Introduction to Bioethics-Georgetown University
by Joel Rich
I really wanted to understand how others wrestle with issues that halachists are dealing with. Interesting parallels and reminder that a Torah state would require us to deal with a lot of issues which we’ve avoided. Again, I perceive a lot of “heart gut” positions with backed into logic.
Unit 0 Introduction
Up until 1970’s medicine was very paternalistic. Biotech has introduced many new issues. (Me – and society has changed.)
Unit 1 Patient Autonomy
Patient rights were abused up through the 1970’s (me – or maybe rights were evolving?)
Autonomy and Medical Paternalism
Autonomy and paternalism are often a matter of degree. A patient may be in a weakened emotional, mental or physical state. Is it paternalistic to not allow someone to die? (Immediate thought – our halachic focus on obligations vs. American law’s focus on rights.)
Informed consent is more than just signing a form that you don’t read. (Is there a halachic parallel to informed consent?)
Are staged disclosure or ambiguous responses ever-appropriate paternalism? (I’m pretty sure the halachic response is yes.)
Refusal of Life-saving Treatment
Does patient autonomy allow refusal of life-saving treating (e.g. Christian Science)?
Parents have decision-making rights for their children but are limited by state’s interest in the child’s health and welfare. [What is the parents’ role according to Halacha (vs. that of beit din)?]
Unit 2 Provider Autonomy
There’s negative autonomy (you can’t stop me from exercising my autonomy) and positive (I need you to help me do something). The former is clearly a stronger right. Your obligation to help me may be contingent on (i) are you violating other obligations?; (ii) how serious is my situation?; (iii) how well situated are you to help?; (iv) does your roll have specific responsibility? (e.g. first responder). [Halacha certainly trumps autonomy in many cases. It’s the grey ones that are tough.]
Obligations and Autonomy of Providers
Look at those 4 issues above when patient and provider autonomy conflict. The first is where the real action is when the provider has a conscientious objection. (I don’t think Halacha recognizes a conscientious objection.)
Seems clear we allow exemptions for individual conscientious objection although there’s a difference between declining to participate vs. putting new obstacles in place. The boundaries are not clear (me – and continue to change!).
Borderline is unclear in how much involvement makes you guilty for the results of an act.
Institutions and Complicity
Catholic hospitals provide much care. Do institutions have “rights”? Catholic hospitals have rules for how much involvement they can have in treatments they disagree with. Everyone would agree you need clear communication and guidelines.
Unit 3 Disability
What is a disability? What is a trauma? What is normal?
What is disability? What is normal? We’re all “disabled” at different points in our lives and we’re all dependent on technology and other people just about all our lives. It’s only “unusual” dependence we notice.
Two Models of Disability
The more traditional medical model is disability is a disease of the body that needs bodily intervention. The social model looks at the interaction between society (through the environment [physical and non-physical] it creates) and the individual.
Genetic Testing and the Paradox of Harm
While we might think of prenatal genetic testing as a form of our reproductive autonomy, we might also ask about the baby’s autonomy – isn’t existence almost always better than non-existence for the child?
Critiques of Routine Prenatal Testing
Does routine prenatal genetic testing:
- send a negative message to those already living with the disease?
send a negative message to parents that they shouldn’t want imperfect kids?
encourage abortion based on prejudice
encourage the medical rather than social model of disease/disability and lead to more discrimination. No one mentioned shomeir ptaim hashem.
Creating a Deaf Child
The deaf community is very active and parents may want their children to be part of it. Some argue that children are entitled to the broadest options available to them but this is not so clear.
Unit 4 Enhancement
Think about Cyborgs and genome alterations – they’re here already.
The Concept of Biomedical Enhancement
We already have biomedical enhancement (caffeine). Each possibility needs to be considered in the context of the goal pursued and how we pursue it. Issues include: 1) how confident are we that we understand all the risks?; 2) what are the implications for social justice?; 3) how will it affect our human identity/sense of self? (Who makes these decisions? Who would make them in a Torah run world?)
Enhancement and the Ends of Medicine
What about off label uses (e.g. ritalin for increased concentration)? Are we aware of all the dangers? Is the purpose of medicine to combat illness or to enhance our lives? There is also a social downside – who will have access? Will there be pressure to be perfect? Will what’s normal now become unacceptable later?
