Learning Module

Bioethics

MEET YOUR LECTURER

Mary Carman

Mary Carman is a Lecturer in Philosophy at the University of the Witwatersrand (Wits) in Johannesburg, South Africa, specializing in the Philosophy of Emotion and Philosophy of Action. Between 2020 and 2022, she conducted a three-year research project titled ‘Working with anger: A step towards a philosophy of emotion for Africa’, funded by a National Research Foundation Thuthuka grant.She completed her undergraduate degree at Wits, before heading to the UK for a PhD at King’s College London. There, she wrote a dissertation titled ‘Feeling Reasons: How emotions explain action’, supervised by Dr Maria Alvarez and Prof. Bill Brewer. Her PhD was awarded in 2015. She returned to Wits as a Postdoctoral Researcher from 2015-2016, before joining Thumos, the Genevan Research Group on Emotions, Values and Norms, at the Swiss Centre for Affective Sciences (CISA), University of Geneva, as a Postdoctoral Research Fellow from 2016-2017. She returned to Wits in 2018.

Her general interest is in understanding the role that emotion plays in both our personal and social lives. Her primary research aim, starting with her PhD, is to contribute towards developing a robust conception of rational agency, one that acknowledges our emotional nature and that is able to incorporate emotions into an account of how we do indeed act in many of the cases when we act rationally.

In addition to her theoretical work on how emotions may or may not contribute to rational action, she is also interested in particular emotions such as anger – how we can assess their rational and moral status in political contexts, for instance – as well as how theoretical work on emotion can inform more applied debates, such as within bioethics. She has recently drawn on some of this applied work in collaborative work on the ethics of AI, particularly within an African context.

Lessons

1.

How to Start Thinking Like an Ethical Doctor

2.

Should Healthcare Decisions Be Up to the Patient?

3.

Should Healthcare Providers Have the Right of Conscientious Objection?

4.

Is It Ethical to Pay Subjects for Their Participation in Research Studies?

5.

Why Do People Disagree About the Ethics of Euthanasia?

6.

Is Lethal Injection Worse Than Pulling the Plug?

7.

What is Biomedical Enhancement?

8.

Three Cheers for Enhancement?

9.

What, if Anything, Is Wrong With “Doping” in Competitive Sports?

Module Introduction

  • What distinguishes a normal health variation from a disease? 
  • Which patients and ailments should we prioritize when distributing healthcare resources? 
  • Should parents be allowed to use genetic engineering technology to give their kids highly desirable traits?

Questions like these – that is, ethical and conceptual questions arising from matters of healthcare, or of the life sciences more broadly – lie at the heart of the field known as bioethics. In particular, bioethical questions address challenges encountered in the context of clinical relationships, biomedical research studies, public health decisions, biotechnology development, and even our relationships with animals and the environment.

While some bioethical questions were probably among the earliest ethical questions humans ever asked themselves, rapid advancements in biomedical science and technology in recent decades – as well as greater inclusion of diverse perspectives – have led to the emergence of bioethics as a distinct and robust field, in which both new and long-standing questions are investigated and debated by a burgeoning mix of thinkers, practitioners, and policymakers.

This module aims to present a brief but provocative introduction to bioethical concerns and controversies. Rather than attempting a comprehensive, systematic survey of such a complex and wide-ranging field, the lessons in this module are designed simply to provide a glimpse into a few of the central topics discussed in bioethics and a sense of how these issues are explored and debated by philosophically-minded thinkers.

One of the earliest and most important areas of bioethical discussion centers on the relationships between healthcare professionals and the clinical patients or medical research participants in their care. These inherently asymmetrical relationships leave patients and participants in a uniquely vulnerable position, as they entrust their lives and wellbeing to professionals who (history has shown) aren’t always worthy of this trust – and who, even when trustworthy, are often pressed to make consequential medical judgments in the face of significant uncertainties, limited options, and painful trade-offs. How, then, should an ethically responsible doctor navigate so many complicated decisions about care without overstepping their role? After surveying several core principles of healthcare ethics, we zoom in to more closely analyze one of these principles in particular: the requirement that doctors respect and protect the autonomy of patients by giving them the final say in decisions about their own care. Having grasped the importance of this principle, we then shift to probing its limits. First, we ask whether any exceptions should be made to accommodate the autonomy of doctors in determining which care options to pursue with their patients – particularly when they strongly disagree with a patient’s decision. Then we highlight some concerns regarding the recruitment of medical research participants and ask whether there are times when curtailing the autonomy of patients and participants is ethically warranted as a means of protecting them from their own propensity to make misguided or compromised choices under certain conditions.

