An introduction to bioethics

1. An introduction to bioethics Ma. Cristina S. Sombilon, M.D., F.P.S.P. Department of Medical Humanities UERMMMC College of Medicine

2. ETHICS • a branch of philosophy • Practical science of MORALITY of human acts • Teaches us how to judge accurately the moral GOODNESS or BADNESS of any human action Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

3. Basic principles in bioethics 1. BENEFICENCE – ONE OUGHT TO DO GOOD • Seek the patient’s well-being • Provide standards of due care and risk/benefit assessment 2. NON-MALEFICENCE – DO NO HARM • Avoid unnecessary expense, consult, procedures and medications Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

4. Basic principles in bioethics 3. INFORMED CONSENT • Provide the patient with a COMPLETE, ADEQUATE DISCLOSURE of his illness and OPTIONS in a language he understands for the patient to be able to make a rational and free decision 4. AUTONOMY (RESPECT FOR PERSONS) • Respect the patient’s rational decision as long as he is aware of the consequences • The patient has a right to refuse 5. JUSTICE • Allocating scarce resources fairly and according to medical needs Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

5. BIOETHICS • “life ethics” – philosophical • More encompassing than medical ethics, includes additional issues not necessarily a part of medical ethics • Medical ethics • Business ethics • Sexual ethics • Social ethics • Environmental policy and ethics Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

6. Bioethics • Medical ethics is a “subset” of bioethics • Clinical or case-based approach • Used interchangeably “BIOETHICS” “MEDICAL ETHICS” “BIOMEDICAL ETHICS” Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

7. Bioethics • HIV/AIDS issues • organ transplantation • genetic engineering • reproductive rights and assisted reproductive techniques • stem cell research • human cloning MEDICAL ETHICS • abortion • euthanasia • confidentiality • truth telling • fair distribution of resources • informed consent • research involving human subjects Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

8. Bioethics BUSINESS ETHICS • Corporate responsibility • Rights and obligations of employees • Diversity and discrimination in the workplace • Care for the environment from industry and business • Minimum wage vs. Living wage • Age discrimination • School discrimination Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

9. Bioethics SEXUAL ETHICS • Homosexuality and gender sensitivity issues • Prostitution • Adultery SOCIAL ETHICS • Family responsibility • Distribution of social resources • Society’s obligation to the poor Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

10. MEDICAL ETHICS • The application of the GENERAL PRINCIPLES of ethics to the moral problems of the medical profession • CORE: ethics of a physician-patient relationship (TRUST) Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

11. Medical ethics • Specific RULES OF CONDUCT of physician • What the physician PROVIDES for the patient • What the physician’s DUTIES are to the patient and VICE-VERSA Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

12. Medical ethics TRADITIONAL MEDICAL ETHICS • Equality of health care professionals • and patients • stewardship • autonomy • Purpose of health care is TOTAL PATIENT CARE (value based ethics) Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

13. Medical ethics • Duty to help the patient: BENEFICENCE • Duty not to harm the patient: NON-MALEFICENCE Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

14. Medical humanities • Coined to cover PHILOSOPHICAL, LITERARY, HUMANISTIC approaches to problems in medicine • Ethics is an area of study in philosophy and philosophy is a part of the humanities • Contemporary use of the term includes LITERATURE, POETRY, FILM, MUSIC to increase appreciation for the HUMANISTIC, INTERPERSONAL, and EMPATHETIC aspects of medicine Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

15. Medical humanities THE HEART OF MEDICINE Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

16. HISTORY OF BIOETHICS When and where was bioethics born? ANCIENT HISTORY • HIPPOCRATIC OATH – first code of medical ethics • “first do no harm” • A promise to respect a patient’s personal dignity and privacy • A promise to use medical knowledge FOR THE GOOD OF THE PATIENT Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

17. History of bioethics • The oath and prayer of MAIMOINIDES (c. 1200) • Rabbi Moshe Ben Maimon, a Jewish philosopher • a meditative piece which implores physicians to look at the sick with respect and dignity OATH “The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all times: may neither avarice nor miserliness; nor thirst for glory or for a great reputation engage my mind... ” Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

18. History of bioethics OATH OF MAIMOINIDES “May I never see in the patient anything but a fellow creature in pain.” “...God, thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto Thy calling.” Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

19. History of bioethics PERCIVAL’S CODE (1794) – first code of medical ethics adopted by a professional group of physicians. AMERICAN MEDICAL ASSOCIATION (AMA) – first code of ethics was adopted in 1847 in Philadelphia • Duties and obligations of physicians to their patients and vice-versa • Duties of physicians to society and medicine itself • Revised and updated over time Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

