9,000 attempts and one third of them died young.
Notably, although the first clones were frogs, no adult cloned frog has yet been produced from a somatic
adult nucleus donor cell.
Human cloning is the creation of a genetically identical copy of an existing or previously existing
human. The term is generally used to refer to artificial human cloning; human clones in the form of identical
twins are commonplace, with their cloning occurring during the natural process of reproduction. There are
two commonly discussed types of human cloning: therapeutic cloning and reproductive cloning.
Therapeutic cloning involves cloning cells from an adult for use in medicine and is an active area of
research: while reproductive cloning would involve making cloned human beings. Such reproductive
cloning has not been performed and is illegal in many countries.

Ethical debates over reproductive human cloning

The ethical status of cloning humans has been a hotly debated issue, touched off by the controversy over
Dolly, the first cloned mammal. Proponents of cloning argue that it is no more unnatural than binary fission,
the process by which bacteria reproduce to produce identical copies of themselves; they go on to state that
cloning is no more unethical than growing a plant from a cutting or giving birth to identical twins, both of
which involve two separate and distinct organisms with identical genomes. Since identical twins have the
exact same genome, but still grow up with different personalities, clones raised in entirely different time
periods and social contexts will be entirely individual despite identical genes. In this view, cloning is just
another scientific topic and will become just another reproductive option, and those who wish to research
cloning or to be cloned should not be stopped.
There is a small group of people who oppose cloning - or at least propose a moratorium on it for the time
being - for practical, not moral or ethical, reasons. These people argue that cloning is ethically acceptable,
but practically unsound because of the resultant decrease in the genetic diversity of the human gene pool.
They also advise more extensive experiments on the effects of cloning on animals before human beings are
cloned.
Finally, a large majority of people argue that cloning humans is both unnatural and unethical. They cite
fears that include: people's individuality being impaired or ruined due to cloning technologies; aggressor
nations creating armies of cloned soldiers to assault other nations; overpopulation due to sudden ease of
reproduction; depletion of the human gene pool; and a number of concerns about the moral status of clones.

46
Some go so far as to postulate a stratified society divided into the cloned and the uncloned, and fears about
eugenics or of reserving cloning technology to the "genetically desirable" generally surface. Many religions
also object to cloning, again by claiming that it is "playing God".

4.4. Study cases


Comment the cases!
Euthanasia – Case Studies
http://www.rsrevision.com/Alevel/ethics/euthanasia/Euthanasia_Case_Studies.pdf

Case of Dax Cowart


Dax Cowart was very badly burnt after a gas explosion engulfed his car. He said “I was burned so severely
and in so much pain that I did not want to live even in the early moments following the explosion.” Dax
repeatedly asked his doctors, family and friends to help him end his suffering, which lasted through 10
years of agonising treatment. Dax is blind and cannot use his hands, but is otherwise healthy and currently
works as an attorney. He still believes it was wrong to deny his request for euthanasia. An interactive CD
ROM of this case has been produced, with interviews from Dax, his doctors and friends and family.

Case of Dr Jack Kevorkian


Kevorkian earned the name 'Dr Death' by photographing the eyes of dying patients. Later in his career
(starting in 1987) he began to advertise his services as a physician offering 'death counselling'. When
terminally ill patients learned that he was helping people to die, more and more people came to him. Despite
several failed court cases, Kevorkian helped over 130 people to die.
Kevorkian believed that helping people was not enough, and actually killed Thomas Youk, filmed himself
doing so and showed the film on 60 Minutes. He left the studio in handcuffs, and, defending himself
unsuccessfully in court, was sentenced to 10-25 years in prison. In 2006 Kevorkian became terminally ill
with Hepatitis C and asked to be pardoned.

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Chapter 5

Social problems of bioethics: socio-philosophical analysis. Rights and obligations in


the biomedical world
5.1. Ethics and sex: transexualism.

The Diagnostic and Statistical Manual of Mental Disorders accepts the expression of desire to be
of the opposite sex, or assertion that one is of the sex opposite from the one with which one was assigned
at birth, as sufficient for being transsexual. Transsexualism is a condition in which a person identifies with
a physical sex different from the one with which they were born. A medical diagnosis can be made if a
person experiences discomfort as a result of a desire to be a member of the opposite sex, or if a person
experiences impaired functioning or distress as a result of that gender identification. Many transsexual
people believe that gender is hard-wired in the brain before birth, arguing that being transsexual is an
intersex condition, a congenital birth issue unseen by others due to its location in the brain: a mis-match in
the sex of a person between that of the brain and that of the body. The main symptom of this condition is a
unique type of depression, anxiety or even psychological pain: Gender Dysphoria. Commonly, transsexual
people assert that their brain-based inner perception of their sexual self is their true identity and so change
their physical sex in an effort to align their inner and outer self. If untreated, Gender Dysphoria can lead to
mental and emotional problems, and sometimes suicide. Most transsexual men and women desire to
establish a permanent social role as a member of the gender with which they identify. Many transsexual
people also desire various types of medical alterations to their bodies. These physical alterations are
collectively referred to as sex reassignment therapy and often include hormone replacement therapy and
48
surgery. The entire process of switching from one physical sex and social gender presentation to the other
is often referred to as transition, and usually takes several years. There is no conclusive evidence that sex
change operations improve the lives of transsexuals, with many people remaining severely distressed and
even suicidal after the operation, according to a medical review conducted exclusively for Guardian
Weekend tomorrow.
The review of more than 100 international medical studies of post-operative transsexuals by the University
of Birmingham's aggressive research intelligence facility (Arif) found no robust scientific evidence that
gender reassignment surgery is clinically effective. Against the statistic above indicating that 1% to 2% of
post-operative persons have serious regrets, the Report itself states: Paradoxically, a growing number of
post-operative transsexuals are scathing about their medical care. International research suggests that 3-
18% of them come to regret switching gender.

Sex reassignment therapy raise also social and ethical issue as it is unfolded in article below.

Technology on the Social and Ethical, Aspects of Transsexual Surgery

By Janice G. Raymond Assistant Professor of Medical Ethics and Women's


Studies, Hampshire College/University of Massachusetts Amherst, Massachusetts, June, 1980.
http://www.susans.org/reference/usts1-9.html

