Concepts & Terms to Review & Know

• Differences between job, profession, and vocation 

  • Job is a position that you specialize in based on your background and qualification

  • Profession 

    • Def 1: A body of knowledge shared by a group of individuals with specialized education and training and common value 

    • Def 2: A disciplined group of individuals who adhere to high ethical standards. Uphold themselves to, and are accepted 

  • Vocation 

    • Vocation is a calling/way of thinking 

• Ignation vocation discernment — Desires, authenticity, consolation, desolation, indifference

  • Ignation vocation discernment is “spiritual interpretation and evaluation of feelings… particularly in the direction to which they move us”

  • Desire is a primary way that God leads people to discover who they are and what they are meant to do

  • Authenticity is knowing your purpose

  • Discernment recognizes and responds to one’s vocation(s); i.e., God’s calls through desires

  • Consolation admits discernment - naturally a sense of peace, trust your gut

    • perfect happiness or perfect peace

    • imperfect peace

  • Desolation are life movement signaling that you’re on the wrong path

    • anything that moves you toward hopelessness

    • discernment is personal but not individual

  • Indifference

    • freedom from bias, freedom for impartiality

• Nonmaleficence and negative duty | Beneficence and positive duty

  • Nonmaleficence is no harm

    • negative duty is to do no harm

  • Beneficence is do good

    • positive duty in or out of compassion

• Values, principles, and norms—definition of each, the relationship between

  • ethics and professionalism are intertwined, standards are shaped by

    • value (abstract ideal) are intuitive, experiential importance → experience of human worth

    • principle (articulated concept) are articulation of values → human dignity

    • norm (rule) are rules that guides action to protect, promote, principles →. do not murder

• Ethical and Religious Directives—purpose and audience

  • Ethical and Religious Directives (ERDs) Catholic Church extends the ministry of Jesus who was concerned about and healed physical, emotional, social, and spiritual illnesses of persons and communities

    • structured into 6 parts divided by two sections - expository (value or principle) and presumptive (norms)

    • intends to address the audience who are involved in institutions and services

• Belmont Report (background and three principles)

  • The background of the Belmont Report goes back to the 1979 Tuskegee Study

    • DHHS adopted the Belmont Report as a statement of its policy. The. content of the Belmont Report was incorporated into federal regulations that govern research human research following up with the Tuskegee Study

  • Three principles of the report are respect for persons (informed consent), beneficence (assessment of risk), and justice (giving what’s due)

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• Individual versus social good of research—Panicola et al. topline summary

  • Humans must never be treated as a means to an end

  • Intrinsic evil stands by research ought to never be done, even if some people provide their informed consent

  • “The desire to pursue scientific inquiry must never be allowed to trump the interests and inherent value [dignity] of the irreplaceable human beings who enroll in such research . . . humans must never be treated as a means to an end.”

  • Kant’s Categorical Imperative - The Formula of the End In Itself

    • “To use someone as a mere means is to involve them in a scheme of action to which they could not in principle consent” (Introduction to Catholic Ethics, 56). •

    • Intrinsic evil: “Might there be research that ought never be done, even if some people provide their informed consent?”

    • “Still, dignity and consent (with autonomy, beneficence and non- maleficence, and justice) provide cornerstone values for human subject research norms that satisfy the Common Rule minimum and strive to satisfy the ERD’s.”

• Triple Bottom Line and Externality

  • 3 P’s people, planet, profit

  • For-profit healthcare maximizes economic profit (emphasis on ROI / elective procedures, volume, and patients ability to pay)

  • Nonprofit healthcare bodies the Triple Bottom Line “posits firms to commit social and environmental impact — in addition to their financial performance — rather than solely focusing on generating profit, or std. bottom line”

  • Externality is the cost (benefit) incurred by a third party rather than a producer

    • “when making the rise of natural resources, we should be concerned for their protection and consider the cost-entailed - environmentally and socially - an essential part of the overall expense occurred”

• Catholic social teaching measure of economic justice

  • Economic justice - giving what is due through rights and duties

    • Justice is GIVING WHAT’S DUE

  • Catholic Social Teachings reject the notion that a free market automatically produces justice

    • state and subsidiarity

• Nonpersonal and personal positions; implications for abortion, IVF, and stem cell research