Another central area of bioethical discussion investigates the nature, value, and dignity of life itself. Many of the issues raised in this area concern the beginning of life, with substantial attention paid to questions about abortion and about the use of various reproductive technologies. We instead focus on end of life issues, specifically the ethics of voluntary euthanasia. Can it sometimes be in a suffering patient’s best interest to have their life brought to a quick and immediate end, rather than living out their remaining time? Is it contrary to the purpose of caring for a patient’s health and wellbeing for a doctor to help hasten the patient ’s death? We explore the controversial topic of euthanasia, first by considering several questions that define the primary fault lines within the euthanasia debate, and then by further interrogating one specific point of entrenched disagreement: namely, whether there is a crucial ethical difference between euthanizing a patient by active killing versus euthanizing the patient by withholding treatment.

Lastly, we turn to an area of bioethics that has been growing in urgent and exciting ways, fed by the continuous flood of advances in biomedical science and technology. Many advances – from vaccines, antibiotics, and anesthesia to MRI machines, bypass surgery, and Prozac – have been critical in enabling us to live longer, healthier, and generally better lives. But as scientists make tremendous strides in technologies like genomic engineering and brain-controlled prosthetics, widely-shared visions of being able to cure particular illnesses are increasingly overshadowed by more controversial visions of being able to enhance our capacities, perhaps even transform ourselves into something “beyond human.” Among the most publicly-debated biomedical enhancement technologies are performance-enhancing drugs (PEDs), and we get a view into this debate by presenting and evaluating some common ethical objections raised against the use of PEDs in competitive sports. Before investigating this “doping” issue, though, we consider what to think about the advancement and proliferation of biomedical enhancement technology more generally. And where best to begin this discussion than by trying to clarify what is meant by biomedical enhancement and how exactly enhancement is distinguished from other categories of biomedical improvement, such as treatment?

In presenting this small sampling of bioethical issues and debates, we hope to spark your interest and curiosity, inspiring you to further explore these and the many other fascinating topics within the growing field of bioethics.

Learning Outcomes

  • Summarize and provide examples of the kinds of issues, questions, and ideas that fall within the purview of bioethical investigation and debate
  • Gain greater appreciation for an approach to ethical discourse that strives to balance intellectual honesty and incisive critique with perspectival inclusivity and creative problem-solving – an approach that harnesses the virtues of philosophical curiosity while remaining grounded in stubborn, if hopefully malleable, realities
  • Articulate and defend a number of the core principles of healthcare ethics, demonstrating how the application of these principles within a particular scenario can help us identify and assess its key ethical features so as to draw ethically sharper and deeper conclusions about the case
  • Describe the inherently asymmetrical nature of healthcare relationships, and how concerns about this asymmetry significantly shape the ethical considerations that healthcare professionals are expected to take into account when working with clinical patients or research participants 
  • Explain the importance – and complexity – of respecting and protecting patient autonomy and consent, especially in a pluralistic society
  • Evaluate the ethical justifiability of voluntary euthanasia, understanding how these judgments might be affected not just by the particular circumstances of a case, but also by one’s views on certain conceptual questions, such as what constitutes a patient’s health or wellbeing; what makes a patient’s decision count as autonomous; and what marks the distinction between killing and letting die
  • Identify and assess some of the ethical and conceptual challenges arising from the advancement of biomedical enhancement technology, in general – and from the development and use of performance-enhancing drugs in competitive sports, in particular 
  • Marshal concrete examples to demonstrate the challenges of establishing clear, consistent, and justifiable policies in matters of bioethics – particularly given the complicated downstream effects of these policies, along with the substantive disagreements that inevitably arise in pluralistic societies
LESSON ONE

How to Start Thinking Like an Ethical Doctor

By the end of this lesson, you will be able to:

  • Describe several key ethical principles that healthcare providers must consider and balance in their clinical work
  • Explain how these principles might influence certain clinical decisions made by healthcare professionals 
  • Draw your own ethical conclusions about a case in which a group of clinical doctors decide to take a highly controversial course of action

Watch

Comprehending the argument

1. Suppose a patient who has already undergone a series of failed treatments for advanced stage cancer asks his oncologist to approve another round of intense treatment, and the oncologist refuses, believing that the patient’s cancer is terminal. Which ethical considerations most likely led the oncologist to refuse her patient’s request?

