Welcome to Medical Ethics online. My name is Kevin Browne and I'll be your instructor this semester. I have been teaching philosophy for over 10 years. I earned my Master's Degree in Philosophy from the University of Louisville in 1995. Since then I have taught courses in philosophy at U of L, Indiana University Southeast, and Jefferson Community College. Having introduced myself, I would like you to send me an e-mail introducing yourself. Tell me your name, your location, your major (if you have one), and what you hope to gain from taking this class. And anything else you'd like to tell me.
I am looking forward to a very interesting semester. I've got a lot of information to share with you and discuss so I hope you're prepared for a very interactive class. I will post a folder for each section of the course which will contain a summary PowerPoint as well as links to other relevant information on the topic. I will also be posting multi-media web casts from various sources. For those of you with hi speed internet connections I encourage you to access this material as it will enhance your experience of addressing the issues in bioethics. If you don't have a hi-speed internet connection you can certainly still access these materials though it will take you longer to download them. We will also be interacting through the use of discussion boards which you will be graded on. There will be one discussion board per unit and it is very important that you engage in these discussions not only for a grade but also because it will help you understand and apply the ethical principles we'll be discussing. There will also be short assignments where you will have to apply the ethical principles we discuss to a real world case. Lastly, for each unit we cover I will post a study guide which will outline the main points from each article and help guide our discussion. It is very important that you not substitute the study guide for reading the articles in the text. I have deliberately made the study guides very brief because they serve only as a guide for you not for the content you need to engage in discussion or succeed on the exams.
Most, if not all, of you are going into the medical field. The information covered in the articles is not simply trivial information you need to memorize only to pass exams for this class. You NEED this information! It is vital that you familiarize yourself with the issues, ideas, and arguments in bioethics. As you may already know, it is not only doctors who face ethical decisions in the medical field. Therefore, no matter what role you intend to play in this field it is important that you familiarize yourself with bioethics.
The biologist and physician Lewis Thomas once called medicine "the youngest science." As you well know from your own studies there is as much art as science in medicine and this is true of bioethics as well. The very nature of an ethics class is different from many other classes you've taken. The difference is there from the very start and lies somewhat hidden in the word "should."
In many areas of knowledge and theory like physics, economics, sociology, and psychology, the central concern is over getting the facts straight. We are trying to find out how things are.Our theories in these areas are largely descriptive and predictive. This is not true in ethics. Sure, we're concerned about facts and predictions but there's another important element. That element is normative. This is a fancy word which simply means we're concerned with how things ought to be. This is what makes ethics unique and potentially controversial.
Disagreements about facts are common in such areas as biology and the social sciences. Sometimes they come to blows but as often as not the disagreements are restricted to polite academic discussions. In ethics and morality there's more at stake precisely because we're asking normative questions and these inevitably involve value judgments. We're trying to formulate an answer to how we ought to live and this is a very personal issue but also very social inasmuch as we are social beings. Our answers affect others and their answers affect us. Sometimes we find ourselves at odds with one another and what makes matters worse the disagreements are much more difficult to resolve. This is because we're not simply dealing with observable facts. We're not just dealing with how things are, but with how they ought to be.
What I want to do this semester is to invite you to join me in a discussion of precisely these issues. However, I want to assure you that this discussion will be civil and I am not trying to persuade you or tell you what to think. There's always a fear in classes like this that the professor will try to unduly influence students or tell them what they ought to think and feel and believe about certain issues. I don't think this is my job. What I want to do is to expose you to some of the conversations that philosophers have on the questions of ethics and morality as they relate to medical issues and allow you a forum to engage in those conversations as well.
To do this the class will consist of several parts. First, we'll examine some attempts to formulate ethical theories which are designed to help us answer the question of what we ought to do. Some of these ethical theories will have problems which need to be addressed and in doing so we'll try to refine our theories. Secondly, we'll attempt to apply some of these theories to actual issues such as the relationship between patients and medical professionals, abortion, end of life issues, genetics and morality, and the allocation of medical resources. We may not come to any definitive answers concerning these issues, but at the very least we'll have established a method for discourse which can be valuable in and of itself. The hardest part about many moral issues is discussing them. This is one of the most important values that philosophy has in ethics.