That the transsexual is a person who is trapped in the body of the wrong sex. Thus we have the
popular definition of a transsexual as a "female mind in a male body." This results in the perception of
transsexualism as a disease or as disease-like and thus a medical problem. In many cases, a "cure" can only
be effected through radical intervention such as specialized hormonal treatments and sex conversion
surgery. That it is a therapeutic necessity and a reasonable and humane treatment to perform surgery on
those individuals who have undergone rigorous preoperative psychological evaluations and who can truly
"pass" as members of the opposite sex. Furthermore, proof of the surgery's efficacy is that over 90% of
those who have undergone transsexual operations report that their lives are healthier and happier.
The aim of this paper is to analyze these assumptions and, in so doing, to address the much-
neglected social and ethical issues surrounding transsexual surgery. Transsexualism is an important medical
ethical issue that raises questions that go far beyond the transsexual context -- questions of bodily mutilation
and integrity, medical priorities, unnecessary surgery, the inevitable issue of the medical model in general,
as well as definitions of maleness and femaleness, and the boundaries of such. Scholars will also find that
transsexualism touches the parameters of many of the academic disciplines in such a way as to raise
fundamental questions about the territorial imperatives of biology, psychology, medicine, and the law, to
name but a few. Questions about the causes of transsexualism and the proper methods of treatment have
been hitherto restricted to the domains of psychology and medicine. But as an ethicist, I would maintain
that these issues of causation and treatment are often embedded with social values and philosophical beliefs
-- values and beliefs about the so-called natures of women and men, for example.
Historically, one could say that some people have always felt "trapped" in the wrong body, in the
wrong skin, and in the wrong period of time. But this feeling never certified them as members of the "right"
body, skin, or period of time. For example, persons who felt "trapped" in black skin were never encouraged
to undergo a pigmentation change. Ultimately, it was recognized that such "trapped" feelings were
encouraged by a society that oppressed and discriminated against black people, and that it was the society
that needed changing, not the individual black. In the same way, to acknowledge that a man who feels
trapped in his native-born body is a transsexual (and ultimately, through hormonal and surgical intervention,
49
a woman), is to ignore the social causes and ramifications that surround the issue. Indeed, one must ask
why it is possible in this society that persons could even talk about a "female mind in a male body."
If transsexualism is a disease, then does desire qualify as disease? As Thomas Szasz has asked,
does the old person who wants to be young suffer from the "disease" of being a "transchronological" or
does the poor person who wants to be rich suffer from the "disease" of being a "transeconomical?" Thus ,
there is an absence of those objective diagnostic tests normally available to confirm or indicate the presence
of pathological illness or disease. The doctor, or so it seems, can only assess the validity of the potential
transsexual's claims in relation to his/ her actions and when compared with the behaviour and statements
of previously 'diagnosed' 'sufferers'. This problem is further compounded by the variety of theories outlined,
which suggest possible causes for transsexuality ranging from the biological to the cultural, and from
psychosis to upbringing. Selection is made by matching the claims of existing clients to those of past clients
for whom reassignment was successful. Not only is this an unsatisfactory method of diagnosis (though not
perhaps of selection) it implies that ultimately, radical surgery is performed on the strength of the patient's
self-diagnosis.
Transsexualism as disease raises many deeper issues about the medical model in general and the
ways in which transsexualism has come to the defined as legitimate medical territory. Within the last
century, more and more areas of life have come to be defined as medical and technical problems. This is
most evident, of course, in the mental health realm where all sorts of behaviors have been categorized as
diseases, and then treated by drugs, surgery, and other medical-technical means. My point here is to affirm
that more and more personal, moral, and now social problems are defined as medical problems when they
are actually human and social conflicts. Approaching these conflicts from a diagnostic and disease
perspective prevents the person who is dissatisfied with his sex from seeing the issue in an alternative
framework. Specifically, persons who think they are transsexuals are not encouraged presently to see this
desire as arising from the social constraints of masculine and feminine role-defined behavior. Thus a man
who wishes to be emotional or non-aggressive is encouraged to think of himself as a woman instead of as
a man who is trying to break out of the masculine role.
The ultimate effect of defining transsexualism as a disease, and as a medical problem, is to
encourage persons to view other persons (especially children) who do not live out proper and appropriate
sex role behavior as potential transsexuals. Thus, for example, for the boy who likes to play with dolls or
the girl who wants to be a truck driver, these behaviors can be interpreted as transsexual behavior instead
of as non-stereotypical behavior that helps to break down sex roles. Thus the classification of
transsexualism as a disease or as a therapeutic category relegates non-stereotypical sex-role behavior to the
medical realm.
It is important to understand that doctors here are not curing a disease. They are actually engaged
in the political and social shaping of masculine and feminine behavior. Several facts bear out this
contention. Here especially, I note the role of the so-called gender identity clinics and private therapists
who foster and reinforce stereotyped behavior. Persons wishing to change sex come to these clinics or go
to individual therapists to receive counseling and ultimately to be referred for treatment and surgery. It is a
primary requirement of these centers that men who wish to be transsexed must prove that they can "pass"
as "true women" in order to qualify for treatment and surgery. "Passing" requirements evaluate everything
from an individual's feminine dress, to feminine body language, to so-called feminine positions in
intercourse. Most clinics require candidates for surgery to live out opposite sex-roles and rigidly defined
stereotypical behavior for periods of six months to two years. Thus the role of these clinics and clinicians
in reinforcing sex-role stereotypes is significant and, as I have tried to show above, one that has
consequences that reach far beyond the transsexual issue. I would suggest that what we are witnessing here
is a "benevolent" form of behavior control and modification. It is not inconceivable that gender clinics, in
the name of therapy, could become potential centers of sex-role control for non-transsexuals--e.g. children
50
whose parents have strong ideas about the kind of masculine or feminine children they want their offspring
to be.
The ultimate effect of viewing the desire to live as a member of the opposite sex as a disease or as
a medical category is that a social and ethical issue becomes transformed into a therapeutic and medical-
technical problem to be solved by "passing" requirements, hormone therapy, and sex conversion surgery.
Medicine focuses on the surgical construction of desired genitalia. Artifacts of silicone breasts, artificial
vaginas, and the like come to incarnate the essence of femaleness which the transsexual so desperately
desires. Since the general result of sex conversion surgery is that the transsexual becomes an agreeable
participant in a society which encourages conformity to rigid sex role behavior, then ultimately the medical
solution becomes a "social tranquilizer." Sexism, and its foundation of sex-role stereotyping, is reinforced.
Transsexual surgery also enables doctors to gain medical knowledge about the manipulation of
human sexuality that probably could not be acquired by any other medical procedures. In what other
medical situation could a penectomy be done upon a healthy penis and an artificial vagina inserted into a
chromosomal male? What we also witness in the transsexual context is a number of medical specialties
combining to create transsexuals -- urologists, gynecologists, endocrinologists, plastic surgeons, and the
like. The proliferation of treatments that has been generated to take care of the "disease" is remarkable.
These range from the initial and basic operative procedures undergone by all transsexuals to highly
specialized forms of secondary cosmetic surgery such as eye, nose, and chin operations. Not coincidentally,
hormone therapy and surgery are expensive.
Finally, treating transsexualism as a disease and making it medical territory have also masked the
fact that a unique group of medical consumers has been created by medicine itself. The terminology of
transsexualism disguises the reality that transsexuals prove they are "real" transsexuals by conforming to
the canons of a medical institution that evaluates them on the basis of their being able to pass as
stereotypically masculine or feminine, and that ultimately grants surgery on this basis. Once sex-role
dissatisfaction is given the name of transsexualism, institutionalized in gender identity clinics, and treated
by hormone therapy and surgery, the category of transsexualism functions to explain and order very valid
dissatisfactions with sex-role stereotypes.
The terminology of transsexualism raises the inevitable question of is it possible to change sex, i.e.,
to transsex? To answer this, it is necessary to discuss various meanings of the word SEX, a word that has
both a dismaying multiplicity and ambiguity of meanings. John Money has distinguished various
definitional levels of the word SEX that are helpful in assessing whether it is biologically possible to cross
sex. Chromosomal sex determines biological maleness or femaleness, contrary to popular opinion that
anatomical sex is determinative. Normal males have a chromosomal pattern of XY with normal females
being XX. There are some individuals who are born with chromosomal anomalies in which surgery is often
used to bring the anomalous person in line with the anatomical characteristics that become most dominant,
or else the developing anatomical characteristics are altered in line with the sex in which the child has been
reared. The pattern of sex chromosomes is present and unchangeable in every body cell, including blood
cells. Chromosomal sex can, however, conflict with anatomical sex.
Anatomical sex refers to primary and secondary sex characteristics. Primary characteristics include
the testes in the male and the ovaries in the female. Secondary anatomical sex characters include the penis,
scrotum, prostate, hair distribution, and a deeper voice in the male; and the clitoris, vulva, uterus, vagina,
breasts, a wide pelvis, female voice, and hair distribution in the female. Transsexual surgery alters
anatomical sex through hormonal and operative procedures. Genital or Gonadal sex is the collective term
for the tests in the male or the ovaries in the female. Legal sex is designated most often by genital sex,
although this is not actually defined in the codes. It is in this area that errors of sex do occur, since the

51
obstetrician or mid-wife may be deceived by the apparent genital sex. Endocrine or Hormonal sex is
determined by androgen in the male and estrogen in the female, supplied by not only the sex glands, but
also by the pituitary or adrenal glands. Endocrine sex is mixed to certain extents since, for example, the
testes as well as male adrenals, produce certain amounts of estrogen. Psychological sex or the word gender
are terms used in much of the literature to designate attitudes, traits, characteristics, and behavior that are
said to accompany biological maleness or femaleness. I would prefer the term psychosocial sex to indicate
the all-important factor that such attitudes, traits, characteristics, and behavior are socially influence and
orchestrated. Historical sex is a term that I would add to this already lengthy list of distinctions. History is
important, in this context, because there is a certain constellation of events that attend the sex into which
one is born. For example, menstruation for a girl is a biological happening, but it is also a historical event
around which cluster a certain set of very different yet also very similar collective female experiences. Men
do not have a history of menstruation nor the experiences which surround its onset, its monthly occurrence,
or its demise. What significance does this delineation of the various terminologies of sex have in answering
the question of is it possible to change sex? Beginning in order with the list of sex distinctions, the most
important reality is that it is biologically impossible to change chromosomal sex. If chromosomal sex is
taken as the bottom line of maleness or femaleness, the male who undergoes sex conversion surgery is NOT
female.
Anatomically, transsexualism does take place, but anatomical changes also happen in what is
commonly termed plastic surgery. Transsexual surgery alters genital or gonadal sex most intrinsically. For
example, it is possible to remove a woman's ovaries or a man's testes through this surgery, and it is also
possible to construct an artificial vagina in a man whose penis and testes have been removed. The question
then becomes how much value one would give to this kind of alteration in terms of changing the totality of
a person's sex. George Burou, a Casablancan physician who has operated on over 700 American men who
wanted to become women, expressed the superficiality of changing genital sex in this way: "I don't change
men into women. I transform male genitals into genitals that have a female aspect. All the rest is in the
patient's mind." Furthermore, a change in genital sex does not make reproduction possible.
Endocrine or hormonal sex is the most susceptible to alteration, but this is done without surgical
intervention. Hormonal intake of opposite-sex hormones have certain anatomical effects resulting in, for
example, breast for men or a redistribution of body hair for both women and men. Hormonal treatments
must be lifelong, however, for most of the anatomical effects to be prolonged.
In law, it is possible to transsex; that is, it is possible to change one's legal sex. However, the whole
area of legal sex has been one of contention for the transsexual who wishes to have sex conversion surgery
validated by a corresponding change of sex on official papers such as birth certificates, social security,
drivers' licenses, and the like.
If it is impossible to change basic chromosomal structure, then it is necessary to take a more in-
depth look at not only the terminology but also the reality of transsexualism? Can we call a person a
transsexual, biologically speaking, whose anatomical structure and hormonal balance have changed, but
who is still genetically XY and XX? If chromosomal sex is not the bottom line, what are we really talking
about when we say that a person is a biological male or female?
Is there any such enduring reality as biological maleness or femaleness? Obviously, there is more
to maleness or femaleness than chromosomal make-up. Feminists have been arguing this for years, and I
am not re-affirming the biology is destiny argument. In fact, it is transsexuals and defenders of the surgery
who are asserting a new form of biology is destiny. For what they are ultimately saying is that it is
impossible to change male or female behavior, traits, characteristics, and the like UNLESS one also changes
one's body. Transsexuals define themselves by exclusive reference to the body of the sex they want to be.

52
This is a new variation on the theme of biology is destiny. What transsexuals and those who support the
surgery affirm is that persons are irrevocably determined by what body they are born with. In the transsexual
context, persons desiring the surgery become enfettered by both the unwanted body of their chromosomal
sex (which they reject) and the body of the opposite sex for which they are willing to undergo painful and
mutilating surgery. Ultimately, the transsexual and the medical community which supports surgery give the
message that the body is all-important, that it does guide one's destiny, and that all else is body-bound.
Chromosomal sex is the enduring reality which determines biological maleness or femaleness. This
can never change. What is more significant in determining the totality of maleness or femaleness, however,
is what I have called historical sex. No man can have the history of being born and located in any culture
as a woman. He can have the history of wishing to be a woman and of acting like a woman, but this is the
history of one who DESIRES to be a woman, not of one who is a woman. Surgery may confer the artifacts
of outer and inner female organs, but it cannot confer the history of being born a woman in this society.
History, of course, is not static. All of us make changes in both our personal and social history. I
am not advocating that history should determine the boundaries, life, and location of the self. However,
there are aspects of anyone's personal and social history that cannot be changed. For example, a person who
is born into a particular class cannot change that history. He can change his class attitudes, habits, and
complex of behaviors that accompany a certain class typology. Likewise, in the transsexual context, a man
cannot change his history of having grown up male. Men who want to change masculine attitudes, habits,
and complex of behaviors should not take on the bodies of women but rather should try to change their
unwanted history in their own bodies.
To summarize, it is impossible to change sex, i.e., to transsex, because it is impossible to change
not only the chromosomes of one's native-born sex but also much of the personal and social history that
accompanies biological maleness and femaleness.
Proponents of transsexual surgery claim that the only way of treating those individuals who find
themselves to be born into "the wrong sex," and who have undergone rigorous preoperative screening
procedures, is ultimately through sex conversion surgery. It is emphasized that many persons who think
they might be candidates for surgery are weeded out through these stringent evaluations, and only those
who can truly "pass" as women (or men) are referred for surgery. For this small number of individuals,
transsexual surgery is not only a therapeutic necessity but a reasonable and humane treatment. Furthermore,
the majority of postoperative reports of transsexuals testify that the surgery has been proven effective and
efficacious and is therefore no longer experimental. They cite the fact that 90% of those persons who have
undergone surgery report that their lives are happier and healthier. These reports, however, do not explore
the deeper social issues, nor do they question a satisfaction that is achieved at the expense of never
investigating the underlying social and ethical issues. They do not state that after surgery the transsexual
fits into a role-defined world better than most native-born women who live out their feminine roles.
Critics of this position maintain that it would be an overwhelming burden on both the transsexual
and the therapist to attack so large a problem as sex-role socialization in the therapeutic, never mind social,
context. Therefore, it is easier, to confront the problem within role limits, making use of a ready-made
social structure that created transsexualism initially. While proponents of transsexual surgery may admit
that it would be preferable to modify society's attitudes toward masculine and feminine behavior, they
emphasize that in the immediacy of the therapeutic moment, the task of social change is impossible. Faced
with the personal crisis of a gender-disturbed individual, they opt for ignoring or relegating the social effects
to a secondary place. However, in the name of dealing with an individual crisis, it is important to note
that this kind of therapy does not foster genuine individualism. Current transsexual therapy and surgery
promote an individualism that serves a role-defined society. Thus, it is more accurate to say that these are