Performance Enhancing Drugs
What performance enhancing drugs should be banned in sports? Should we only be concerned with “natural” talent (and how do you define natural)? Key issues are safety, will everyone be forced to take drugs to compete and what is the goal of sports anyway?
Should we just rely on evolution to do the job but evolution doesn’t really optimize for current happiness. There are social justice concerns and we need to carefully consider the trade-offs. (Paradigm shift always hurts some groups – see mid-career changes from a defined benefit to a defined contribution plan.)
Radical Enhancement and the Human Good
While changes occur naturally to the genome over time there are philosophical and practical issue with making them ourselves. Do the changes violate human dignity or should we change things for the better? Is the genome a private or a community good? (Me – law of unintended consequences.)
Unit 5 Collaborative Reproduction
With modern fertility technology, there are a number of participants who could be called parents. We also now end up with a mixture of contract and family law. (Lots of Halacha still evolving on this issue – the wheel is still in spin.)
What Is a Parent?
Is parent defined by who raises them (social parent), the genetic contributor or the gestational parent?!
Is There a Right to Be a Parent?
Do the children have a right to know their genetic lineage? Who decides the nature of the relationship of the various participants (including the right to know). [Me – Halacha seems concerned about the lineage from a forbidden marriage viewpoint, but what about medical and kavod av issues?]
More on identity issues.
Reproduction, Markets, & Commodification
Should there be a free market in fertility related field (babies, sperm, eggs…) or are there some elements of human dignity that should not be for sale? (And would melech or beit din enforce?!)
Surrogacy & Exploitation
Surrogate mothers in India – is this exploitation or an act of beneficence by allowing those women to better themselves compared to the alternative life they might lead?
Unit 6 Abortion
Pro Life vs. Pro Choice – be a little humble and try to understand the other side!
The Concept of Moral Status
The embryo and mother, how do we think about their competing rights? Think about “moral status” of each and is it possible to have partial (vs. full) moral status and what is it dependent on? (Me – pre-40 days, pre-crowning seem halachic triggers for varying levels of moral status.)
Restrictive Views of Abortion
Does the embryo have full or partial moral status? Is it’s status based on future life autonomy?
Under natural law we’d define an embryo as having moral status because that’s what it naturally is – in its development state.
fetus or embryo has a moral status
Even under natural law, in case of rape can a mother be forced to take on an involuntary risk or can we place her back in her original condition?
Permissive Views of Abortion
Maybe moral status is based on conscious state of mind (i.e. an embryo isn’t conscious).
early human life develops gradually
Maybe a person develops over time and so moral status isn’t Boolean and you can have partial moral status.
three importantly different permissive views of abortion
Three views that support permissive abortion are: 1) early human life has no moral status; 2) woman’s view is key and she can terminate pregnancy if continuation is a setback (in almost any sense); 3) a woman’s dominion over her body is the key right.
Unit 7 Death & Surrogate Decision-Making
Most folks want to die comfortably at home surrounded by family but in the U.S. this doesn’t happen in the majority of cases. Part of this may be cultural – we are “battling” death (especially medical folks) and view death as a failure.
Ending Life Support for Others: An Overview
Who decides when it’s time to allow the process of death (brain death, etc.) to continue when the individual is unable to do so?
The Definition of Death
Physiological tests of “brain death” are available (Europe has an additional test) but how does society define death? 1) cessation of circulation?; 2) whole brain death (all brain functions cease) [he says orthodox Jews do not accept this]; 3) higher brain death (e.g. just having a gag reflex isn’t enough to be considered alive). Defined as irreversible loss of consciousness (yeah – like we know what consciousness really is). Maybe there should be one standard with options for individuals to choose other definitions.
Is there a duty to continue treatment for all patients? The consensus view is you don’t have to continue if: 1) stopping is passive; 2) you are not intentionally causing death (not stopping treatment is the same as not starting); 3) not extraordinary measure (extraordinary is defined as where benefit is less than the burden – the mainstream view is anything, even water, can, in the right circumstances, be stopped). [Me – compare to mainstream halacha – generally can’t stop water, air. (btw – Halacha requires whom to pay for continued care?]