We shouldn't underestimate this factor. Philosophy provides us with a method for analyzing concepts and arguments and as we'll see throughout the semester this will be useful in helping us to sort through moral dilemmas. To aid in this we will discuss some important critical thinking skills as well. Philosophers have been thinking about problems in ethics for centuries and we can certainly benefit from that collected wisdom. Professionals in bioethics have been thinking about the specific issues we'll discuss for several decades now and we can benefit from their insights as well. In closing, I want to consider four other important points that may get the conversation started for us.
1. Ethics and Morality: These two terms are often thought of and used synonymously. This is not entirely correct but there are similarities inasmuch as both words have their origin in common. One is the Greek and the other is the Latin word for custom. However, for us we'll use them to denote different concepts. We can consider morality as the set of beliefs that we have regarding right and wrong. Ethics can be understood as the method for justifying these beliefs and the set of rules which guide us in applying them.
2. Ethical Theory: We can think of ethical theory as a decision model. As we'll see the critical element in morality is the need to make decisions regarding fairly difficult issues. What we need is a well reasoned method for taking the facts and making the best decision we can in terms of our moral principles. This often involves the process of judgment.
3. Judgment: Many people have a bad impression of the notion of judgment. Who are we to judge other people and their moral beliefs? The simple fact of the matter is that judgment is an important part of human life and unavoidable in the realm of morality. What we need to do is make sure our judgments are well reasoned and justified. But, we cannot refrain from judging. Think about this. If you're married or in a relationship you had to make a judgment when you entered the relationship. Unless you just randomly picked someone to marry! You can probably easily think of other examples. The difficulty in ethics and morality is how to make these judgments with the facts at hand.
4. The Is-Ought Problem: The reason this is so difficult is because of something called the is-ought problem. This has probably been around ever since people began thinking of ethics but David Hume formulated it in concrete terms in the 18th century. Basically the problem is that you cannot deduce from a set of facts what ought to be. For example, murders occur in this country. That's a fact. But, can we deduce from that fact that murders ought to occur? No. What's especially troubling is that we also cannot deduce that murders ought not to occur. That's the problem. How we solve this problem will be an important part of our look at ethical theory.
To illustrate consider this case. You are a student in a writing course and have an assignment to write a 10 page paper. You know the following facts: the professor has a strong policy against plagiarism and being caught with a plagiarized paper means automatic failure of the course, studies show that at least 75% of students claim to cheat in one form or another during their college career, papers are easily available for purchase online that fit your assigned topic, you have a friend who has told you that you can use his paper from last semester. So, you have a decision to make! You can either decide what must be done and provide a good justification for this decision or ask for more facts first. But, you can only appeal to the facts to make your decision. If you ask for more facts I can provide them but ask yourself how will those additional facts help us answer the question of what they should do? Hume's point is that no additional facts will help. I'll make a discussion board available for us to talk about this. Let me know what you think.
Please bear in mind that the point of this case is to get us to think about the process involved in making decisions with an ethical component. Don't simply say that it is not our place to decide or that this is a personal issue. Of course, it is a personal issue but every case we examine will be a personal issue. The point of examining such cases is to force us to think about ethical issues in context. One way to think about these cases is as follows. At a certain point in your life you may find yourself in a similar situation. Thinking about these cases now allows you to "rehearse" what you might have to think through in such a situation. In addition to this, there is simply no way to avoid making decisions for others at times in bioethics. You may not find yourself in such a sitation as the decision maker, but it is likely that in your career in health care, you will find yourself close to a situation where the person involved cannot make the decision directly. You may be their health care professional of some kind or you may be a family member. But, these issues are worth thinking about before you get in such a sitation. The questions we need to consider include: How does one go about making a decision in such a situation? What factors are important? What principles can assist someone in making such a decision? From a philosophical point of view, in this class we are also interested in questions such as: What justification can be provided for the principles used to make such a decision? Do some ethical principles provide conflicting advice in such cases? How do we resolve these conflicts? From the specific context of bioethics we can raise questions such as: Who should decide the outcome in cases where the person directly affected cannot decide for themselves? How do we assess competence to make such decisions? How much information should be provided to insure informed consent and a good outcome? While these questions may not be directly relevant to the example above, they will be questions we need to consider during the semester.