20. History of bioethics MODERN DAY BIOETHICS • Emerged from the atrocities and scandals in human experimentation • Horrific experiments performed on prisoners by doctors in Nazi concentration camps • NUREMBURG MILITARY TRIBUNAL TRIALS • (Nov. 14, 1945 – Oct. 1, 1946) • NUREMBURG CODE – influenced the direction of research ethics and policy Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

21. History of bioethics NUREMBURG CODE • Code of ethics on human experimentation • Ten point statement delimiting permissible medical experimentation on human subjects • First line emphasizes that VOLUNTARY CONSENT of human subject is absolutely essential in any experiment Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

22. History of bioethics MODERN DAY BIOETHICS • A new discipline which tries to reconcile the discrepancies between the 2400 year old Hippocratic Code with today’s medico-moral issues FROM AN ETHICAL POINT OF VIEW, MEDICINE IS THE VICTIM OF ITS OWN SUCCESS Today in medicine, the CRITERION OF WHAT IS GOOD (ethical or moral) is being replaced by WHAT IS USEFUL (Utilitarianism) Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

23. History of bioethics • 1966 article by Dr. Henry Beecher, Harvard Univ., in the New England Journal of Medicine (NEJM) • Several unethical and experimental research programs in clinical research in the U.S. • Used unknowing human subjects exposed to extreme health risks • “moral basis” or purpose is to advance scientific knowledge • Other well publicized events in health care and research questioned the norms of medical ethics Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

24. History of bioethics WILLOWBROOK STUDY/EXPERIMENT • Infecting mentally retarded school children of the Willowbrook State School in New York with HEPATITIS • To study the course of the disease • Consent to the study became a “prerequisite” for enrolment Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

25. History of bioethics TUSKEGEE EXPERIMENT • 1930s U.S. Government study • 400 Black American men with SYPHILIS were signed up to observe the course of the disease • 1949- discovery of a cure PENICILLIN • Treatment was DELIBERATELY WITHELD from the subjects in order to observe the progress of the disease and its complications until death Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

26. History of bioethics TUSKEGEE EXPERIMENT • “bad blood” • Patients lived with the disease until their death, some in the 1970s • U.S. Gov’t. reparations and recognition of these men did little to regain the trust of the public in human experimentation • Only in the last term of Pres. W. Clinton was a FORMAL APOLOGY to the families of the Tuskegee victims given Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

27. History of bioethics MODERN DAY BIOETHICS CANDIDATES • 1962: LIFE magazine article by Shana Alexander on the Seattle Artificial Kidney Program • 1967: Dr.Christiaan Barnard, South Africa, first successful heart transplant • 1973: Roe vs. Wade – U.S. Supreme Court decision on abortion Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

28. History of bioethics • 1974: exposure of Tuskegee Syphilis study • 1974: The National Commission for the Protection of Human Subjects in Biomedical and Behavioural Research • 1976: Quinlan case – U.S. Supreme Court decision on end-of-life Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

29. History of bioethics MODERN DAY BIOETHICS RECENT EVENTS • 1978: Drs. Patrick Steptoe and Robert Edwards – first test tube baby (IVF) and embryo transplant baby Louise Brown • 1980s – present: HIV/AIDS • 1991: the Patient Self-determination Act (advanced directives, living will, ethics committees) Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

30. History of bioethics • 1996: Dolly, the first cloned sheep; stem cell technology • 2002: legalization of euthanasia in the Netherlands, emergence of Right to Die advocates and movement, Oregon Death with Dignity Act • 2007: Terri Schiavo – end of life case, termination of feeding Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

31. History of bioethics BIOETHICS AS A FIELD MORE DEFINED • Bioethics institutes • 1969 Hastings Center • 1971 Kennedy Institute for Ethics (Georgetown Univ.) • 1977 Tom Beauchamp and James Childress • The Principles of Biomedical Ethics (a synthesis of approaches and methods in biomedical decision making) • 1995 – 2001 National Bioethics Advisory Committee; President’s Council on Bioethics Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

32. History of bioethics • HOSPITAL ETHICS COMMITTEESS • ETHICS REVIEW BOARD THE FUTURE OF BIOETHICS • Brain mapping and highly precise imagine technology – neuroethical issues to determine personality traits and disease and behavior predisposition: accessing a person’s memories for legal or forensic purposes Ma. Cristina S. Sombilon, MD, FPSP || Depatment of Medical Humanities UERMMMC

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