53
solutions that promote the values of social conformity. To use another example: Many oppressed people
use heroin to make life tolerable in intolerable conditions. Heroin usage is a highly effective yet dangerous
treatment for dissatisfaction and despair. Recently, black leaders have drawn attention to heroin as a pacifier
of black people. The contentment and euphoria produced by the drug diffuses the critical consciousness of
the users. Although there are many real differences between the users of heroin and the recipients of
transsexual surgery, the analogy is appropriate in at least one significant way. Transsexual surgery produces
satisfaction and relief for the transsexual at the expense of muting his or her critical consciousness of the
ways in which such surgery reinforces sex role behavior. Thus transsexuals are not encouraged to ask how
their own socialization conditioned not only their choice of surgery, but also their motivation to choose.
It is in this sense that transsexual surgery can be said to be experimental surgery. Transsexuals are
seeking surgery to relieve gender discomfort and dissatisfaction. Within the context of a role defined
society, the surgery is narrowly successful at doing this for some transsexuals. But there is no evidence to
prove that the surgery "cures" the deeper problems which lead many persons to seek the surgery. In other
words, sex conversion surgery cannot bestow upon the transsexual the sense of self that he or she lacks.
Furthermore, there is evidence, at least in some postoperative cases, that transsexuals themselves have come
to realize this, but too late. Meyer and Hoopes, as early as 1974, noted that a group of their patients had
reacted self-destructively after surgery. These reactions included multiple and serious suicide attempts,
drug abuse, and serious physical complications. Randall in an earlier study, reported on four cases (out of
29) in which postoperative adjustment was worse than before the operation. The behavior included suicide,
suicidal impulse, moral depravity, and a wish to reverse the effects of the operation.
One of the first well-known physicians to work in the areas was Charles Ihlenfeld, an
endocrinologist, who was a co-worker and protege of Harry Benjamin. Ihlenfeld left the field after helping
one hundred or more transsexuals change sex because as he reported to have said: "Whatever surgery did,
it did not fulfill a basic yearning for something that is difficult to define. This goes along with the idea that
we are trying to treat superficially something that is much deeper." Finally, Johns Hopkins terminated
transsexual surgery in 1979 after conducting a study of fifty transsexuals which showed that there was no
significant difference in successful life adjustment between those who underwent transsexual surgery and
those who did not. The study was the first to compare postoperative transsexuals with an unoperated group
of persons who wanted the surgery. The study, initially reported in the ARCHIVES OF GENERAL
PSYCHIATRY and in the press release issued by Johns Hopkins which appeared in newspapers across the
country said, among other things: "Physicians have to ask themselves if transsexual surgery is medically
necessary. To say that this type of surgery cures psychiatric disturbance is incorrect. We now have objective
evidence that there is no real difference in the transsexual's adjustment to life in terms of jobs, educational
attainment, marital adjustment, and social stability."
On physical grounds alone, there is a substantial amount of evidence to confirm that sex conversion surgery
is experimental. Transsexual treatment is far from established as a safe medical procedure. In some
instances, it has been known to cause cancer. In 1968, W. Symmers reported two cases of carcinoma of the
breast in which the transsexuals died. He suggested that the malignance was entirely due to the hormonal
imbalance created by castration plus the massive does of estrogen received. There are several other studies
that have investigated the correlation between male-to=constructed female transsexualism and cancer. One
might also ask why initial long term research with a control group was not undertaken. Without such studies
it is difficult to see how the patient can be informed about the potential outcome of his/her operation. Within
the context of transsexuality, the radical nature of the surgery itself poses several ethical questions. Most
obvious is that of gaining fully informed consent. It is reported that the majority of patients selected for the
operation are at best intermittently depressed and at worst simultaneously suffering from psychiatric

54
illness. In either case, judgement may be impaired. Furthermore, the research results given suggest that
post-operative euphoria declines over the years, meaning that complete long-term adjustment cannot be
inferred from early apparent success.
This paper has argued that the issue of transsexualism is an ethical one that has profound social and
moral ramifications. Transsexualism itself is a deeply moral question rather than a medical technical
answer. In concluding, I would list some suggestions for change that address the more social and ethical
arguments I have raised in the preceding pages. While there are many who feel that morality must be built
into law, I believe that the elimination of transsexualism is not best achieved by legislation prohibiting
transsexual treatment and surgery but rather by legislation that limits it and by other legislation that lessens
the support given to sex-role stereotyping, which generated the problem to begin with. Any legislation
should be aimed at the social conditions that initiate and promote the surgery as well as the growth of the
medical-institutional complex that translates these stereotypes into flesh and blood. More generally, the
education of children is one case in point here. Images of sex roles continue to be reinforced, at public
expense, in school textbooks. Children learn to role play at an early age.
Nonsexist counseling is another direction for change that should be explored. The kind of
counseling to "pass" successfully as masculine or feminine that now reigns in gender identity clinics only
reinforces the problem of transsexualism. It does nothing to develop critical awareness, and makes
transsexuals dependent upon medical-technical solutions. What I am advocating is a counseling that
explores the social origins of the transsexual problem and the consequences of the medicaltechnical
solution. It would raise questions such as the following: is individual gender suffering relieved at the price
of role conformity and the perpetuation of role stereotypes on a social level? In changing sex, does the
transsexual encourage a sexist society whose continued existence depends upon the perpetuation of these
roles and stereotypes? These and similar questions are seldom raised in transsexual therapy at present. I
am not so naive as to think that these measures would make transsexualism disappear overnight, but they
would at least pose the existence of a real alternative to be explored and tried. Given encouragement to
cultural definitions of both masculinity and femininity, persons considering transsexual surgery might not
find it as necessary to resort to sex conversion surgery.
Public education must also be emphasized. Up to this point, the transsexual and the transsexual
professionals have been the sources of information for the general public. The mere existence of the
postoperative transsexual, moreover, and the fact of the surgery's availability permit people to restrict their
thinking about sex role dissatisfaction to these medical-surgical boundaries. One way in which education
about transsexualism has reached the general public is through the media. Famous transsexual personages
such as Jan Morris or Renee Richards appear in widely circulated magazines and on television talk shows.
Thus transsexualism becomes "media-ized" in certain prejudicial ways, which contribute to public opinion
that surgery is indeed the solution to gender dissatisfaction. Different perspectives on the issues of
transsexualism need to receive more attention and publicity. We need to hear more from those men and
women who, at one time, thought they might be transsexuals but decided differently -- persons who
successfully overcame their gender crises without resorting to medicine and surgery.
We need to hear more also from professionals such as endocrinologist Charles Ihlenfeld who, after
helping many to change sex, left the field. Finally, we need to listen to persons, such as feminists, who have
experienced sex role dissatisfaction but did not become transsexuals.
In the final analysis, it is important to remember that transsexualism is merely one of the most
obvious forms of gender dissatisfaction and sex-role playing in a role-defined society. It is one of the most
obvious because, in the transsexual situation, we have the stereotypes on stage, so to speak, for all to see
and examine in an alien context. What can be overlooked, however, is that these same stereotypical

55
behaviors are lived out every day in "native" bodies. The issues that this paper has highlighted should by
no means be confined to the transsexual context. Rather they should be confronted in the "normal" society
that spawned the problem of transsexualism to begin with.

5.2. Ethical issues in mental disorder patients.

The definition and classification of mental disorder is a key issue for the mental health professions
and for users and providers of mental health services. Most international clinical documents use the term
"mental disorder" rather than "mental illness". There is no single definition and the inclusion criteria are
said to vary depending on the social, legal and political context. In general, however, a mental disorder has
been characterized as a clinically significant behavioral or psychological pattern that occurs in an individual
and is usually associated with distress, disability or increased risk of suffering. The term "serious mental
illness" (SMI) is sometimes used to refer to more severe and long-lasting disorder. A broad definition can
cover mental disorder, mental retardation, personality disorder and substance dependence. The phrase
"mental health problems" may be used to refer only to milder or more transient issues. There is often a
criterion that a condition should not be expected to occur as part of a person's usual culture or religion.
Nevertheless, the term "mental" is not necessarily used to imply a distinction between mental
(dys)functioning and brain (dys)functioning, or indeed between the brain and the rest of the body.
There are currently two widely established systems that classify mental disorders - Chapter V of the
International Classification of Diseases (ICD-10), produced by the World Health Organization (WHO), and
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American
Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for
diagnosis. Some approaches to classification do not employ distinct categories based on cut-offs separating
the abnormal from the normal. They are variously referred to as spectrum, continuum or dimensional
systems. There is a significant scientific debate about the relative merits of a categorical or a non-categorical
system. There is also significant controversy about the role of science and values in classification schemes,
and about the professional, legal and social uses to which they are put.

Disorders

There are many different categories of mental disorder, and many different facets of human behavior
and personality that can become disordered.

The state of anxiety or fear can become disordered, so that it is unusually intense or generalized
over a prolonged period of time. Commonly recognized categories of anxiety disorders include specific
phobia, Generalized anxiety disorder, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-
Compulsive Disorder, Post-traumatic stress disorder. Relatively long lasting affective states can also
become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or
despair is know as Clinical depression (or Major depression), and may more generally be described as
Emotional dysregulation. Milder but prolonged depression can be diagnosed as dysthymia. Bipolar disorder
involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with
normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of
disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under
debate in the scientific literature.