A few other comments might be in order at the beginning of our investigation into ethics. A common question which prevents many people from taking a stand regarding issues of right and wrong is the question: Who are we to judge others? I've heard this question from students as well as adults serving on jury duty. I suspect it is a quite common question and one to which most who ask it believe they have the answer. Namely, it is not our place to judge others. After all, doesn't the Bible counsel not to make judgments: "judge not lest ye be judged?" But, we cannot live without making judgments. The question philosophy can help with, in particular through the study of ethics, is how to make good judgments.
However, before we can directly address this point, we need to explore some preliminary topics. Why are so many people reluctant to make judgments? I believe this comes from three sources. First, people may believe that judgments are inherently negative. Second, people may believe that judgments imply objective standards, which they believe, do not exist. Third, people may believe that making judgments will cause unnecessary controversy or hurt feelings.
Let's begin by examining the notion of judgment itself. I believe most people's stated reluctance to making judgments (which differs from their action of making judgments) comes from the mistaken belief that judgments are inherently negative. But, judgment itself is a neutral term. Judgments can be negative such as "she's a bad dresser," "he's not a kind person," etc. However, judgments can also be positive as when we favorably evaluate someone's athletic skill, charismatic personality, organizational skills in the office, or cooking skills. In each case, positive or negative, we are making an evaluative claim. My claim is simply that judgments are unavoidable. I sometimes ask my students who are reluctant to make judgments if they are married or in a serious relationship. When they say yes I point out that this fact alone illustrates that they must have made some judgments. Unless of course they simply choose the first person on the street they saw to marry! But, even in this case they must have made the judgment that this was a good way to pick a mate. Judgments do imply objective standards and the problem many people have with this is their belief that there are no such standards. But, as we'll discuss later in the Relativism Lecture, there are good reasons for thinking that there are some objective standards.
A third reason for the reluctance to make judgments is very likely people's fear of causing controversy or hurting others' feelings. Discussing controversial ethical issues can be difficult for many precisely because they have a strong emotional content. While no one suggests completely ignoring one's emotions when addressing these issues, it is beneficial and constructive to be able to distinguish reason from emotion and to allow reason to guide and inform our emotions. This may sound like an impossible task but it can be done. There are several useful philosophical insights that might make this task easier. First, we should distinguish the person making a statement or argument from the person himself. Second, we should distinguish offense and harm. Lastly, we can benefit from the insights of the Stoic philosophers who have had a strong influence on the psychological school of thought known as rational emotive therapy. I won't be able to address all of these points in sufficient detail here. But perhaps an introduction to each will help clarify the issues and inspire you to learn more about these useful insights so that you can benefit from them, not only in this class, but also in other classes and perhaps in your life in general.
In logic there is a fallacy of reasoning known as argument against the person. The reason this is a logical fallacy (mistake in reasoning) is because there is a difference between the person and what that person says. If you disagree with something I say that doesn't mean you are disagreeing with me as a person. In other words, if you disagree with me it doesn't mean you are insulting me or attacking me personally. You may very well like me as a person but dislike something I think or say. For example, if I say I think golf is a great way to relax you may disagree with that. But does that mean you are insulting me or does that mean you dislike me? No. Now while that is a fairly tame example, logically speaking the same should hold true for other issues as well. Perhaps you disagree with someone's view of capital punishment. You can say that you disagree and argue passionately for your view just as they can. But that does not mean that you dislike that person or are insulting or attacking them. Recognizing this should allow us to engage in spirited discussions without worry about offending anyone. We just have to remember that we can discuss an issue without personally attacking or insulting someone.
