The Doctor and the Good Life - Introduction to Bioethics and Natural Law

The Doctor and
the Good Life
Cary Amiel G. Villanueva, M.D.
UP College of Medicine Class 2017
Integrated Liberal Arts and Medicine Program
IDC 201: History of Medicine
An Introduction to
Bioethics and Natural Law

Hello!
DISCLOSURE
I am not (yet) a philosopher nor a bioethicist.
I am a doctor with an interest in bioethics.
Content based on my personal study and do not
necessarily reflect the views of my employer
nor of my affiliations

Witherspoon Institute’s Medical Ethics: A Natural Law Perspective Seminar
Summer 2016 | Princeton, NJ

LEARNING OUTCOMES
At the end of the lecture, the student should be able
to:
1. Describe the scope of medical ethics and bioethics
2. Distinguish bioethical theories including the four
principles and natural law approaches
3. Apply natural law principles to selected bioethical
cases

Brief History
of Bioethics
Bioethics and
the Good Life
Bioethics at
the Bedside
OUTLINE

Medicine is about people.
Medicine is about helping
people live good lives.

ETHICS
◉ Moral philosophy
◉ “A normative discipline that attempts to determine at the
most general level which human actions are morally right
and which are wrong”
Gomez-Lobo, A. & Keown, J. (2015). Bioethics and the human goods: An introduction to natural law bioethics.
Washington, DC: Georgetown University Press

ETHICS
◉ Is about three things:
Good
the thing desired, the ideal
Right
opposite of wrong as defined by some law
Ought
personal obligation, duty, responsibility
Kreeft, P. (2003). Ethics: A history of moral thought course guide [PDF]. The Modern Scholar.
Recorded Books, LLC

BIO
“bios”
life
“ethos”
behavior
ETHICS

BIOETHICS
Medical Ethics
Animal Ethics
Environmental
Ethics
Research
Ethics
Disability
Ethics
Transplant
Ethics
Genetic
Ethics
Health Care
Ethics
Neuroethics
Medical Ethics

What questions are answered by
bioethics?

• What is a human being?
• What is a person?
• Is the fetus a person?
• How should we treat human
beings?
• How should we treat human
beings with severe mental
disability?
• Is it permissible to eliminate
human beings with undesirable
traits? (eugenics)
Ontogeny
Ethics

BRIEF HISTORY OF BIOETHICS
A History of Medical Ethics

““Modern medical technology has raised many
difficult ethical questions at both
the beginning and end of life.”
“On the other hand, human conduct has always had
the ability to affect life, either positively or negatively;
thus, bioethics – albeit by another name –
has existed for quite some time.”

“
“Some of the contemporary questions of bioethics
are essentially old questions in a new form.”

HIPPOCRATIC OATH
Image: http://medicaltourismgreece.com/hippocrates

Solemn Oath
“I swear by Apollo
Physician and Asclepius
and Hygieia and Panaceia
and all the gods and
goddesses, making them
my witnesses, that I will
fulfil according to my
ability and judgment this
oath and this covenant”
“If I fulfil this oath and do
not violate it, may it be
granted to me to enjoy life
and art, being honored
with fame among all men
for all time to come; if I
transgress it and swear
falsely, may the opposite
of all this be my lot.”
HIPPOCRATIC OATH
Translation from the Greek by Ludwig Edelstein.

Respect for Mentors
“To hold him who has
taught me this art as equal
to my parents and to live
my life in partnership with
him”
HIPPOCRATIC OATH

Duty to the Sick
“Whatever houses I may
visit, I will come for the
benefit of the sick”
“I will apply dietetic
measures for the benefit
of the sick according to my
ability and judgment; I will
keep them from harm and
injustice.”
HIPPOCRATIC OATH

Not to Harm
“I will neither give a deadly
drug to anybody who
asked for it, nor will I make
a suggestion to this effect.
Similarly I will not give to a
woman an abortive
remedy. In purity and
holiness I will guard my
life and my art.”
HIPPOCRATIC OATH

Confidentiality
“What I may see or hear in
the course of the
treatment or even outside
of the treatment in regard
to the life of men, which
on no account one must
spread abroad, I will keep
to myself, holding such
things shameful to be
spoken about.”
HIPPOCRATIC OATH

HUMAN EXPERIMENTATION
◉Nazi Medical Experiments (1940s)
◉Tuskegee Syphilis Experiment (1930-1970)
◉Willowbrook Hepatitis Study, New York (1963-1966)

20th CENTURY MEDICAL ETHICS
◉Nuremberg Code (1947)
Following the Nuremberg Trials of Dr. Mengele et al.
◉Declaration of Helsinki (1964) –
World Medical Association
“It is the duty of the physician to promote and safeguard
the health of the people. The physician’s knowledge and
conscience are dedicated to the fulfilment of this duty.”
“In medical research on human subjects, considerations
related to the well-being of the human subject should
take precedence over the interests of science and
society.