  • nonpersonal position of personhood - not a person at conception

    • Justice Blackmen on “arbitrary”, absolutist says the right to autonomy is absolute “my body, my choice”

    • implication of IVF ethics = none

    • stem cell research = using embryos are good for research

  • personal position of personhood - is a person at conception

    • the right to life establishes an absolute obligation never to intend the destruction of innocent human life (page 111)

      • direct and intentional killing of innocent persons is always wrong

    • absolutist says the right to life is a prerequisite to all others

    • perspectivist says the right to autonomy but not absolute

    • implication of IVF ethics = “unused” embryos are human persons with legal and moral rights

    • “To call cloning for this purpose ‘therapeutic’ is little misleading...it is not therapeutic for the embryo, which has to be destroyed for its stem cells to be obtained.”

• Principle of Double Effect: Action and types of foreseeable outcomes, four criteria

  • Indirect abortion: “When the fetus dies as a ‘side effect’ of [action] performed primarily for the purpose of saving the mother’s life” (100)

  • Four Criteria (270-272): Cancerous uterus that, if left, will kill mother and child

    1. “The primary action [object, intention, and circumstance] itself is good or indifferent”

       • “Removing the uterus is a morally indifferent action”

    2. “The good effect is not produced by means of the evil effect”

       • “Saving the life of the mother is not necessarily produced by means of the death of the fetus, but by removing the uterus”

         • Last resort: If there was another way to save the mother, we would do that instead

    3. “The evil effect is not directly intended”

       • “The direct intention is to save the life of the mother”

    4. “A proportionate reason supports causing or tolerating the evil effect”

       • The “reason” is a value/principle at stake

       • “The proportionate reason is the mother’s life”

• Relationship between three parts of an issue stance

  • Issue stance judges the problem, diagnoses a cause, and proposes a solution

  • Relationship between these parts

    • 1 (issue) → 2 (diagnosis) → 3 (stance)

• Difference between direct and indirect abortion

  • Direct abortion - “primary purpose is ending the life of the fetus for some other ultimate goal besides eliminating a threat to the woman’s life” (pg 100)

  • Indirect abortion - “fetus dies as a ‘side effect ‘ of actions performed primarily for the purpose of saving the mother’s life”

    • Understood in this context, the right to life does not necessarily imply a positive obligation always to do everything that can be done to save human life” (111)

      • NOT necessarily positive duty to protect life in all cases | Killing vs. letting die

    • “Nor does the right to life so understood imply an obligation never to do something that might indirectly result in the death of a human being” (111).

      • NOT necessarily negative duty to avoid indirect death (indirect abortion)

      • “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child” (USCCB Ethical and Religious Directive, no. 47).

• Three ethical standards in care for critically ill newborns

  • (1) medical indication standards are decisions based exclusively on data

    • any treatment judged to be medically beneficial

  • (2) best indication standards are decisions based on the “best interests” of — and only of — the newborn

    • 1. “Death is imminent, 2. “Treatment is medically contraindicated [e.g., aspirin is contraindication for a person with a bleeding disorder – may help one pathology but risk harmful excessive bleeding], or 3. “Continued existence would represent a fate worse than death” in the eyes of those responsible, e.g., abandonment

  • (3) relational quality of life standard says life is good but must be protected “insofar as it offers hope in striving for other goods”

• Difference between killing and letting die

  • Killing means you’re culpable for withholding or withdrawing morally obligatory treatment

    • “One is only morally obligated to use medical means that offer a proportionate hope of benefit without imposing an excessive burden or an excessive expense on one's family or the community (this is what is meant by ‘ordinary’ or ‘proportionate’ means).

    • “One is not morally obligated, however, to use medical means that either fail to offer a proportionate hope of benefit or impose an excessive burden or expense in the family or the community (this is what is meant by ‘extraordinary’ or ‘disproportionate’ means)” (Panicola et al., 281)

  • Letting die means you are not culpable for foregoing treatment that is not morally obligatory

    • Withholding or “stopping treatment that is burdensome or offers no reasonable hope of benefit so that the underlying pathological condition, which called for the use of the treatment in the first place, will run its course and eventually cause the patient's death” (CHA, “Care of Dying”).