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The fundamental characteristics of a person that influence his or her cognitions, motivations, and
behaviors across situations and time - can be seen as disordered due to being abnormally rigid and
maladaptive. Categorical schemes list a number of different personality disorders, such as those classed as
eccentric (e.g. Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality
disorder), those described as dramatic or emotional (Antisocial personality disorder, Borderline personality
disorder, Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-related
(Avoidant personality disorder, Dependent personality disorder, Obsessive-compulsive personality
disorder).
There may be an emerging consensus that personality disorders, like personality traits in the normal
range, incorporate a mixture of more acute dysfunctional behaviors that resolve in relatively short periods,
and maladaptive temperamental traits that are relatively more stable. Other disorders may involve other
attributes of human functioning. Eating practices can be disordered, at least in relatively rich industrialized
areas, with either compulsive over-eating or under-eating or binging. Categories of disorder in this area
include Anorexia nervosa, Bulimia nervosa, Exercise Bulimia or Binge eating disorder. Sleep disorders
such as Insomnia also exist and can disrupt normal sleep patterns. Sexual and gender identity disorders,
such as Dyspareunia or Gender identity disorder or ego-dystonic homosexuality. People who are
abnormally unable to resist urges, or impulses, to perform acts that could be harmful to themselves or
others, may be classed as having an impulse control disorder, including various kinds of Tic disorders such
as Tourette's Syndrome, and disorders such as Kleptomania (stealing) or Pyromania (fire-setting).
Substance-use disorders include Substance abuse disorder. Addictive gambling may be classed as a
disorder. Inability to sufficiently adjust to life circumstances may be classed as an Adjustment disorder.
The category of adjustment disorder is usually reserved for problems beginning within three months of the
event or situation and ending within six months after the stressor stops or is eliminated. People who suffer
severe disturbances of their self-identity, memory and general awareness of themselves and their
surroundings may be classed as having a Dissociative identity disorder, such as Depersonalization disorder
or Dissociative Identify Disorder itself (which has also been called multiple personality disorder, or "split
personality".). Factitious disorders, such as Munchausen syndrome, also exist where symptoms are
experienced and/or reported for personal gain.
Disorders appearing to originate in the body, but thought to be mental, are known as somatoform
disorders, including Somatization disorder. There are also disorders of the perception of the body, including
Body dysmorphic disorder. Neurasthenia is a category involving somatic complaints as well as fatigue and
low spirits/depression, which is officially recognized by the ICD-10 but not by the DSM-IV. Memory or
cognitive disorders, such as amnesia or Alzheimer's disease exist.
Some disorders are thought to usually first occur in the context of early childhood development,
although they may continue into adulthood. The category of Specific developmental disorder may be used
to refer to circumscribed patterns of disorder in particular learning skills, motor skills, or communication
skills. Disorders which appear more generalized may be classed as pervasive developmental disorders
(PDD) also known as autism spectrum disorders (ASD); these include autism, Asperger's, Rett syndrome,
childhood disintegrative disorder and other types of PDD whose exact diagnosis may not be specified.
Other disorders mainly or first occurring in childhood include Reactive attachment disorder; Separation
Anxiety Disorder; Oppositional Defiant Disorder; Attention Deficit Hyperactivity Disorder.

Causes

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Numerous factors have been linked to the development of mental disorders. In many cases there is
no single accepted or consistent cause currently established. A common view held is that disorders often
result from genetic vulnerabilities combining with environmental stressors (Diathesis-stress model). An
eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of
contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model - incorporating
biological, psychological and social factors - although this may not be applied in practice. Biopsychiatry
has tended to follow a biomedical model, focusing on "organic" or "hardware" pathology of the brain.
Psychoanalytic theories have been popular but are now less so. Evolutionary psychology may be used as
an overall explanatory theory. Attachment theory is another kind of evolutionary-psychological approach
sometimes applied in the context for mental disorders. A distinction is sometimes made between a "medical
model" or a "social model" of disorder and related disability.
Genetic studies have indicated that genes often play an important role in the development of mental
disorders, via developmental pathways interacting with environmental factors. The reliable identification
of connections between specific genes and specific categories of disorder has proven more difficult.
Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain
injury may increase the risk of developing certain mental disorders. There have been some tentative
inconsistent links found to certain viral infections, to substance misuse, and to general physical health.
Abnormal functioning of neurotransmitter systems has been implicated, including serotonin,
norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity
of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as
cognitive and emotional processes, personality, temperament and coping style.
Social influences have been found to be important, including abuse, bullying and other negative or
stressful life experiences. The specific risks and pathways to particular disorders are less clear, however.
Aspects of the wider community have also been implicated, including employment problems,
socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular
societies and cultures.

Laws and policies

Three quarters of countries around the world have mental health legislation. Compulsory admission
to mental health facilities (also known as Involuntary commitment or sectioning), is a controversial topic.
From some points of view it can impinge on personal liberty and the right to choose, and carry the risk of
abuse for political, social and other reasons; from other points of view, it can potentially prevent harm to
self and others, and assist some people in attaining their right to healthcare when unable to decide in their
own interests. All human-rights oriented mental health laws require proof of the presence of a mental
disorder as defined by internationally accepted standards, but the type and severity of disorder that counts
can vary in different jurisdictions. The two most often utilized grounds for involuntary admission are said
to be serious likelihood of immediate or imminent danger to self or others, and the need for treatment.
Applications for someone to be involuntarily admitted may usually come from a mental health practitioner,
a family member, a close relative, or a guardian. Human-rights-oriented laws usually stipulate that
independent medical practitioners or other accredited mental health practitioners must examine the patient
separately and that there should be regular, time-bound review by an independent review body An
individual must be shown to lack the capacity to give or withhold informed consent (i.e. to understand
treatment information and its implications). Legal challenges in some areas have resulted in supreme court
decisions that a person does NOT have to agree with a psychiatrist's characterization of their issues as an

58
"illness", nor with a psychiatrist's conviction in medication, but only recognise the issues and the
information about treatment options.
Proxy consent (also known as substituted decision-making) may be given to a personal
representative, a family member or a legally appointed guardian, or patients may have been able to enact
an advance directive as to how they wish to be treated. The right to supported decision-making may also
be included in legislation. Involuntary treatment laws are increasingly extended to those living in the
community, for example outpatient commitment laws (known by different names) are used in New Zealand,
Australia, United Kingdom and most of the United States.
The World Health Organization reports that in many instances national mental health legislation
takes away the rights of persons with mental disorders rather than protecting rights, and is often outdated.
In 1991, the United Nations adopted the Principles for the Protection of Persons with Mental Illness and
the Improvement of Mental Health Care, which established minimum human rights standards of practice
in the mental health field. In 2006 the UN formally agreed the Convention on the Rights of Persons with
Disabilities to protect and enhance the rights and opportunities of disabled people, including those with
psychosocial disabilities. The term insanity, sometimes used colloquially as a synonym for mental illness,
is often used technically as a legal term.

Perception and discrimination

Stigma

The social stigma associated with mental disorders is a widespread problem. Some people believe
those with serious mental illnesses cannot recover, or are to blame for problems. The US Surgeon General
stated in 1999 that: "Powerful and pervasive, stigma prevents people from acknowledging their own mental
health problems, much less disclosing them to others. Employment discrimination is reported to play a
significant part in the high rate of unemployment among those with a diagnosis of mental illness. Efforts
are being undertaken worldwide to eliminate the stigma of mental illness. Their methods and outcomes
have sometimes been criticized as counterproductive.
A study by Baylor University researchers found that clergy often deny or dismiss the existence of
the mental illness. In a study published in Mental Health, Religion and Culture, researchers found that in a
study of 293 Christians church members, more than 32 percent were told by their church pastor that they
or their loved one did not really have a mental illness. The study found these church members were told the
cause of their problem was solely spiritual in nature, such as a personal sin, lack of faith or demonic
involvement. Baylor researchers also found that women were more likely than men to have their mental
disorders dismissed by the church. All of the participants in both studies were previously diagnosed by a
licensed mental health provider as having a serious mental illness, like bipolar disorder and schizophrenia,
prior to approaching their local church for assistance.

Media and general public

Media coverage of mental illness comprises predominantly negative depictions, for example, of
incompetence, violence or criminality, with far less coverage of positive issues such as accomplishments
or human rights issues. Such negative depictions, including in children's cartoons, are thought to contribute
to stigma and negative attitudes in the public and in those with mental health problems themselves, although
more sensitive or serious cinematic portrayals have increased in prevalence. In the United States, The Carter
Center has created fellowships for journalists in South Africa, the U.S., and Romania, to enable reporters
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to research and write stories on mental health topics. Former U.S. First Lady Rosalynn Carter began the
fellowships not only to train reporters in how to sensitively and accurately discuss mental health and mental
illness, but also to increase the number of stories on these topics in the news media. The general public
have been found to hold a strong stereotype of dangerousness and desire for social distance from individuals
described as mentally ill.

Violence

People with mental disorders are often afraid of violence against them. Over a quarter of individuals
diagnosed with "severe mental illness" accessing community mental health services in a US inner-city area
were found to have been victims of at least one violent crime in a year, a proportion eleven times higher
than the inner-city average. The proportion is many times greater in every category of crime, including
rape/sexual assault, other violent assaults, and personal and property theft. Findings consistently indicate
that it is many times more likely that people diagnosed with a serious mental illness living in the community
will be the victims rather than the perpetrators of violence.
However, fear of unpredictable violent acts by people with mental illness is also common. One US
national survey indicated that a far higher percentage of Americans rated individuals described as
displaying the characteristics of a mental disorder (for example Schizophrenia or Substance Use Disorder)
as "likely to do something violent to others" compared to those described as being 'troubled'. Research
indicates, on balance, a higher than average number of violent acts by some individuals with certain
diagnoses, notably antisocial or psychopathic personality disorders, but conflicting findings about specific
symptoms (for example links between psychosis and violence in community settings) - but the mediating
factors of such acts are most consistently found to be mainly socio-demographic and socio-economic factors
such as being young, male, of lower socio-economic status and, in particular, substance abuse (including
alcohol). For the most serious crimes, such as homicide, some diagnoses are over-represented in
arrests/convictions; however, although high-profile cases have lead to fears that this has increased due to
deinstitutionalization, this does not reflect the evidence. Violence related to mental disorder (in either
direction) typically occurs in the context of complex social interactions, often in a family setting rather than
between strangers. It is also an issue in health care settings and the wider community.