Correct! Wrong!

 

2. Which of the following cases most clearly shows that an ethical doctor must be guided by MORE than just doing what seems best for their patient’s overall health and well-being?

Correct! Wrong!

Evaluating the argument

This video discusses a rogue group of doctors who are so committed to finding a malaria vaccine and thereby saving millions of lives that they decide to subject hundreds of their patients to painful, dangerous, and sometimes even fatal experiments without their consent.

Which of the following statements best reflects YOUR opinion on whether it is ethically acceptable for these doctors to take such a radical approach to addressing one of the worst public health threats facing humanity today?
LESSON TWO

Should Healthcare Decisions Be Up to the Patient?

By the end of this lesson, you will be able to:

  • Describe the proper role of a healthcare provider in their patient’s healthcare decisions
  • Explain why, despite the central role of doctors in the diagnosis and treatment of healthcare conditions, they must ultimately defer to the patient in deciding whether or not to pursue a medically-recommended test or procedure
  • Express your personal ethical assessment of a healthcare provider’s choice to abide by her patient’s treatment decision, even though it conflicts with her own medical advice

Watch

Comprehending the argument

1. According to the discussion in this video, which of the following clinical steps would be UNETHICAL for an urgent care provider to take WITHOUT first getting explicit consent from a patient injured in a bicycle accident?

Correct! Wrong!

 

2. Which of the following is NOT a reason that the final say in a treatment decision should be in the hands of the patient rather than the doctor?

Correct! Wrong!

Evaluating the argument

Suppose a patient who has been suffering from chronic, debilitating back pain for many months and has already tried various non-invasive treatments with no success, is now speaking with his doctor about the possibility of spine surgery. Aware that the patient is a Jehovah’s Witness, the doctor explains that the surgery has a very high success rate but involves significant blood loss that, in 30% of cases, requires a blood transfusion. No longer able to deal with the incapacitating pain – and having given up hope in alternatives – the patient decides that he wants the surgery anyway, but insists that he not be given a blood transfusion even if it’s needed to save his life.

In YOUR opinion, if the doctor is unable to convince her patient to agree to the transfusion, what should she do?
LESSON THREE

Should Healthcare Providers Have the Right of Conscientious Objection?

By the end of this lesson, you will be able to:

  • Describe several key reasons that proponents give for supporting the right of conscientious objection for healthcare providers
  • Analyze common objections to conscientious objections for providers, identifying a core concern underlying these objections
  • Evaluate a potential case of conscientious objection to determine what should happen

Watch

Comprehending the argument

1. According to the video, which of the following is NOT a reason given in support of a right of conscientious objection for healthcare providers?

Correct! Wrong!

 

2. The following are two important arguments leveled against the right of conscientious objection for healthcare providers:
  • Such conscientious objectors violate their duty of care to their patients
  • Patients with the fewest viable alternatives for getting the care they seek are disproportionately likely to be harmed by such conscientious objection
Which aspect of the doctor-patient relationship is a core factor underlying BOTH of these concerns?

Correct! Wrong!

Evaluating the argument

Carl is an orthopedic surgeon in the local hospital of a thinly-populated area, who has recently decided that he will never again prescribe opioids for his patients’ postoperative pain. He’s simply witnessed and heard about too many heartbreaking, infuriating cases of patients ending up with life-destroying addictions after being prescribed opioids for pain. Instead he’s started relying exclusively on — perhaps less effective,  but certainly less addictive — non-opioid medications to manage his patients’ postoperative pain. 

The few surgical patients he’s had since making this decision were willing to stick to non-opioid pain medications, and it worked well for them all. Carl’s current patient, however, needs a surgery that tends to have a rather painful recovery period, and the patient insists that Carl give him opioids. Although this request meets the standards of care for such surgical recoveries, Carl refuses — despite knowing that he’s the only surgeon within 300 miles who can perform this operation reliably well. 

As Carl’s colleagues join the patient’s side of the debate, Carl finally declares that this is a matter of conscientious objection: he finds it morally despicable to get a patient started on opioids, and so he absolutely refuses to perform any surgery unless the patient first contractually agrees not to use opioids for the pain.

In YOUR opinion, should Carl have the right to conscientiously object to this and any future surgery until the no-opioid contract is signed?
LESSON FOUR

Is It Ethical to Pay Subjects for Their Participation in Research Studies?