The Birth of Bioethics (Jonsen)
• 1962, November 9 - Life Magazine Article:
“They Decide Who Lives, Who Dies”
Seattle committee decides which patients enter into new
chronic hemodialysis program
• 1966, June 16 - Henry Beecher’s New England Journal
of Medicine Article
Cites 22 unethically designed and conducted studies
published in journals
Jonsen, A. (1993). The birth of bioethics. Hastings Center Report, 23(6): S1-S15. doi:10.2307/3562928

• 1967 – First Heart Transplant
Christian Barnard transplants a human heart. Questions
on the source of the organ raised.
• 1967, March 31 – In the Matter of Karen Ann Quinlan
New Jersey Supreme Court upholds parents’ decisions
to remove life support vs. doctors and hospital

• 1968 – Harvard Medical School’s “Brain Death”
Committee headed by Beecher proposes definition of
“brain death”
• 1969
The Hastings Center founded by Dan Callahan and
Will Gaylin
The Kennedy Institute of Ethics at Georgetown
University founded by Andre Hellegers

Belmont Report (1978):
3 principles
◉ Respect for persons
◉ Beneficence
(and Non-maleficence)
◉ Justice
Beauchamp and
Childress: 4 principles
◉ Beneficence
◉ Non-maleficence
◉ Autonomy
◉ Justice

MODERN PHYSICIAN’S PLEDGE
Declaration of Geneva
◉ First adopted in 1948
◉ Recently revised
October 14, 2017
Cook, M. (2017, November 30). World medical association updates Hippocratic oath.
https://www.mercatornet.com/mobile/view/world-medical-association-updates-hippocratic-oath

◉ A pledge, rather than an oath
◉ Innate universal laws replaced by positive law
1948: “even under threat, I will not use my medical
knowledge contrary to the laws of humanity”
2017: “I will not use my medical knowledge to violate
human rights and civil liberties, even under threat”
aaa

◉ Implicitly permits abortion
◉ 1948: “I will maintain the utmost respect for human life
from the time of conception.”
◉ 2017: "“I will maintain the utmost respect for human
life”
◉ Puts a heavy emphasis on autonomy
2017: “I will respect the autonomy and dignity of my
patient”
aaa

PHILIPPINE BIOETHICS
Screencap from Star Cinema trailer of “Seven Sundays”, https://www.youtube.com/watch?v=8f9bHB1sMFg

Alora, A.T., & Lumitao, J.M. (2001). Beyond a western bioethics: Voices from the developing world.
Western Bioethics Filipino Bioethics
Focuses on the individual Focuses on social units (the family)
Oriented to principles Articulated in lived moral virtues
Uses discursive terms
Is part of the phenomenological
world of living experience
A thought system An embodied activity of virtue

◉ PMA Code of Ethics
Article I. General Principles
Article II. Duties of Physicians to their Patients
Article III. Duties of Physicians to the
Community
Article IV. Duties of Physicians to their
Colleagues and to the Profession
Article V. Duties of Physicians to Allied
Professionals
Article VI. Relationship of Physicians with the
Health Products Industry
Article VII. Amendments

◉ PMA Code of Ethics
“On entering the profession, a physician assumes
the obligation of maintaining the honorable
tradition that confers the well deserved title of a
“friend of mankind”. (Article I, Section 2)
“A physician shall waive his professional fees to
a colleague, his or her spouse, children and
parents who are financially dependent on him.”
(Article IV, Section 1)

◉ PCP Code of Ethics
◉ All members shall be exemplary in their
behavior as members of the community and of
the profession. They shall work harmoniously
and regard as uppermost the best interest of
patients who are entrusted to their care.
Although the internist is entitled to just
compensation, patients’ welfare should be
primary.
◉ The internist shall ensure that the patient’s best
interest is safeguarded. He is obliged to inform
his patient as to the nature of illness,
diagnosis, progress of care and prognosis.