5.3. Suicide

Suicide (Latin suicidium, from sui caedere, to kill oneself) is the act of terminating one's own life.
Many dictionaries also note the metaphorical sense of "willful destruction of one's self-interest". The World
Health Organization noted that someone commits suicide every 39 seconds, making it one of the leading
causes of death in the world. There are an estimated 10 to 20 million non-fatal attempted suicides every
year. Self-sacrifice for others is not usually considered suicide, as the goal is not to kill oneself but to save
another.
The predominant view of modern medicine is that suicide is a mental health concern, associated
with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear,
or other mental disorders and pressures. Suicide is sometimes interpreted in this framework as a "cry for
help" and attention, or to express despair and the wish to escape, rather than a genuine intent to die. Most
people who attempt suicide do not complete suicide on a first attempt; those who later gain a history of
repetitions have a significantly higher probability of eventual completion of suicide.

Epidemiology
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According to official statistics, about a million people die by suicide annually, more than those
murdered or killed in war. According to 2005 data, suicides in the U.S. outnumber homicides by nearly 2
to 1 and ranks as the 11th leading cause of death in the country, ahead of liver disease and Parkinson's
disease.http://en.wikipedia.org/wiki/Suicide - cite_note-7 According to a 2008 report from the Johns
Hopkins Bloomberg School of Public Health’s Center for Injury Research and Policy, the rate of suicide in
the United States is increasing for the first time in a decade. The increase in the overall suicide rate between
1999 and 2005 was due primarily to an increase in suicides among whites aged 40-64, with white middle-
aged women experiencing the largest annual increase. Worldwide suicide rates have increased by 60% in
the past 50 years, mainly in the developing countries. Most suicides in the world occur in Asia, which is
estimated to account for up to 60% of all suicides. According to the World Health Organization, China,
India and Japan may account for 40% of all world suicides.
Gender and suicide: In the Western world, males die much more often by means of suicide than
do females, although females attempt suicide more often. This pattern has held for at least a century. Some
medical professionals believe this stems from the fact that males are more likely to end their lives through
effective violent means (guns, knives, hanging, etc.), while women primarily use more allure-prone
methods such as overdosing on medications. Others ascribe the difference to inherent differences in
male/female psychology. Greater social stigma against male depression and a lack of social networks of
support and help with depression are often identified as key reasons for men's disproportionately higher
level of suicides, since suicide as a "cry for help" is not seen by men as an equally viable option. Typically
males die from suicide three to four times more often as females, and not unusually five or more times as
often. Excess male mortality from suicide is also evident from data from non-western countries. In 1979–
81, 74 territories reported one or more cases of suicides. Two of these reported equal rates for both sexes:
Seychelles and Kenya. Three territories reported female rates exceeding male rates: Papua New Guinea,
Macau, French Guiana. The remaining 69 territories had male suicide rates greater than female suicide
rates.
Ethnic groups and suicide: In the USA, Asian-Americans are more likely to die by suicide than
any other ethnic group. Caucasians die by suicide more often than African Americans do. This is true for
both genders. Non-Hispanic Caucasians are nearly 2.5 times more likely to kill themselves than are African
Americans or Hispanics.
Age and suicide: In the USA, males over the age of seventy die by suicide more often than younger
males. There is no such trend for females. Older non-Hispanic Caucasian men are much more likely to kill
themselves than older men or women of any other group.
Season and suicide: People die by suicide more often during spring and summer. The idea that
suicide is more common during Christmas is a common misconception. There is also potential risk of
suicide in some people experiencing Seasonal affective disorder. Some studies have found that elderly
people are more likely to commit suicide around their birthdays.

Impact of suicide

It is estimated that each suicide in the United States leaves an average of six people intimately
affected by the death, either as a spouse, parent, significant other, sibling, or child of the deceased person.
These people are referred to as survivors. Of course, this estimate does not represent the total number of
people who may be affected by an individual suicide. For example, the suicide of a child may leave not
only his/her immediate family to make sense of the act, but also his/her extended family, school and entire
community. As with any death, family and friends of a suicide victim feel grief associated with loss.

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However, suicide deaths leave behind a unique set of issues for the survivors. Suicide survivors are often
overwhelmed with psychological trauma that vary depending on the factors comprising the event, including
discovery of the body. The survivor's trauma can leave him/her feeling guilty, angry, remorseful, helpless,
and confused. It can be especially difficult for survivors because many of their questions as to the victim's
final decision are left unanswered, even if a suicide note is left behind (the "why" questions). Moreover,
survivors often feel that they should have intervened in some way to prevent the suicide, even if the suicide
comes as a surprise and there are no obvious warning signs. Along with this sense of regret and failure,
there is sometimes relief if the survivor's relationship with the victim was difficult, strained, or otherwise
complicated. Given this complex and conflicting set of emotions associated with a loved one's suicide,
survivors usually find it difficult to discuss the death with others, even with those who have also faced the
death of a loved one, but by some other means. These feelings cause survivors to feel isolated from their
network of family and friends as well as often making them reluctant to form new relationships. Fortunately,
"survivor support groups" can offer counseling and help bring many of the issues associated with suicide
out into the open. They can also help survivors reach out to their own friends and family who may be feeling
similarly and thus begin the healing process. In addition, counseling services and therapy can provide
invaluable support to the bereaved. Some such groups can be found online, providing a forum for discussion
amongst survivors of suicide. Economic impact. In the United States, deaths and injuries from suicidal
behavior represent $25 billion each year in direct costs, including health care services, funeral services,
autopsies and investigations, and indirect costs like lost productivity. These costs may be counterbalanced
by economic gains. Expenditure on those who would have continued living is reduced, including pensions,
social security, health care services for those with brain disorders ("mentally ill"), as well as other normal
budgetary expenditure per head of living population.

Views on suicide

A. Medical

Modern medicine treats suicide as a mental health issue. Overwhelming or persistent suicidal
thoughts are considered an emotional crisis. Mental health professionals advise that people who have
expressed plans to kill themselves be encouraged to seek help. This is especially relevant if the means
(weapons, drugs, or other methods) are available, or if the person has crafted a detailed plan for executing
the suicide. Medical personnel and mental health professionals frequently receive special training to look
for suicidal signs in those designated "as at risk" within that system. Individuals suffering from depression
are considered a high-risk group for suicidal behavior. Suicide hotlines are widely available for people
seeking help anonymously. http://en.wikipedia.org/wiki/Suicide - cite_note-38In the United States,
individuals who express the intent to harm themselves are automatically determined to lack the present
mental capacity to refuse treatment, and can be transported to the emergency department against their will.
An emergency physician will determine whether inpatient care at a mental health care facility is warranted.
This is sometimes referred to as being "committed". A court hearing may be held to determine the
individual's competence. In most states, a psychiatrist may hold the person for a specific time period without
a judicial order. If the psychiatrist determines the person to be a threat to himself or others, the person may
be admitted involuntarily to a psychiatric treatment facility. This period is usually of three days duration.
After this time the person must be discharged or appear in front of a judge. As in any judicial proceeding
this person has a right to legal counsel.

B. Criminal
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In some jurisdictions, an act or incomplete act of suicide is considered to be a crime. More
commonly, a surviving party member who assisted in the suicide attempt will face criminal charges. In
Brazil, if the help is directed to a minor, the penalty is applied in its double and not considered as homicide.
In Italy and Canada, instigating another to suicide is also a criminal offense. In Singapore, assisting in the
suicide of a mentally handicapped person is a capital offense. In India, abetting suicide of a minor or a
mentally challenged person can result in a possible death penalty, otherwise a maximum 1 year prison term
with a possible fine. In North Korea, suicide is considered treason against the party and is punishable by
death. Due to Kim Il Sung's decree that the seed of class enemies should be destroyed to the third generation,
families of persons who have committed suicide are sent to labor camps with life sentences.

In Germany, the following laws apply to cases of suicide:

 Active euthanasia (killing on request) is prohibited by article 216 of the StGB (Strafgesetzbuch,
German Criminal Code), punishable with six months to five years in jail
 German law interprets suicide as an accident and anyone present during suicide may be prosecuted
for failure to render aid in an emergency. A suicide legally becomes emergency when a suicidal
person loses consciousness. Failure to render aid is punishable under article 323c of the StGB, with
a maximum one year jail sentence.
 Article 212 can be used sometimes against a person found guilty of persuading someone to commit
suicide, with a charge of indirect manslaughter punishable by five to fifteen years in jail
 Unlike other countries, helping a suicidal person to obtain the materials or medication needed to
carry out the act is not usually viewed as a criminal offense

C. Religious and cultural

Views on suicide have been influenced by cultural views on existential themes such as religion,
honor, and the meaning of life. The Abraham, Christian and Islamic religions consider suicide a
dishonorable act; it was often regarded as a serious crime and an offense towards God due to religious belief
in the sanctity of life. However, Christianity and other religions have a concept of martyrdom, which is
considered a highly meritorious act and separate to suicide. Japanese views on honor and religion led to
seppuku, one of the most painful methods of suicide, to be respected as a means to atone for mistakes or
failure, or as a form of protest during the samurai era. In the 20th century, suicide in the form of self-
immolation has been used as a form of protest, and in the form of kamikaze and suicide bombing as a
military or terrorist tactic. Sati is a Hindu funeral practice in which the widow would immolate herself on
her husband's funeral pyre, either willingly, or under pressure from the family and in-laws.

C. Philosophical / ethical

Some see suicide as a legitimate matter of personal choice and a human right (colloquially known
as the right to die movement), and maintain that no one should be forced to suffer against their will,
particularly from conditions such as incurable disease, mental illness, and old age that have no possibility
of improvement. Proponents of this view reject the belief that suicide is always irrational, arguing instead
that it can be a valid last resort for those enduring major pain or trauma. This perspective is most popular
in continental Europe, where euthanasia and other such topics are commonly discussed in parliament,
although it has a good deal of support. A narrower segment of this group considers suicide something
between a grave but condonable choice in some circumstances and a sacrosanct right for anyone (even a
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young and healthy person) who believes they have rationally and conscientiously come to the decision to
end their own lives. Notable supporters of this school of thought include German pessimist philosopher
Arthur Schopenhauer, and Scottish empiricist David Hume. Hume rejects the thesis that suicide violates
our duties to self. Sickness, old age, and other misfortunes can make life sufficiently miserable that
continued existence is worse than death. As to worries that people are likely to attempt to take their lives
capriciously, Hume replies that our natural fear of death ensures that only after careful deliberation and
assessment of our future prospects will we have the courage and clarity of mind to kill ourselves. In the
end, Hume concludes that suicide “may be free of imputation of guilt and blame.” His position is largely
utilitarian, allied with a strong presumption of personal liberty. Adherents of this view often advocate the
abrogation of statutes that restrict the liberties of people known to be suicidal, such as laws permitting their
involuntary commitment to mental hospitals.