By the end of this lesson, you will be able to:

  • Explain why many believe that research subjects should be paid for their participation in medical studies
  • Identify the central ethical concern that limits compensation for medical research participants
  • Express your own assessment of the worry that compensating participants will increase the chance of exploitation

Watch

Comprehending the argument

1. This video discussed various reasons for believing that research subjects ought to receive substantial monetary compensation for their participation in medical studies. Which of the following considerations is NOT such a reason?

Correct! Wrong!

 

2. According to this video, what is the primary ethical justification for not providing substantial monetary compensation to medical research participants?

Correct! Wrong!

Evaluating the argument

In YOUR opinion, how concerned should we be that compensating medical research subjects through substantial monetary payments could end up increasing the likelihood of their exploitation?
LESSON FIVE

Why Do People Disagree About the Ethics of Euthanasia?

By the end of this lesson, you will be able to:

  • Articulate four central questions that must be asked when determining whether a provider should be allowed to help fulfill a patient’s request for euthanasia
  • Explain some of the challenges faced in answering these core questions
  • Use these questions to analyze a given case and draw your own conclusions about whether the patient’s request for euthanasia in this case ought to be carried out

Watch

Comprehending the argument

1. One of the key questions to ask when determining whether or not to allow euthanasia for a particular patient is whether ending the patient’s life now is the best way to care for the patient’s overall well-being. According to the video, there are several core reasons that people (even people who basically agree about the medical facts) might end up strongly disagreeing about whether euthanasia is truly in the patient’s overall best interest. Which of the following is NOT one of those reasons?

Correct! Wrong!

 

2. Jack’s doctor, Tina, has a colleague named Andrew. Andrew believes not only that Jack’s request for euthanasia is genuinely autonomous but also that, given Jack’s particular circumstances, he’s probably right that dying a quick death now would be in his overall best interest. Andrew also believes that the method of euthanasia that Jack has requested – being injected by Tina with a dose of lethal drugs – is itself an ethically acceptable way of ending a person’s life. Given all this (and considering the discussion in the video), what’s the most likely reason that Andrew nevertheless believes Tina ought to be prohibited from fulfilling Jack’s request?

Correct! Wrong!

Evaluating the argument

Eva has always been a risk-taker, never letting fear stop her from activities that look exciting or challenging. Unfortunately, during a recent rock climbing trip, Eva made a dangerous choice and fell several stories, hitting the ground before her partner could stop the fall. Although the medics managed to save Eva’s life, six months and many surgeries later, she is still in the ICU with catastrophic injuries to her spine and internal organs.

Since being brought out of her medically induced coma, Eva has gradually regained her alertness and cognitive abilities, though these are usually dulled by the heavy doses of morphine given to moderate her otherwise debilitating pain. A week ago, though, her medical condition started deteriorating, and her doctors regretfully reported that they no longer saw much chance for recovery, recommending that she transition to hospice care where her pain could continue to be managed for the remaining weeks of her life. 

Faced with the prospect of living out these final weeks tormented by pain and suffering, unable to engage in anything like the activities that mattered the most to her and made her feel alive, and otherwise loaded up with drugs, Eva has spent her moments of lucidity over the past week contemplating her options and discussing them with her family.

She’s now come to a decision: it’s not worth it to continue living in this miserable state, just waiting for the inevitable. She wants her doctor to provide her with a lethal dose of drugs, which she will then inject into her own feeding tube, ending her life on her own terms.

1. In YOUR opinion, would hastening Eva’s death be in her overall best interest?

2. In YOUR opinion, should Eva’s decision to end her own life count as a genuinely autonomous decision?

3. In YOUR opinion, is the method Eva has proposed for carrying out her euthanasia an ethically acceptable method one for her to use?

4. In YOUR opinion, how concerned should we be that allowing euthanasia in cases “like this” might send a bad message to others in similar cases – or have other objectionable social consequences?

5. Which of the previous four questions did you find the most challenging to answer in reflecting on this case?

6. In YOUR opinion, should Eva’s doctor fulfill her request and assist her in dying?
LESSON SIX

Is Lethal Injection Worse Than Pulling the Plug?