◉ Ethical and Legal Issues in the PH
◉ Abortion: illegal under the constitution but it happens
◉ Contraception: legal, expanded by the RPRH law,
subject to the SC TRO
◉ In vitro fertilization: legal
◉ Surrogacy: not allowed by local OB/GYN societies
◉ Capital punishment: outlawed in 2006
◉ Euthanasia: no specific law but contrary to general
sentiment
◉ Terminal sedation: not allowed by local hospice and
palliative care physicians
◉ HIV testing: generally opt-in

◉ When Ordinary Care Becomes Extraordinary
◉ The situation: Inequity in healthcare access
Corruption
Exorbitant cost of medicines
◉ Most cases in PH: not euthanasia but rather
knowing when "enough is enough“
McTavish, J. (2016). Justice and health care: When “ordinary” is extraordinary. Linacre Quarterly, 83(1):26-34.

◉ When Ordinary Care Becomes Extraordinary
◉ “Ordinary (or extraordinary) is not simply a technical
explanation of the complexity of a treatment, but
rather a description of the overall set of
circumstances including the treatment proposed,
the burden imposed, the degree of success, pain
incurred, as well as the financial situation of the
patient and family.”
McTavish, J. (2016). Justice and health care: When “ordinary” is extraordinary. Linacre Quarterly, 83(1):26-34.

BIOETHICS AND THE GOOD LIFE
Natural Law Bioethics

DEONTOLOGY
Immanuel Kant
duty / obligation
“Do not ever…”
PRINCIPLISM
Tom Beauchamp and
James Childress
prima facie principles
of biomedical ethics
UTILITARIANISM
John Stuart Mill
Jeremy Bentham
Maximization of
pleasure
Greatest good for the
greatest number
ETHICAL THEORIES
NATURAL LAW
Aristotle
Thomas Aquinas
The “Good Life”
All action is oriented to
goods

NON-
MALEFICENCE
AUTONOMY
BENEFICENCE JUSTICE
FOUR PRINCIPLES

Primum
non nocere.
First,
do no harm.

“Good is to be done and pursued
and evil avoided.”
- Thomas Aquinas

◉Life
◉Health
◉Friendship
◉Knowledge
◉Art and beauty
◉Practical reasonableness
◉Religion
Human Flourishing
BASIC HUMAN GOODS
Brugger, E.C. (2016). The first principles of the natural law and bioethics. Christian Bioethics, 22(2):88-103.

FIRST PRINCIPLES
◉“Good is what all things desire; this, then is the first
precept of the law, that good is to be done and pursued
and evil avoided.” (Thomas Aquinas, Summa Theologiae)
Brugger, E.C. (2016). The first principles of the natural law and bioethics.
Christian Bioethics, 22(2):88-103.
“Openness to, pursuit of and no intentional damage to,
the basic goods across all persons”
Tollefsen, C. (2008). The new natural law theory. In Lyceum, 10(1):1-18.

SCOPE OF BIOETHICS
Photo credits: (left) bionalogy.com/human_embryology.htm
(middle) screencap from "Beauty and the Beast“ (right) Shutterstock

BEGINNING OF LIFE
Abortion
- In medicine (obstetrics):
◉ Pregnancy termination before 20 weeks’ gestation or
with a fetus born weighing < 500 g (WHO / CDC)
◉ May be spontaneous (miscarriage), recurrent or induced
(medically or surgically)
- In ethics:
◉ Typically refers to intentionally induced termination of
pregnancy

BEGINNING OF LIFE
Pro-Choice Arguments
◉ Embryo or fetus is not a human being
◉ Woman’s autonomy over her body

Facts of Embryology
◉ “Almost all higher animals
start their lives from a single
cell, the fertilized ovum
(zygote).”
◉ “The time of fertilization
represents the starting point
in the life history, or ontogeny
of the individual. In its
broadest sense, ontogeny
refers to the individual’s
entire life span.”
BEGINNING OF LIFE
Carlson, B.M. (2003). Patten’s foundations of embryology (6th ed.). Philippines: McGraw-Hill Education (Asia)

BEGINNING OF LIFE
Facts of Embryology
◉ “Human development begins at fertilization when a
male gamete or sperm (spermatozoon) unites with a
female gamete or oocyte (ovum) to produce a single
cell – a zygote. This highly specialized, totipotent cell
marked the beginning of each of us as a unique
individual.”
- Moore and Persaud,
“The Developing Human”
George, R.P., and Tollefsen, C. (2011). Embryo: A defense of human life. Princeton, NJ: The Witherspoon Institute, Inc.