A counterargument of this position is the fact that suicide violates any moral duties to others. No
doubt the suicide of a family member or loved one produces a number of harmful psychological and
economic effects. In addition to the usual grief, suicide “survivors” confront a complex array of feelings.
Various forms of guilt are quite common, such as that arising from (a) the belief that one contributed to the
suicidal person's anguish, or (b) the failure to recognize that anguish, or (c) the inability to prevent the
suicidal act itself. Suicide also leads to rage, loneliness, and awareness of vulnerability in those left behind.
Indeed, the sense that suicide is an essentially selfish act dominates many popular perceptions of suicide
(Fedden 1938, 209). Still, some of these reactions may be due to the strong stigma and shame associated
with suicide, in which case these reactions cannot, without logical circularity, be invoked in arguments that
suicide is wrong because it produces these psychological reactions (Pabst Battin 1996, 68–69). Suicide can
also cause clear economic or material harm, as when the suicidal person leaves behind dependents unable
to support themselves financially. Suicide can therefore be understood as a violation of the distinctive “role
obligations” applicable to spouses, parents, and other caretakers.
The most vociferous opponent of suicide was Immanuel Kant. Kant's arguments, though they reflect
earlier natural law arguments, draw upon his view of moral worth as emanating from the autonomous
rational wills of individuals. (Cholbi 2000) For Kant, our rational wills are the source of our moral duty,
and it is therefore a kind of practical contradiction to suppose that the same will can permissibly destroy
itself. Given the distinctive worth of an autonomous rational will, suicide is an attack on the very source of
moral authority. To annihilate the subject of morality in one's person is to root out the existence of morality
itself from the world as far as one can, even though morality is an end in itself. Consequently, disposing of
oneself as a mere means to some discretionary end is debasing humanity in one's person…
Suicide also is criticize on the position of utilitarian too: Suicide would be morally forbidden
because general adherence to a rule prohibiting suicide would produce better overall consequences than
would general adherence to a rule permitting suicide (Brandt 1975)

5.4. Study Cases

Depression/Suicide Case Study

http://healthinmind.com/english/depressionexample.htm

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Margaret B. was married to a tender and loving second husband who catered to both Margaret and her son
from her previous marriage. However, she became increasingly unhappy and felt unworthy of both her
husband and her son. She thought they deserved a better wife and mother. Her misery led her husband to
persuade her to seek psychiatric help. Unfortunately for her, the psychiatrist she consulted was inflexible
in his therapy style and was unable to change Margaret's view of herself as ugly and inadequate, although
her friends saw her as unusually attractive and bright.

One of Margaret's friends, Vi, met Margaret because the same psychiatrist was treating both of them.
Vi was fond of Margaret because they had similar problems, and they visited each other often. On one visit
to Margaret's house, Vi found Margaret extremely active and quite chipper, in contrast to her usual
depressive and fatigued demeanor. Most people might have regarded that as a great sign of progress, but
the change was too radical, and Vi was suspicious. Immediately after leaving Margaret's house, Vi went to
the nearest pay telephone and called Margaret's husband Burl to tell him that there was something strange
about Margaret's behavior. Burl rushed home from his office and found Margaret lying in the bathtub with
her wrists slashed, bleeding profusely. He applied tourniquets and called an ambulance. Because Vi was
astute and Burl was concerned and quick, Margaret survived. Had he been 30 minutes later, she almost
certainly wouldn't have.

After this incident, Margaret went to a different psychiatrist who prescribed medication that significantly
improved her mood. She still was not an unusually happy person, but her mood was normal, and she did
not repeat her suicide attempt.

Margaret's case occurred a long time ago. Nevertheless, it illustrates some facts about depression better
than a modern case could. First, it shows that the wrong psychotherapy can be worthless, or worse. Second,
it demonstrates the danger of suicide if effective medications and therapy are not administered. Third,
Margaret's sudden surprising improvement in mood before her suicide attempt is typical, a sign that the
depressed person has made a decision and is relieved about it. That is one of several possible danger signs
that should not be ignored (see the discussion of suicide for other signs that should arouse
concern).http://en.wikipedia.org/wiki/Transexuality - cite_note-2

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Chapter 6

Medical ethics - compartment of bioethics


Medical ethics is domain which exists as long as medicine is. It subject matter is related to norms
designed to guide the relation of medicine and community, the relation between physicians and patients,
physicians and the patient family and the relation between physicians (in medical team). The main
categories of medical ethics are: professional authority of physician, patient trust, confidentiality. In what
will follow two subjects are unfolded: patient – doctor relation and the problem of confidentiality.

6.1. Medical ethics: patient-doctor relation

MaryJo Ludwig, MD. Physician-Patient Relationship. 1998, University of Washington. Last date modified:
April 11, 2008. http://depts.washington.edu/bioethx/topics/physpt.html

There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a
physician's care creates ethical obligations that are definite and weighty. Working together, the potential
exists to pursue interventions that can significantly improve the patient's quality of life and health status.
Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the patient
and the physician is vital to the diagnostic and therapeutic process. It forms the basis for the physician-
patient relationship. In order for the physician to make accurate diagnoses and provide optimal treatment
recommendations, the patient must be able to communicate all relevant information about an illness or
injury. Physicians are obliged to refrain from divulging confidential information. This duty is based on
accepted codes of professional ethics which recognize the special nature of these medical relationships.
The historical model for the physician-patient relationship involved patient dependence on the physician's
professional authority. Believing that the patient would benefit from the physician's actions, a patient's
preferences were generally overridden or ignored. For centuries, the concept of physician beneficence
allowed this paternalistic model to thrive. During the second half of the twentieth century, the physician-
patient relationship has evolved towards shared decision making. This model respects the patient as an
autonomous agent with a right to hold views, to make choices, and to take actions based on personal values
and beliefs. Patients have been increasingly entitled to weigh the benefits and risks of alternative treatments,
including the alternative of no treatment, and to select the alternative that best promotes their own values
(for further discussion, see the topic page on Informed Consent).
Many patients appreciate a physician who brings a personal touch to the physician-patient encounter.
They may feel more connected to a physician whose extracurricular activities and interests make her seem
more alive. Physicians choose to share parts of their life stories according to their level of comfort.
However, it is essential that the patient, and the patient's concerns, be the focus of every visit.

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Occasionally, a physician may face requests for services, such as contraception or abortion, which
raise a conflict for the physician. Physicians do not have to provide medical services in opposition to their
personal beliefs. In addition, it is acceptable to have a nonjudgmental discussion with a patient regarding
her need for the service, and to ensure that the patient understands alternative forms of therapy. However,
it is never appropriate to proselytize. While the physician may decline to provide the requested service, the
patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be
provided with resources about how to obtain the desired service.
There may be many barriers to effective physician-patient communication. Patients may feel that they are
wasting the physician's valuable time; omit details of their history which they deem unimportant; be
embarrassed to mention things they think will place them in an unfavorable light; not understand medical
terminology; or believe the physician has not really listened and, therefore, does not have the information
needed to make good treatment decisions. Several approaches can be used to facilitate open communication
with a patient. Physicians should:

- sit down
- attend to patient comfort
- establish eye contact
- listen without interrupting
- show attention with nonverbal cues, such as nodding
- allow silences while patients search for words
- acknowledge and legitimize feelings
- explain and reassure during examinations
- ask explicitly if there are other areas of concern
- What happens when physicians and patients disagree?
One third to one half of patients will fail to follow a physician's treatment recommendations. Labeling such
patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best.
Patients filter physician instructions through their existing belief system; they decide whether the
recommended actions are possible or desirable in the context of their everyday lives. Compliance can be
improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay
in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve
them together." Or, "I can give you a medication to help with your symptoms, but I also suspect the
symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?" Or,
"I understand that you are not ready to consider counseling yet. Would you be willing to take this
information and find out when the next support group meets?" Or, "Sometimes it's difficult to take
medications, even though you know they are important. What will make it hard for you to take this
medication?"
Competent patients have a right to refuse medical intervention. Dilemmas may arise when a patient
refuses medical intervention, but does not withdraw from the role of being a patient. For instance, an
intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often
does not present the option for the physician to withdraw from participation in her care (see the

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Maternal/Fetal Conflict topic page). In most cases, choices of competent patients must be respected when
the patient cannot be persuaded to change them.
Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic alliance.
Many times, an honest discussion with the patient about the boundaries of the relationship will resolve such
misunderstandings. The physician can initiate a discussion by saying, "I see that you have a long list of
health concerns. Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most
urgent problem today and reschedule you for a longer appointment. That way, we can be sure to address
everything on your list." Or, "I know that it has been hard to schedule this appointment with me, but using
abusive language with the staff is not acceptable. What do you think we could do to meet everybody's
needs?"
There may be occasions when no agreeable compromise can be reached between the physician and the
patient. And yet, physicians may not abandon patients. When the physician-patient relationship must be
severed, the physician is obliged to provide the patient with resources to locate ongoing medical care.
Under certain conditions, a physician should strongly encourage specific actions. When there is a high
likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without
coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment.

Court orders may be invoked to override a patient's preferences. However, such disregard for the patient's
right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during
pregnancy; if harm is threatened towards oneself or others; with concern for mental incompetence; or when
the patient is a sole surviving parent of dependent children. However, the use of such compulsory powers
is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no
longer subject to the sanctions.

When can a patient be held for medical treatment against her will? This is a controversial area in law,
and the law varies by state. The ethical justification for treatment of a patient against his will is based on
balancing of the risk to the public versus respecting the patient's personal freedom. If the magnitude of risk
to the public is great, many states allow for involuntary treatment. For example, a patient with active
pulmonary tuberculosis that is resistant to multiple anti-tuberculosis medications presents a grave risk to
the public if her condition is untreated. This arises in part because of the high infectivity of active pulmonary
tuberculosis and the relatively small risk to the patient from oral medications for TB treatment. Other
conditions for which non-treatment poses little or no threat to the public, such as untreated acute leukemia,
can rarely have involuntary treatment justified.

