Biomedical ethics exam 2

Nuremberg code

Consent: participation must be voluntary + with informed consent (IF)

benefit: produce valuable knowledge for society

animal testing: test the safety of a procedure on animals before humans

risk balance: potential benefits outweigh risk to the participants

belmont report

Autonomy: autonomous person can think about their goals and make own choices, we must respect these choices

Voluntary entry; must join voluntarily and have complete information

Informed consent: must be told the risk, benefits, and alt options. explanations must match the participants ability to understand. consent must be free of coercion

beneficence: do no harm, maximize the possible benefits while minimizing possible risks

Justice: must not use the vulnerable, low income, or marginalized gorups for risky expriemts bc theyre easier to recruit

canterbury vs spence

roberston: there is a duty to disclose to patients all info about their condition that a reasonable person in that patients position would consider relevant.

1. everyone (competent) has the right to bodily autonomy

2. precondition for a pt to effectively exervice the right to bodily autonomy is that the pt has the info that is necessary to knowledgably evaluate and choose treatment option

robertson judge ruling contiued

defended objective standard: a risk is material when a resonable person in what the physician knowns or should now to be the pt positions, would be likely to attach significanve to the risk or cluster of risk in deciding whether or not to forgo the proposed therapy

what the exceptions to robertson ruling

emergency where the pt is unconscious or for some other reason unable to consent, there is harm from failure to treat, and it is impractical to confer with a relative

therapeutic privilege: patients can be so ill that they foreclose a rational decision, or complicate or hinder the treatment or psyc damage to the patientK

Katz, Physicians and patients thesis

Claims that Robinson gave self-determination short-shriff when he opted for his objective standard over the subjective one

Katz: Substantive standard

req disclosure of what an individual pat would have considered a significant risk

Katz argument

because different patients will have different values and beliefs, the belief hat ther is one reasonable or prudent response to every stitiation inviting medical intervention is nonsense

2. applying the objective standard will not ensure that each pat gets the info needed to make informed treatment decisions, as is necessary to exercise the right to bodily autonomy.

3. applying the subjective standard ensures patients will get the info they need, so it myst be applied,

4. treatment decisions require a sustained dialogue in which patients are viewed as participants in medical decisions affecting their lives.

Katz; coercion

P coerces Q if P tried to control whether Q does an action, warns Q of a punishment of if Q does it, makes the threat believable, and causes Q to (choose to) avoid the action mainly to escape punishment

Force vs coercion

Force requires an active agent to exert it, meaning natural occurrences (like being struck by lightning) do not qualify. Furthermore, force is distinct from coercion because force completely bypasses the victim's rational choice and agency, leaving them with no option to exercise.

threats vs offers

threats but not offers can count as coercive.

• A threat occurs when someone proposes to make your situation worse than it naturally would be if you do not comply.

• An offer occurs when someone proposes to make your situation better than (or equal to) what it would be if you accept.

Undue influence

coercion can occur when an overt threat of harm is intentionally presented by one person to antoher in order to obtain compliance

Undue: as occurring through an offer of an excessive, unwarranted, or improper reward or other overture to obtain complicanve

so offers are not coercion by may or may not be undue influence

what we consider as undue hinges on what counts as excessive…..

Exploitation

some sort of purportedly appropriate baseline condition. If you offer me an inventive to do something, and i accept, but i am below the baseline, and i would not have accepted your offer if weren't below it, then i am exploited by your offer.

ex. justice, whether exploitation is objectionable will depend on the significance of the baseline

terminal diagnosis

patient must by an adult with an incurable illness documented to cause death within 6 months

mental compentence

patient must possess full decision-making capacity. If a physician suspects depression or impaired judgement, a formal psych eval is mandatory

request process

patients must make two separete oral request and one writte request witnessed by independent individuals. a mandatory cooling off waiting period req between request

physical self administration

patients must be physically capable of ingesting the medication on their own

out of state care

Oregon and vermont have removed their residency req allowing out of state patients to travel there for care

Oregon death with dignity act

legalized physician-assisted suicide (PAS), physicians may legally prescribe lethal drugs for terminally ill patients in great main. Must make request 3 times, must be terminally ill (6 months) by 2 physicians