BEGINNING OF LIFE
Abortion
◉ Violates the principle of non-maleficence
◉ Intentionally destroys the life on a human being
◉ Child is deprived of the good of life which allows the
other human goods to be enjoyed
◉ No other goods are preserved or promoted which
justify the loss of life

Contraception
◉ Damages the possibility
of future life coming out
from the act
In Vitro Fertilization
◉ Destruction of embryos in
the process
◉ Analogous to “making”
◉ “the child is being
brought into being as a
benefit to the parents”
◉ “the child is being treated
merely as a means to
someone else’s end”
Tollefsen, C. (2014). In vitro fertilization
should not be an option for a woman.
In Arp, R., and Caplan, A. (eds.). Contemporary
Debates in Bioethics. John Wiley & Sons, Inc.
BEGINNING OF LIFE
Photo credit: http://www.ihrivf.net/in-vitro-fertilization/

CASE
A 26-year-old primigravid presents to the OBAS with
abdominal pain and vaginal bleeding on the 8th week
after her last menses.
On internal examination, her cervix is closed but has
cervical motion tenderness.
Pregnancy test done is positive. She is sent for
transvaginal ultrasound which reveals an extrauterine
gestational sac with fluid in the cul-de-sac.
She is diagnosed with an ectopic pregnancy and is
advised salpingostomy (surgical procedure to remove
the products of conception in the fallopian tube).

DOUBLE EFFECT
Principle of Double Effect
1. The action must be morally good or at least indifferent in its
object, ends and circumstances. It must not be evil in itself.
2. The good effect must immediately follow the act or at least
come simultaneously with the evil effect. The good effect
cannot be the consequence of the bad effect.
3. The intention of the doer must be morally good -- that is, one
desires the good effect. One foresees and permits the evil
effect but does not desire it. The evil effect can never be
desired, not even to bring about the good effect. Neither can
the doer desire both effects.
4. A proportionately grave reason must exist to justify the evil
effect. There should be a reasonable proportion between the
good intended and the evil permitted.
Monge, M. (2014). Ethics in medical practice:
Summary, explanation and defense of concrete ethical problems (2nd ed.). Manila: Sinag-tala Publishers

DOUBLE EFFECT
Applications of the Principle of Double Effect
◉ Ectopic pregnancy
- mother’s life vs. child’s life
- loss of fetal life is not intended
◉ Chemotherapy for cancer
- nausea, weakness, hair loss may be unavoidable
side effects
- treatment of the cancer

TRIUMPH OF SCIENCE OVER DEATH
Original photo from
upcm89.wordpress.com
Screencap from “Extremis” (Netflix)

Proportionate means
Ordinary means
Ethically obligatory
Burdens < Benefits
Disproportionate means
Extraordinary means
Ethically optional
Burdens > Benefits
May be futile
SUSTAINING LIFE
Excessive burdens can be an ethical reason to
refuse potentially life-sustaining treatment.

END OF LIFE
Euthanasia
◉Physician intentionally ends the life of a patient to end
the patient’s suffering
◉Patient’s death as a means to alleviate suffering
◉Actively seeking the patient’s death violates
non-maleficence (the good of life)
◉Related issue : physician-assisted suicide

Intention Side Effect
INTENTION
vs.

END OF LIFE
Sedation
Proportional palliative sedation
◉Least amount of sedative to maintain adequate control
of symptoms
◉Intention is to relieve pain/suffering
Palliative sedation to unconsciousness
(terminal sedation)
◉ Sedative enough to make the patient unconscious
◉ Intention is to relieve pain/suffering by killing the
patient
Based on class discussions with Farr Curlin and Christopher Tollefsen in the Wiitherspoon Institute’s Medical Ethics Seminar

BIOETHICS AT THE BEDSIDE
The Doctor-Patient Relationship

MEDICAL ETHICS
◉Deals with ethical questions arising from the
doctor-patient relationship
◉Focused on the medical profession (i.e. physicians)

The Doctor (Sir Luke Fildes)
Photo credit: kerrisdalegallery.com

What is the doctor-patient relationship
oriented towards?

THE END OF MEDICINE
Possible ends of medicine
• Happiness
• Social adjustment or civic virtue
• Prevention of death or prolongation of life
The proper end of medicine is health.
cf. Kass, L.R. (1975). Regarding the end of medicine and the pursuit of health. The Public Interest, 40 :11-42.

HEALTH
◉Reductionist view:
health as the absence of disease
◉World Health Organization / Alma Ata definition:
“a state of complete physical, mental and social
wellbeing, and not merely the absence of disease or
infirmity”
◉Leon Kass’ definition:
“the well-working of the organism as a whole”

HEALTH
Leon Kass (1975)
Health: “the well-working of the organism as a whole”
◉A natural standard or norm
◉A state of being that reveals itself in activity as a
standard of bodily excellence or fitness
◉Recognizable if not definable
◉To some extent attainable
Unhealth, rather than illness or disease, is the opposite
of health.