Advance Care Planning

Robert A. Pearlman, MD, MPH. Advance Care Planning. University of Washington School of Medicine.
Last date modified: April 11, 2008

http://depts.washington.edu/bioethx/topics/adcare.html

An arrangement for efficiency of care is advance care planning. Advance care planning is a process aimed
at extending the rights of competent adults to guide their medical care through periods of decisional
incapacity. The process, when accomplished comprehensively, involves three steps: (1) thinking through
one's values and preferences, (2) talking about one's values and preferences with others, and (3)
documenting them. Advance care planning is the process. Advance directives usually are the written
documents that provide information about the patient's wishes and/or her designated spokesperson. Verbal

68
directives may be ethically valid, but most patients and health care providers prefer written documentation
in the form of official forms. If official forms are not used, health care providers should document the result
of their advance care planning conversations in a medical record progress note. The goals of advance care
planning are four-fold. In the event of decisional incapacity, they are to:

- maximize the likelihood that medical care serves the patients goals,

- minimize the likelihood of over- or undertreatment,

- reduce the likelihood of conflicts between family members (and close friends) and health care
providers, and

- minimize the burden of decision making on family members or close friends.

As a health care provider who engages her patient in advance care planning, you can expect to better
understand your patient's views about the goals of medicine, his preferred approach to end of life care, what
makes life worth living, as well as his fears about medical interventions and loss of dignity. In addition,
you can expect to have a discussion that clarifies misunderstandings. For example, patients often think that
cardiopulmonary resuscitation is successful 80% of the time, that mechanical ventilation is a fancy word
for nasal prongs, and that coma patients still have the ability to enjoy life.
You can also expect to have better communication with the patient's family members or loved ones because
there should be enhanced shared understanding of the patient's values and wishes. Thus, you can expect to
have fewer conflicts with family members about the approach to end of life care.
Advance directives will not be the outcome of most advance care planning. At a minimum patients should
become familiar with the concept and rationale for advance care planning. Some patients will want to mull
things over, others will want to discuss the topic with their close friends or family and health care providers.
Fewer will be ready to sign documents and even fewer will be interested in personalizing their advance
directives so that they are clear and contain pertinent information with clinical relevance.
We usually think of doing advance care planning with patients who are at higher risk for decisional
incapacity. You should consider having a conversation about this with patients with the following
conditions:

- at risk for strokes (e.g., those with hypertension)

- experiencing early dementia

- engaging in risky behavior that is associated with head trauma and coma (e.g., motorcyclists, riding
in cars without seat belts)

- experiencing severe, recurrent psychiatric illnesses

- terminal illness

It is unknown when or where advance care planning should ideally occur. It is generally thought that this
should occur initially in the outpatient setting, and then be reviewed upon admission to and discharge from
inpatient settings. It is also recommended that whenever there is a significant change in a patient's social or
health status, the patient's views about advance care planning should be reviewed.
You can raise advance care planning as one of many health promotion activities. These discussions are
aimed at avoiding harms (over- and undertreatment), and promoting benefits (treatments tailored to the

69
patient's goals). You should reassure the patient that raising this issue does not mean that there is something
unspoken to worry about. You also may tell the patient that this topic is difficult for many patients and that
you will understand if she does not want to come to any conclusions during this discussion.
When having a discussion about advance care planning, the following questions are recommended:

- Who should speak on your behalf if you become so sick you can't speak for yourself?

- Are there any circumstances that you've heard about through the news or TV where you've said to
yourself, "I would never want to live like that?" If so, what are they and why do you feel this way
about them?

- Are there any life-sustaining treatments that you would not want to receive under any
circumstances? If so, what are they and why do you feel this way about them?

- Some people have more concerns about the way they will die or dying than death itself. Do you
have any fears or concerns about this?

- In the event that you are dying, where do you want to receive medical care?

- Should your current preferences be strictly applied to future situations or serve as a general guide
to your family (or loved ones)?

- How should I advise a patient if she doesn't have anyone to name as a proxy? You should inform
the patient that the best course of action under these circumstances is to write down her wishes and
give a copy to her health care providers. She should fill out a legal form, such as a living will, with
as much detail as possible, and then include a personalized statement to provide a better
understanding of her wishes.

- How should I advise a patient if he believes that some family members will disagree with his
wishes?The patient should be informed that the best way to prevent disagreements is to
communicate with everyone ahead of time to let them know who has been picked as a spokesperson
and what kind of approach to medical care he wants.

6.2. The problem of confidentiality

Kelly A. Edwards, M.A. Confidentiality. University of Washington, 1998


http://depts.washington.edu/bioethx/topics/confiden.html

Confidentiality is one of the core tenets of medical practice. Yet daily physicians face challenges to this
long-standing obligation to keep all information between physician and patient private.
Where does the duty of confidentiality come from? Patients share personal information with physicians.
You have a duty as a physician to respect the patient's trust and keep this information private. This requires
the physician to respect the patient's privacy by restricting access of others to that information. Furthermore,
creating a trusting environment by respecting patient privacy can encourage the patient to be as honest as
possible during the course of the visit. (See also Physician-Patient Relationship.)
The obligation of confidentiality both prohibits the physician from disclosing information about the
patient's case to other interested parties and encourages the physician to take precautions with the
information to ensure that only authorized access occurs. Yet the context of medical practice does constrain
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the physician's obligation to protect patient confidentiality. In the course of caring for patients, you will
find yourself exchanging information about your patients with other physicians. These discussions are often
critical for patient care and are an integral part of the learning experience in a teaching hospital. As such,
they are justifiable so long as precautions are taken to limit the ability of others to hear or see confidential
information. Computerized patient records pose new and unique challenges to confidentiality. You should
follow prescribed procedures for computer access and security as an added measure to protect patient
information.
What kinds of disclosure are inappropriate? Inappropriate disclosure of information can occur in clinical
settings. When pressed for time, the temptation to discuss a case in the elevator may be great, but in that
setting it is very difficult to keep others from hearing the information exchanges. Similarly, extra copies of
handouts from teaching conferences that contain identifiable patients should be removed at the conclusion
of the session. The patient's right to privacy is not being respected in these sorts of cases.
Confidentiality is not an absolute obligation. Situations arise where the harm in maintaining
confidentiality is greater than the harm brought about by disclosing confidential information. In general,
two such situations that may give rise to exceptions exist. In each situation, you should ask - will lack of
this specific information about this patient put a specific person you can identify at high risk of serious
harm? Legal regulations exist that both protect and limit your patient's right to privacy, noting specific
exceptions to that right. These exceptions follow.

Exception 1:

Concern for the safety of other specific persons. On the one hand, the law restricts access to medical
information and records. On the other, clinicians have a duty to protect identifiable individuals from any
serious threat of harm if they have information that could prevent the harm. As mentioned above, the
determining factor in justifying breaking confidentiality is whether there is good reason to believe specific
individuals (or groups) are placed in serious danger depending on the medical information at hand. The
most famous case of this sort of exception is that of homicidal ideation, when the patient shares a specific
plan with a physician or psychotherapist to harm a particular individual. The court has required that
traditional patient confidentiality be breached in these sorts of cases.

Exception 2:

Concern for public welfare. In the most clear cut cases of limited confidentiality, you are required by state
law to report certain communicable/infectious diseases to the public health authorities. In these cases, the
duty to protect public health outweighs the duty to maintain a patient's confidence. From a legal perspective,
the State has an interest in protecting public health that outweighs individual liberties in certain cases. For
instance, reportable diseases in Washington State include (but are not limited to): AIDS and Class IV HIV,
hepatitis A and B, measles, rabies, tetanus, and tuberculosis. Suspected cases of child, dependent adult, and
elder abuse are reportable, as are gunshot wounds. Local municipal code and institutional policies can vary
regarding what is reportable and standards of evidence required. It is best to clarify institutional policy
when arriving at a new site.

What if a family member asks how the patient is doing? While there may be cases where the physician
feels compelled to share information regarding the patient's health and prognosis with, for instance, the
patient's inquiring spouse, without explicit permission from the patient it is generally unjustifiable to do so.
Except in cases where the spouse is at specific risk of harm directly related to the diagnosis, it remains the
patient's, rather than the physician's, obligation to inform the spouse.
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6.3. Study cases

Case 1

Physician-Patient Relationship: http://depts.washington.edu/bioethx/topics/physptd1.html

During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa.
She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies.
Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At
5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended
therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical
intervention. She continues to present to the family physician, offering a variety of somatic complaints.

When a patient's preferences conflict with a physician's goal to restore health, which ethical principle should
prevail, patient autonomy or physician beneficence? Does the patient's depression render her incompetent to
refuse treatment for her anorexia?

Case 2

Advance Care Planning: http://depts.washington.edu/bioethx/topics/adcared1.html

An elderly woman told her daughters that if she ever ended up with dementia she wouldn't want to live like
that. Years later she developed senile dementia and her daughters had her move into a nursing home.
Although she did not recognize family or friends, she enjoyed the company of others and the nursing home's
cat. When she stopped eating, her daughters were asked whether she should receive a feeding tube.

Should the daughters consider her previously stated wishes as an advance directive?

Case 3

Confidentiality:

Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his wife of the results
and claims he is not ready to tell her yet.

What is your role legally? What would you say to your patient?