Where there’s written or prior oral guidance from the patient, you do what they wanted. If no one is available and the person was never competent, courts will appoint someone to decide. If no direction, the family is allowed a “reasonable range” to decide “what is in the best interest of the patient”. [Me – R’HS has said in this case you have to guess what the patient would want which is different from this standard.]
Who gets to decide when more care is futile? Parties may agree that no improvement will come (physiological futility) but place different value on life. So why stop treatment? 1) limited medical resources; 2) professional integrity (Dr. doesn’t think it’s appropriate to continue treatment).
Court says if there’s: (i) an ongoing physician relationship; (ii) technically can continue treatment; (iii) no other physician will do it; (iv) there’s equitable (private) funding and (v) no one else will die, then medical provider must continue care in U.S.
(The actuary in me would point out that resources are always limited and “private” insurance funding comes from public pocket pretty much as Medicare does!)
Unit 8 Voluntary Euthanasia
The Euthanasia Debate: Overview and Definitions
Euthanasia (easy death) is a contentious issue. We need to be clear on definitions – speaker views it as intentional termination of patients life by doctor because doctor thinks death will benefit the patient (reduced suffering). Need to consider voluntary vs. non-voluntary, active vs. passive interventions.
Three Approaches to the Value of Human Life
Three approaches to putting a value on human life:
1) Vitalism – human life is the supreme good
2) Sanctity of life – human life is a basic/intrinsic good but there are other considerations (e.g. Doctrine of Double Effect)
3) Instrumentality of life – human life is an instrumental good (so just need to worry about what is a good life)
The Argument from Autonomy
“It’s my life and I’ll do what I want” (cue “The Animals”). The counter arguments are that life is still more important than your autonomy and if someone is depressed, etc. can they truly be considered autonomous? (Of course we say we’re just trustees of our bodies.)
The Argument from Beneficence
Doctor has right/duty to put an end to suffering. Even so, couldn’t you do this short of death and who will define applicability (is existential pain actionable?).
The Argument from Hypocrisy
Doctors can accomplish the same end (physician assisted suicide) through legal means. Yes, but perhaps that doesn’t allow non-moral means.
Slippery Slope Arguments
Maybe physician assisted suicide is OK but it’s a slippery slope to non-voluntary euthanasia and how can you be sure you’ll prevent abuses (e.g. people feeling pressure to do so, depression, palliative care).
Unit 9 Climate Change
Climate Change as a Moral Issue
The global poor are likely to suffer through any environmental improvements. The likely impact of global warming is dramatic, developed nations must address this.
Costs and Options
How can we deal with climate change? Combination of adaptation (deal with results) and mitigation (reduce greenhouse gasses). It’s getting worse and can be expensive.
Models of Moral Responsibility
There are a number of philosophical issues in deciding how to apportion the costs of adaptation and mitigation across countries and individuals.
Climate Change and Human Rights
Using human rights as a basis for allocating responsibility to fix the situation. Should there be global reciprocity? [Me – how would Halacha deal with ambiguous causes and damages?]
What Can Individuals Do?
Philosophical positions concerning whether there is a moral case for individuals to take action to offset their (excess?) carbon footprint.
Unit 10 Global Issues in Bioethics
There are a number of ethical issues concerning cost and ethics involved in medical tourism, clinical trials overseas and the manipulation of the food chain.
From a pure free market standpoint, medical tourism makes sense and it would be hard to stop as long as there is cost/availability benefit. However, it can be seen as exploitive of citizens in poorer countries and there are accountability issues if things go wrong). (Does Halacha have an opinion?)
Cross border research (conducted on 2nd country population by 1st country). May be cheaper/easier to recruit participants or it’s about local conditions. First case has lots of room for exploitation but both can have ethical issues (cultural misunderstandings, informed consent).
What Is Exploitation?
Defining exploitation for our purposes: Exploiter has direct advantage from offering exploitee poor choices (even if exploitee is still better off than if no choice was offered).
Feeding the World in 2050
Global demand for nutrition is increasing as is the demand for certain types of nutrition. How will we allocate the resources and outputs with global equity?
Fairness & Concentration of Market Power
Elongated food supply chains have led to market consolidation which can have negative implications for global poor.