Another useful distinction which will help us is the distinction between offense and harm. A good resource on this subject is Lou Marinoff's bookThe Big Questions. In one chapter he asks the question "if you're offended are you harmed? The answer turns out to be no. Consider this. Suppose someone walks up to you and steps on your toe. You have no choice about whether that's going to hurt. It is! So, here you are harmed. Being harmed is involuntary, you have no choice about whether to feel pain or not. Now, offense is not like this. If someone walks up to you and says "wow, you have really big feet" you have a choice to make. The choice is how you will react to this comment. I'm sure you've heard the expressions "no offense intended" and "none taken." These are very revealing. Offense is something that can be offered and it's also something that can be taken. But, importantly for us, offense is also something that can be refused. You have a choice in this and that's what distinguishes offense from harm.
As human beings we are emotional beings. But, we are not slaves to our emotions. We have the ability to reason and think and this can aid us in our emotional reactions. This was a very important insight of the ancient Stoic philosophers. The basic idea behind stoicism is that we have no control over external circumstances. What we do have control over is out attitude towards them. As Epictetus once said "it is not things which disturb us, but our attitude towards them." This perfectly sums up the stoic idea as well as how to handle offense. Similarly, the Roman emperor and stoic philosopher Marcus Aurelius said "if you are pained by any external thing, it is not the thing that disturbs you, but your judgment about it. And, it is in your power to wipe out this judgment now."
Of course, this takes skill and practice but it can be learned. One good approach to learning this is discussed by the psychologist Albert Ellis who developed something called rational emotive therapy. His approach is very stoic inasmuch as he maintains that what really disturbs us is not our emotions themselves but our rational (or more correctly irrational) beliefs. It is our beliefs which in large part determine what our emotional response to a situation will be. If we can formulate rational beliefs then our emotional responses won't be ones of depression, anxiety, or offense. One way to begin is to reflect on why you're having the emotional reaction that you're having. As Ellis would advise, ask what beliefs you have that are contributing to your emotional response. Then ask whether those beliefs are reasonable. Chances are if the beliefs are unreasonable then your emotional response may be causing you to become unhappy or upset needlessly. It should go without saying that there is nothing at all wrong with emotions or having them. But, if our emotions are ones of depression and unhappiness then it's good to know that something can be done to address that. Notice as we go through the texts in our class that while we're discussing many emotionally charged issues the attempt is always being made to discuss them from the standpoint of reason. Of course emotions inform our reason just as our reason informs emotions. The trick is not to allow either side to dominate to the exclusion of the benefits of the other.
Another very common question related to ethics regards who is to decide what counts as right and wrong. In large part this question is misguided and reveals a lack of a clear understanding of the basic principles of ethical reasoning. Once again, philosophy can provide useful insight here. In particular, the insights of Wittgenstein prove helpful by illustrating that there are certain ways of living for human beings that all humans share; what Wittgenstein called forms of life. Just as all humans share a need to eat and seek shelter so too all humans have an interest in furthering their interests in terms of what will bring them happiness. But, don't radically different things bring people happiness? Not really. When you seriously investigate what brings happiness you find a great deal of similarity across cultures and time. Epicurus once said that all that is required for happiness is friendship, freedom, and contemplation. Though Epicurus pointed this out centuries ago, these values still provide the basis for happiness today.
It is when we begin to investigate more specific issues that differences seem to occur and tempt people to draw the conclusion that there are no values in common and since ethics is just each person's opinion anyway, we are left with the problem of figuring out who should decide what is right and wrong. But, the mistake occurs in thinking that there are no values in common and ethics is nothing more than opinion. If we look at ethics as being deeply rooted in how we live as human beings we begin to see that there is much we have in common and far from individuals deciding for themselves, we arrive at ethical principles which naturally further our interests as human beings. I am not simply of the opinion that murder is wrong. It does not further human interests neither of the murderer or the victim. Yes, there are many ethical questions which are more difficult to resolve but look closely at the disagreements that seem to be occurring when people discuss such issues as abortion. Are they really disagreeing about fundamental values and interests or how best to preserve these values and further these interests?