By the end of this lesson, you will be able to:

  • Describe the difference between active and passive euthanasia, and explain why many believe that there is a crucial ethical distinction between these two types of methods of helping a patient die
  • Critically challenge these attempts to justify the purported ethical distinction between active and passive forms of euthanasia
  • Analyze a case of potential euthanasia and draw your own conclusions about the ethics of this case

Watch

Comprehending the argument

1. Some people believe that actively euthanizing a patient (eg, by administering a lethal injection) is always ethically objectionable but that passively euthanizing a patient (eg, by withdrawing life support) is sometimes ethically permissible. To justify drawing this ethical distinction, proponents are known to cite all of the following considerations EXCEPT:

Correct! Wrong!

 

2. Some people argue that there is no legitimate ethical distinction between actively euthanizing a patient and passively euthanizing them. Which of the following is NOT a point that such opponents commonly raise in objecting to this distinction?

Correct! Wrong!

Evaluating the argument

Suppose that Tina wants to help relieve Jack’s awful pain and suffering but feels uncomfortable carrying out his initial request to inject him with lethal drugs. Instead, she proposes taking a much more aggressive approach with his pain meds, boosting his morphine dosage to levels that would more effectively manage his pain and suffering – although this would also significantly increase the risk of shutting down his respiration. While Jack still prefers the lethal injection, he’s willing to pursue Tina’s suggestion, assuming that this will anyway result in the relatively quick and painless death he seeks.

Ethically speaking, should Tina be permitted to increase Jack’s pain meds to such dangerously high levels? Which of the following options best captures YOUR assessment of this case?
LESSON SEVEN

What is Biomedical Enhancement?

By the end of this lesson, you will be able to:

  • Articulate the conceptual distinction between treatment and biomedical enhancement
  • Apply this distinction to classify various interventions as either an instance of treatment or an instance of enhancement
  • Assess the adequacy of this distinction by using your own intuitions and judgment to classify a given intervention

Watch

Comprehending the argument

1. Which statement best describes the conceptual difference between treatment and enhancement?

Correct! Wrong!

 

2. Which of the following is an example of biomedical enhancement?

Correct! Wrong!

Critical Thinking

Male- and female-pattern hair loss is a highly prevalent condition, progressively affecting a majority of men and a significant proportion of women over the course of their lives. Many people experiencing pattern hair loss try to manage this condition in various ways, including hundreds of thousands who decide to have their hair restored surgically, through hair transplantation.

Considering the discussion in this video – as well as your personal intuitions on the matter – which of the following positions best reflects YOUR view on whether hair transplantation surgery for people with pattern hair loss should count as a healthcare treatment or as a biomedical enhancement?
LESSON EIGHT

Three Cheers for Enhancement?

By the end of the lesson, you will be able to:

  • Describe arguments for and against biomedical enhancement
  • Explain how ethical views of biomedical enhancement often come down to conceptions of the nature and value of human life 
  • Draw ethical conclusions about the ongoing pursuit of biomedical enhancement

Watch

Comprehending the argument

1. Which human capacity tends to be most valued by those who enthusiastically welcome biomedical enhancement?

Correct! Wrong!

 

2. Which of the following is NOT a common objection to biomedical enhancement?

Correct! Wrong!

Critical Thinking

Which of the following best captures YOUR assessment of the ongoing pursuit of biomedical enhancement?
LESSON NINE

What, if Anything, Is Wrong With “Doping” in Competitive Sports?

By the end of this lesson, you will be able to:

  • Critically assess the weight of safety concerns as an argument against doping
  • Explain why victories attained with the help of doping are judged to be undeserved 
  • Articulate your own standard for distinguishing between performance-enhancing substances that should be banned and ones that shouldn’t be

Watch

Comprehending the argument

1. Why does it seem wrong to say that our primary concern about doping in competitive sports is that it endangers the safety of athletes who dope?

Correct! Wrong!

 

2. According to this video, all the following help explain why an athletic victory achieved with the help of performance-enhancing is considered an undeserved victory EXCEPT:

Correct! Wrong!

Critical thinking

Suppose there are two substances, A and B, that athletes sometimes use to help increase muscle mass and speed up recovery time after training sessions and competitions. Anti-doping agencies across major sporting leagues and associations have investigated these substances and decided to officially ban the use of substance A as a performance-enhancing drug, but to allow athletes to continue using Substance B, just as they’re allowed to use protein powders, creatine, ibuprofen, and other non-banned substances. Some athletes and trainers, who see substance A as a valuable supplement, object to this ruling, arguing that it’s unfair to prohibit the use of substance A while permitting the use of substance B.

In YOUR opinion, under what conditions would it be fair for anti-doping agencies to prohibit athletes from using substance A despite allowing athletes to continue using substance B?