• Morally obligatory treatment (benefit, burden, and proportionality) pg 288

  • Human life is a basic good but it’s not absolute; there are limits to this duty

    • moral obligation to preserve life with medical needs is a personal moral assessment taking into consideration one’s total circumstances (flourishing)

    • one is not morally bound to preserve life with medical means if: (1) merely sustains one’s life for a short time and thereby prolongs the dying process (2) cannot improve one’s condition to the point of being able to pursue goods bound up with human flourishing, especially human relationships, even at a minimum level (3) it maintains a condition in which one will be frustrated in the pursuit of these goods or (4) imposes an excessive intension on family

  • “One is only morally obligated to use medical means that offer a proportionate hope of benefit without imposing an excessive burden or an excessive expense on one's family or the community” (281)

  • Beneficial: “Restores health, relieves pain and suffering, improves physical function and mental status, restores consciousness, enables communication with others, prolongs life, and so on” (285). • Burdensome: “Causes pain and suffering, emotional distress and anxiety, physical complications . . . is not easily accessible, confines one to a hospital or bed, is prohibitively expensive, and so on” (Ibid.).

  • Treatment discernment must assess the proportionality of burdens and benefits for each circumstantial person

• Physicalism and personalism as they apply to IVF

  • Physicalism - the right actions conform to the perceived physical laws of nature

    • “human nature is collapsed to the body”

    • natural - conception is inseparably connected to intercourse between married heterosexual couples, it’s morally right

  • Personalism - the right actions promote the flourishing of persons integrally and adequately considered

    • natural - conception is the fruit of just and committed partnership within broader relationships

    • artificial insemination or IVF for conception (intention) by a couple under the right circumstances could be morally right

• Two types of stem cells and differences in potency

  • ESCs: “Embryonic stem cells obtained from five- to seven-day-old embryos (called blastocyst)...”

    • ESCS are pluripotent, i.e., can become different types of cells and potentially also more readily available, easily found, and sustained extracorporeal

  • “Bridge cells” Embryonic Germ Cells (EGCs)

  • ASCs: “Adult stem cells are found in the human body once it has developed beyond the blastocyst stage . . . The term adult stem cell, however, is somewhat misleading.”

    • EGCs and ASCs are multipotent, i.e., “believed to be limited to becoming only the type of cell the tissue found in” | EGCs are more versatile than ASCs

• Formal/material cooperation with evil – difference (intentionality) and acceptability (proportionality*)

  • Formal - One foresees and intends that an action will advance the moral evil of another | Active

    • Never permissible

  • Material - One “foresees but does not intend that his or her action will” advance the evil of another | Passive

    • Permissible under some circumstances

  • example = voting; candidate does good in some way therefore you would vote

• Medical futility (two criteria of definition) pg 298

  • “continue treatment when [A] highly unlikely to succeed in achieving its desired ends or [B] when its rare, beneficial exceptions cannot be systematically explained or reproduced

    • [A] is subjective: Likely futile given circumstances (e.g., chemotherapy to a non-cancer patient)

    • [B] is objective: Not standard of care due to lack of replicable scientific research (e.g., “This worked once, so...”)

Essay Prompts

1. Professionalism entails “the ability to align personal and organizational conduct with ethical and professional standards” (Forrestal and Cellucci, p. 3). First, describe the difference between moral values, principles, and norms. Next, identify one principle from the American College of Healthcare Executives (ACHE) Code of Ethics (Forrestal and Cellucci, p. 76), one expectation from the American College of Health Care Administrators (ACHCA) Code of Ethics (Ibid., p. 78), and one value (principle) from the mission statement of either CHI Health or UNMC that align with your personal morality. For each of your three choices, describe why the selection resonates with you and provide a concrete example of how you might incorporate it into a potential healthcare profession.

   • Step 1 - Values: Intuitive, experiential importance – experience the worth of a human person → Principles: Articulations of values – “Human Dignity” → Norms: Rules that guide action to protect/promote values/principles

   • Step 2 - Forrestal & Callucci (6-7): Healthcare is animated by the values (principles—spirituality) of:

     • 1. Public Service: Altruism as “sacrificing oneself for the public good”

     • 2. Self-Regulation: “Ability to govern or monitor oneself”

     • 3. Sense of Calling and Meaningful Work (Vocation – next class!)