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Chapter 7

Scientific research and clinical trials in the biomedical world from the perspective of
bioethics
7.1. Ethical issues in human subjects research

After Timothy C. Callahan, PhD. Research Ethics. University of Washington School of Medicine.
http://depts.washington.edu/bioethx/topics/resrch.html

European Commotion.. European Textbook on Ethics in Research. Luxembourg: Publications Office of


the European Union, 2010

Scientific research is a systematic investigation designed to develop generalisable knowledge. There are
many reasons for holding that research is something to be encouraged. Several reasons might be given for
viewing research as a valuable activity:
• Research has brought a better quality of life and increased welfare.
We owe our present standard of living to the huge amount of research that has made it possible – huge
improvements in economic efficiency, health care and wellbeing only exist because of research, and it is
reasonable to expect that this will only continue.
• Huge numbers of lives have been saved.
If we think about medical research in particular, huge numbers of lives have been saved by medical
advances. Moreover, advances in our basic understanding of nutrition, sanitation and the environment have
had a profound impact on life expectancy and the quality of life.
• Knowledge may be good for its own sake.
Finally, even where new knowledge has no real world applications we may still think that we are in some
way enriched by understanding more about ourselves, the universe we live in and our relationship
The ethical issues in human subjects’ research have received increasing attention over the last 80 years;
because of same public scandals arise as a result of abuse on humans in scientific research. Among these
scandals are Experiments carried out on concentration camp prisoners included involuntary sterilization,
subjection to radiation, freezing to induce hypothermia, infection of research subjects with malaria and
tuberculosis (TB), and many other unethical experiments, conducted without the consent of the research
subjects, and often leading predictably to extreme pain, mutilation and death.
The Milgram experiments, United States, 1961-63 designed to investigate people’s obedience to authority.
In these experiments the research subjects were deceived about the nature of the research and led to believe
that they (in the process of a different experiment) were administering electric shocks to other research
participants. The aim of the research, which turned out to be very distressing for many of the subjects, was
to see how far they would be willing to go in risking harm to the other research participants. (10)
Surprisingly, the result was that most people (approximately 65 %) were willing to continue to the end of
the experiment, even though had the electric shocks been real they would have been seriously endangering
the other research participant. One observation that might be made about this research is that science that
is ethically questionable is not always scientifically weak or unimportant, since from this research we learnt
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that people will often obey authorities even if this involves behavior that they would normally judge to be
unethical, which has important implications for psychology, sociology and governance.
Tuskegee syphilis study, United States, 1932-72. This was a clinical study carried out between 1932 and
1972 in Tuskegee, Alabama, by the US Public Health Service. About 400 mostly illiterate African-
Americans with syphilis were recruited into the study as well as two hundred healthy controls. The aim of
the study was to observe the natural progression of the disease when left untreated, and in particular to
compare the progression of the disease in African-Americans with the results of an earlier retrospective
study of the disease in Europeans. The participants were not told that they were in a medical trial, and the
tests were described as “special free treatments”. At the outset of the trial there was no effective treatment
for syphilis. However, by 1947 penicillin had become the standard – effective – treatment for syphilis. The
researchers blocked the study subjects from receiving effective treatment, going so far as to prevent the
subjects from being conscripted into the armed forces since that would have necessitated them being treated.
At the end of the study only 74 subjects remained alive, 40 of their wives had been infected and 19 children
had been born with syphilis, some of which might have been prevented if these men had been given
treatment. The aftermath of Tuskegee led to the formalization of ethics review in America, and was also
influential on the 1975 revision of the Declaration of Helsinki which introduced the requirement for the
independent review of all research.
International documents

Nowadays Institutional Review Boards for the Protection of Human Subjects (IRB's) have been
established at most institutions that undertake research with humans. These committees are made up of
scientists, clinical faculty, and administrators who review research according to the procedures set out in
nationals Regulations. The scientific protocol is review accordingly to some principles mentioned in
chapter 2: autonomy or respect for person, beneficence and justice.
There are several ethical issues that must be considered when designing research that will utilize
participants who are human beings.
- The primary concern of the investigator should be the safety of the research participant. This is
accomplished by carefully considering the risk/benefit ratio, using all available information to make
an appropriate assessment and continually monitoring the research as it proceeds.
- The scientific investigator must obtain informed consent from each research participant. This should
be obtained in writing (although oral consents are sometimes acceptable) after the participant has
had the opportunity to carefully consider the risks and benefits and to ask any pertinent questions.
Informed consent should be seen as an ongoing process, not a singular event or a mere formality.

- The investigator must enumerate how privacy and confidentiality concerns will be approached.
Researchers must be sensitive to not only how information is protected from unauthorized
observation, but also if and how participants are to be notified of any unforeseen findings from the
research that they may or may not want to know.

- The investigator must consider how adverse events will be handled; who will provide care for a
participant injured in a study and who will pay for that care are important considerations.

- In addition, before enrolling participants in an experimental trial, the investigator should be in a


state of "equipoise," that is, if a new intervention is being tested against the currently accepted
treatment, the investigator should be genuinely uncertain which approach is superior. In other
words, a true null hypothesis should exist at the onset regarding the outcome of the trial.

Inform consent

For an informed consent to be ethically valid in research setng, the following components must be present:

74
- Disclosure: The potential participant must be informed as fully as possible of the nature and purpose
of the research, the procedures to be used, the expected benefits to the participant and/or society,
the potential of reasonably foreseeable risks, stresses, and discomforts, and alternatives to
participating in the research. There should also be a statement that describes procedures in place to
ensure the confidentiality or anonymity of the participant. The informed consent document must
also disclose what compensation and medical treatment are available in the case of a research-
related injury. The document should make it clear whom to contact with questions about the research
study, research subjects' rights, and in case of injury.

- Understanding: The participant must understand what has been explained and must be given the
opportunity to ask questions and have them answered by one of the investigators. The informed
consent document must be written in lay language, avoiding any technical jargon.

- Voluntariness: The participant's consent to participate in the research must be voluntary, free of any
coercion or promises of benefits unlikely to result from participation.

- Competence: The participant must be competent to give consent. If the participant is not competent
due to mental status, disease, or emergency, a designated surrogate may provide consent if it is in
the participant's best interest to participate. In certain emergency cases, consent may be waived due
to the lack of a competent participant and a surrogate.

The potential participant must be given the opportunity to give full consideration regarding the decision
whether or not to participate in the research study without undue influence from his or her physician, family,
or the scientific investigator. No informed consent may contain any exculpatory language by which the
participant waives any legal rights or releases the investigator or sponsor from liability for negligence.
As a general rule, deception is not acceptable when doing research with humans. Using deception
jeopardizes the integrity of the informed consent process and can potentially harm your participants.
Occasionally exploring your area of interest fully may require misleading your participants about the
subject of your study. For example, if you want to learn about decision-making practices of physicians
without influencing their practice-style, you may consider telling them you are studying "communication
behaviors" more broadly. The IRB will review any proposal that suggests using deception or
misrepresentation very carefully. They will require an in-depth justification of why the deception is
necessary for the study and the steps you will take to safeguard your participants.

7.2. Ethical issues in nonhuman subjects research

The scientific rationale underlying the use of animals in biomedical research is that a living organism
provides an interactive, dynamic system that can be observed and manipulated experimentally in order to
investigate mechanisms of normal function and of disease. As a result, a greater understanding of living
systems can be attained and this knowledge can be generalized to other species including humans,
facilitating the development of effective therapies. One particular use of animals in research is in the
development and use of animal models of particular human physiological functions (e.g., immune
response, cardiovascular function, vision) and diseases. These are commonly used in all areas of
biomedical research and have contributed significantly to medical progress.

The use of animals in research must be done under some ethical request. Nuffield council of bioethics
elaborate guide for involving morally the animals in research. Accordingly to this guide, animal
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experiments can only be carried out if the desired results cannot be achieved by another method, and a
range of replacement methods have been developed in different areas of research. Report gives examples
of replacement, methods called Three Rs.

- Refinement: Improvement of all aspects of the lifetime experience of animals to reduce suffering
and improve welfare.
- Reduction: The use of fewer animals in each experiment without compromising scientific output
and the quality of biomedical research and testing, and without compromising animal welfare.
- Replacement: The use of methods that permit a given scientific purpose to be achieved without
conducting experiments or other scientific procedures on living animals.
See:
http://www.nuffieldbioethics.org/sites/default/files/The%20ethics%20of%20research%20involving%20a
nimals%20-%20short%20guide.pdf

7.3. Study Cases.

Research Ethics: http://depts.washington.edu/bioethx/topics/resrchd1.html

Case 1

Mrs. Franklin, an 81-year-old Alzheimer's patient hospitalized under your care has been asked to participate
in a clinical trial testing a new drug designed to help improve memory. You were present when the clinical
investigator obtained a signed informed consent from Mrs. Franklin a few days ago. However, when you
visit Mrs. Franklin today and ask her if she is ready to begin the study tomorrow, she looks at you blankly
and seems to have no idea what you are talking about.

What should you do?

Case 2

During the conduct of a large clinical trial of an investigational drug, preliminary analysis of results show
that there were three times as many participants in the experimental group who experienced severe nausea
and vomiting compared to the control group. Two of the cases were severe enough to require that the
participants be hospitalized. This is despite the fact that the preliminary analysis shows that there may be a
moderate benefit with the drug. What should be done?

References and Further Reading

1. Anscombe,Elizabeth “Modern Moral Philosophy,” Philosophy, 1958, Vol. 33, reprinted in her
Ethics, Religion and Politics (Oxford: Blackwell, 1981).

2. Aristotle, Nichomachean Ethics, in Barnes, Jonathan, ed., The Complete Works of Aristotle
(Princeton, N.J.: Princeton University Press, 1984).

3. Ayer, A. J., Language, Truth and Logic (New York: Dover Publications, 1946).

4. Baier, Kurt, The Moral Point of View: A Rational Basis of Ethics (Cornell University Press, 1958).

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5. Bentham, Jeremy, Introduction to the Principles of Morals and Legislation (1789), in The Works of
Jeremy Bentham, edited by John Bowring (London: 1838-1843).

6. Hare, R.M., Moral Thinking, (Oxford: Clarendon Press, 1981).

7. Hare, R.M., The Language of Morals (Oxford: Oxford University Press, 1952).

8. Hobbes, Thomas, Leviathan, ed., E. Curley, (Chicago, IL: Hackett Publishing Company, 1994).

9. Hume, David, A Treatise of Human Nature (1739-1740), eds. David Fate Norton, Mary J. Norton
(Oxford; New York: Oxford University Press, 2000).

10. Kant, Immanuel, Grounding for the Metaphysics of Morals, tr, James W. Ellington (Indianapolis:
Hackett Publishing Company, 1985).

11. Locke, John, Two Treatises, ed., Peter Laslett (Cambridge: Cambridge University Press, 1963).

12. MacIntyre, Alasdair, After Virtue, second edition, (Notre Dame: Notre Dame University Press,
1984).

13. Mill, John Stuart, “Utilitarianism,” in Collected Works of John Stuart Mill, ed., J.M. Robson
(London: Routledge and Toronto, Ont.: University of Toronto Press, 1991).

14. Moore, G.E., Principia Ethica, (Cambridge: Cambridge University Press, 1903).

15. Ockham, William of, Fourth Book of the Sentences, tr. Lucan Freppert, The Basis of Morality
According to William Ockham (Chicago: Franciscan Herald Press, 1988).

16. Plato, Republic, 6:510-511, in Cooper, John M., ed., Plato: Complete Works (Indianapolis: Hackett
Publishing Company, 1997).

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