Vacco vs Quill

states may forbid PAS, but states must recognize the right to reguse treatment, which is another matter, since refused treatment is not a form of assisted suicide since the disease kills the patient

Rehequish

drew linw between PAS and both stopping treatment and causing death as a side effect of palliative care, on the other hand, in that the latter two need not involve intending the death of the patient, whyle physician who assist in suicide must intend primarily that the patient be made dead. . Basically states set their own policy

Washington vs gluckberg

Banning PAS becuase the state has an unqualified interest in preserving human life., protecting the integrity and ethics of the medical profession, PAS is fundamentally impcatible with the physicians role as a healer

protecting vulnerable groups, worries about subtle coercion and undue influence in end of life situations

fear that permitting PAS will start it down the path to voluntary and involuntary euthanasia

Stevens also adds reservations

to the idea that there is never intent to kill in cases where patients are allowed to die. A patient and a physician who ends treatment may intend to hasten her death, and that a physican who adminsters terminal sedation may or may not intend to hasten death. Here the actual cause of death is the adminstration of heavy doses of lethal sedatives

Buchanan and Brock: deciding for other compentency

patient competence is relative to the decisions being made. Some medical decisions require substantial competence and other require less. The required level of competence also depends on the risk of the decision. A sliding scale is the appropriate standard: required cognitive ability rises with the risk of the decision

Patient competence is decision-relative and operates on a sliding scale, meaning the required level of cognitive ability rises in proportion to the risk of the medical decision. Under this standard, simple or low-risk choices require less competence, while high-risk decisions require a substantially higher level of cognitive capacity.

buchanan and brock: concept of compentence

Competence is the ability to perform some task, here is the ability to decide about treatment, which vaires with the choice made and the circumstances in which it is to be made. threshold concept

Buchanan and brock: 4 competencies

communication: ability to state a clear preference

understanding: ability to understand relevant information, such as treatment alternatives

conception of the good: a view about what makes on life good

reasoning and deliberation” ability to infer how ones choices will affect ones life.

Buchanan and brock threshold concept

somelimations in competence are partial and matters of degree, needed due to sort people into

1. competent: those whose voluntary decisions must be respected by others

2. incompetent: those whose decisions will be set aside and for whom a decision maker is appointed

How defective must an individuals capacities be for her to be designated as incompetent to make a particular decision

An individual is designated as incompetent to make a particular decision when a cognitive defect prevents them from understanding the relevant facts, appreciating how those facts apply to their situation, logically weighing the options, or communicating a clear choice.

buchanan and brock competing values

Values at stake in the informed consent doctrine are

• well-being: promoting the patients good and

• Self-determination: respecting the patients exercise of autonomy, respecting right to decide

buchanan and brock standards

must balance well-being and self-determination

• value of well-being being sometimes requires persons to be protected from their own harmful choices since those choices may not serve their good even by their own standards

• choosing has a value for one that is partly independent of whether the choice is best for one

buchanan and brock: two values conflict

we must try to avoid

• failing to protect a patient from harm caused by serious defects in the capacity to decide, and setting aside a patients choice even though the patient is able to make it

Buchanan and brock deciding on standards

focuses primarily on the process of reasoning leading to a decision

• the standard aught to vary with the expected harms or benefits to the patients.

• a patient may be competent to accept a treatment yet not competent to refuse it..

Fixed minimum capacity view

patients who have a certain fixed level of capacity are competent for all decisions

against fixed minimum capacity view: reasons why Buchanans and brocks view better

1. their decision-relative approach aligns better with the way people actually judge competence (e.i children can choose their food but not make hard economic choices)

2. aligns with the doctrine of informed consent, as complex and risky choices require more info and better understanding

3. it better coheres with our basic legal framework, such as in its treatment of minors

4. it limits paternalism. finding someone incompetent for some choices applies only to that choice. It leaves the patient in charge of the rest of her life

5. it allows for more refined, case by case balancing between self-determination and well-being

Suicide

the act of self-killing. I did something that constitutes suicide iff i did something that caused by death and i did it in order to cause my death