HEALTH
Surgery and Anesthesia
◉ Surgery: “controlled trauma”
◉ Anesthesia: “reversible coma”
◉ Putting a patient in temporary unhealth to potentially
improve health or sustain life

HEALTH
Risk-Benefit Analysis
◉ Probable benefits should outweigh the potential risks
Examples:
◉ Preoperative clearance / risk stratification
◉ Anticoagulation for patients with atrial fibrillation
(risk of stroke vs. risk of bleeding)
◉ Best possible match for blood transfusions,
e.g. O positive
◉ Palliative care for end-stage cancer

AUTONOMY
Informed consent
Surrogate decision-making
◉In cases that a patient is unable to make an
autonomous decision (e.g. unconsciousness, mental
incapacity)

AUTONOMY
Images: (Charlie Gard) thetablet.co.uk (Alfie Evans) change.org

VOCATION
The Medical Vocation
◉ Vocation: a call towards commitments towards
some goods
◉ Medical vocation: oriented to the good of health
Based on Discussions with Christopher Tollefsen

VOCATION
Patient’s Responsibility for One’s Health
◉“(The) person primarily responsible for the health
of the patient is the patient, not the physician
(though the patient ought to seek medical advice
whenever that is required to help her safeguard her
health.“
Physician’s Responsibility
◉ Not a technician: "A physician should always put
the true good of the patient first, and not simply
do what they are asked to do.”

AUTONOMY and AUTHORITY
Autonomy
◉ From Greek: self + law = “self-directing”
Authority
◉ Authority of Expertise (Doctor)
The doctor makes claims on health-related outcomes
◉ Decisional Authority (Patient)
Based on patient’s vocational commitments
Based on class discussions with Christopher Tollefsen

CONSCIENCE
◉“Conscience therefore is where the objective and
universal Moral Law and the individual person meet.”
◉“Conscience is not the source of good and evil. It is
not the maker of the law but rather a judge of how
the law is correctly applied to a specific action.”

CONSCIENCE
Principle of Conscience
◉“Every agent should perform an action only if she
judges it to be morally permissible, and should
refrain from performing it if she judges it to be
morally impermissible."

Formal Cooperation
Openly or secretly
consents to the act of
another
Cooperates with the
intention
Material Cooperation
Physical assistance to an
action without willing
consent
Does not cooperate with
the intention
COOPERATION

CONSCIENCE
Conscientious objection
◉Respect for provider autonomy
◉Respect for the principle of conscience
◉Examples:
Jehovah’s witness refusing blood transfusions
Philippine Supreme Court struck down RH Law provision
requiring physicians to refer patients for services against
their conscience

““Any bill that compels Doctors to
act against their conscience and 2,500 years
of ethics should and will fail.”
Dr. Michael Gannon
Australian Medical Association

TAKE HOME ARGUMENT
◉Premise 1:
As doctors, we have the obligation to be good.
◉Premise 2:
Bioethics shows us how to be good.
◉Conclusion:
We have an obligation to study bioethics.

LEARN MORE BIOETHICS
◉BioEdge
(bioedge.org)
◉The Public Discourse
(thepublicdiscourse.com)

LEARN MORE BIOETHICS
Inquies Pro Medicina:
Conversations on
Science, Medicine, Law
and Philosophy
facebook.com/bioethicsstudygroup
Oliver M. Tuazon, MSc
(Charis Foundation)
Ma. Rosanna De Guzman, MD, MS
(UP-PGH Psychiatry)
Jose Maria Mariano, MS, PhD
(University of Asia & the Pacific)

““The vocation of the physician, at its core, is little changed
in the millennia since the Oath of Hippocrates was first
uttered: to give care to another person to the utmost of
one’s abilities, respecting the innate dignity of that person
and all the while subordinating one’s personal wants in a
gift of self.”
From “The Vocation of a Doctor”, http://www.thepublicdiscourse.com/2011/07/3458/
Donald W. Landry, MD, PhD
Chair, Department of Medicine,
Columbia University, New York City

Thanks for your attention!
ANY QUESTIONS?
Contact me
cavillanueva@upm.edu.ph
@caryamiel (Twitter)
caryamiel.wordpress.com

Credits
Special thanks to all the people who made and released
these awesome resources for free:
◉ Presentation template by SlidesCarnival
◉ Photographs by Unsplash

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