     • 4. Autonomy: Ability to independently 1) organize their work, 2) make decisions that affect them, and 3) take action

   • Step 3 - American College of Health Care Administrators (ACHCA) Code of Ethics

     • Commitment to each of the following norms is critical for health care professionals” (5):

       • Are these values, principles, or norms? To make it a norm, start with, “Act to promote...”

       • “Public service through education and promotion of the health and well being of patients (including clients and residents) and society in general” • “Honesty with patients, peers, subordinates, associated organizations, and oversight entities”

       • “Fairness in the distribution of resources among patients, employees, departments, organizations, and community members or the public”

       • “Loyalty through stewardship, fiduciary responsibility, and avoidance of conflicts of interest”

       • “Mentoring and training the next generation of professionals”

       • “Self regulation, which protects the public from harm”

       • “Lifelong learning, which elevates skills, knowledge, and awareness”

   • Step 4 - CHI values are compassion, inclusion, integrity, excellence, and collaboration

2. First, outline the nonpersonal and personal positions and the difference between direct and indirect abortion. Next, describe the principle of double effect, including the two types of foreseen outcomes and the four criteria for its application. Finally, use the principle to describe how someone who takes a personal position might support an indirect abortion to save the life of the mother.

   • nonpersonal position of personhood - not a person at conception

     • implication of IVF ethics = none

   • personal position of personhood - is a person at conception

     • implication of IVF ethics = “unused” embryos are human persons with legal and moral rights

   • Direct abortion - “primary purpose is ending the life of the fetus for some other ultimate goal besides eliminating a threat to the woman’s life” (pg 100)

   • Indirect abortion - “fetus dies as a ‘side effect ‘ of actions performed primarily for the purpose of saving the mother’s life”

     • Foreseen effects: One good and intended: Save the life of a pregnant woman | One evil and unintended: Death of unborn child

   • Principle of Double Effect (1) primary action [object, intentions, and circumstances] itself is good or indifferent (2) the good effect is not produced by means of the evil effect (3) the evil effect is not directly intended (4) a proportionate reason supports causing or tolerating the evil effect

   • the principle describes how someone who takes a personal position might support an indirect abortion to save the life of the mother

     • personal position of personhood - is a person at conception

     • Indirect abortion - “fetus dies as a ‘side effect ‘ of actions performed primarily for the purpose of saving the mother’s life”

     • 

     • 

3. First, explain how Panicola et al. differentiates between morally and non-morally obligatory treatment and use the concept to distinguish between killing and letting die. Then, apply this framework to explain whether you think treatment withdrawal in Case 10F is unethical killing or ethical letting die.

   • Human life is a basic good and as such one has a strong moral obligation to protect and preserve it; however, this obligation is not absolute: there are limits to this duty.

     • “The moral obligation to preserve life with medical needs is a personal moral assessment that must be made on a case-by-case basis, taking into consideration one’s total circumstances (e.g., physical, spiritual, financial, familial, social, and so on).

     • “Generally, one is morally bound to preserve life with medical means if it enables one to pursue goods bound up with human flourishing, especially human relationships . . . at least at a minimal level, without opposing excessive burdens or an excessive expense on one's family or the community.

     • “Generally, one is not morally bound to preserve life with medical means if:

       1. it will merely sustain one's life for a short time and thereby prolong the dying process;

       2. it cannot improve one’s condition to the point of being able to pursue goods bound up with human flourishing, especially human relationships, even at a minimum level;

       3. it only maintains a condition in which one will be frustrated in the pursuit of these goods; or

       4. it imposes an excessive expense on one family or the community.

     • “When serious doubt exists as to the benefits and burdens of a particular medical means, such doubt should be resolved by deciding in favor of its use.”

   • Panicola et al. standard “If treatment can enable the newborn to pursue goods bound up with human flourishing, especially human relationships, at least at a minimal level without experiencing excessive burdens, then treatment generally should be considered proportionate and hence morally obligatory.”

   • can’t use someone as a means to some end

     • can’t sacrifice the informed consent of a person for research - e.g., Tuskegee study experiment

     • utilitarianism is not a human means to an end

     • violation of human dignity

   • treatment should be considered proportionate and hence morally obligatory