medical ethics Dr. Rami Abo Ali

1. MEDICAL ETHICS
AND
LEGAL MEDICINE
Dr. Rami Abo Ali
Medical
Ethics
-
Dr.
Rami
Abo
Ali
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2. MEDICAL ETHICS THEORIES
Dr. Rami Abo Ali
Medical
Ethics
-
Dr.
Rami
Abo
Ali
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3. GLOBALIZATION AND MEDICINE
 Globalization
 The world is a big market
 Starts at the end of last century .
 Decreased morals
 Materialistic target > moral target
 Cause a lot of fights and wars between people
 Change the term (patient ) to (costumer / client )
 When moral side is influenced by materialistics ,
there will be a lot of ethical problems
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Medical
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Dr.
Rami
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4. DIFFERENCE BETWEEN MORALS & ETHICS
 Morals :
 Latin word, means : custom
 To do what is right , and to leave what is wrong
 Related to cultures and religions
 Not related to place, job, time ( honesty , goodness )
 It is inside issue , relationship between a person and
his beliefs .
 It is not measurable .
 If it didn’t cause harm , no legal punishment , maybe
social punishment (liar ,..)
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Medical
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Dr.
Rami
Abo
Ali

5. DIFFERENCE BETWEEN MORALS & ETHICS
 Ethics :
Greek word , means character
There is rules and guidelines .
Changes upon time , place and developments
of science
Influenced by developments in human rights.
Morals are different from doctor to other , but
ethics is the same .
Non-ethical behavior have legal punishment
even if didn’t cause physical damage .
(psychological harm ) 5
Medical
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Dr.
Rami
Abo
Ali

6. INTRODUCTION
 Several philosophers have given different theories of
ethics.
 The ethical theories provides an ordered set of moral
standards to be used in assessing what is morally right
and what is morally wrong regarding human action in
general.
 A moral theory is a mechanism for assessing whether a
particular action or rule is ethically justified.
 More precisely, a moral theory can help us to sharpen
our moral vision, it helps us determine whether an
action or a rule is ethically right , wrong, or permissible.
 These theories help us in getting better understanding of
ethics and guide us in making ethical decision.
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7.  Ethical Theories :
 We will talk about three of these ethical
theories :
I. Consequence-based Utilitarian Theory
II. Virtue Theory
III. Deontology Theory
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Medical
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8. I. CONSEQUENCE-BASED
UTILITARIAN THEORY
 An individual act (X) is morally permissible if the
consequences that result from (X) produces the greatest
amount of good for the greatest number of persons affected
by the act .
 It primarily refers to moral views or theories which base their
evaluations of acts solely on consequences
 Opposite of deontology theory .
 Patient’s benefit is the most important thing regardless the
way to achieve that .
 The most common, but not the only, form of
consequentialism is utilitarianism
( The End Justifies The Means)
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9. UTILITARIANISM
 Utilitarianism is a moral theory that advocates actions that
promote overall happiness or pleasure and rejects actions that
cause unhappiness or harm.
 A utilitarian philosophy, when directed to making social,
economic, or political decisions, aims for the betterment of
society.
 According to the “classical” version, what makes a consequence
good or bad is its effect on people’s happiness.
 Roughly, a consequence is bad if it reduces happiness, good if it
increases happiness.
 Happiness, in turn, is understood to mean: an increase in
pleasure and/or decrease in pain.
 Because of the emphasis on happiness, Utilitarianism is
sometimes called “the greatest happiness principle”.
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Medical
Ethics
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Dr.
Rami
Abo
Ali

10. UTILITARIANISM CONT.
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Medical
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Abo
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"The greatest amount of good for the
greatest number of people" is a maxim of
utilitarianism.
The major philosophers who developed the
utilitarian approach were Jermy Bentham (1748-
1832) and John Stuart Mill (1806-1873) , British
philosophers .

11. UTILITARIANISM CONT.
 Utilitarianism appears to be a simple theory because it
consists of only one evaluative principle: Do what
produces the best consequences.
 In fact, however, the theory is complex because we
cannot understand that single principle unless we know
(at least) three things:
a) What things are good and bad;
b) Whose good (i.e. which individuals or groups) we should
aim to maximize;
c) Whether actions, policies, etc. are made right or wrong
by their actual consequences (the results that our actions
actually produce) or by their foreseeable consequences
(the results that we predict will occur based on the
evidence that we have). 11
Medical
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Ali

12. STRENGTHS OF UTILITARIANISM
 It is believed that actions are right if they are useful to a
majority of people. It is most commonly applied ethical
theory
 In this theory, the worth of each action is judged primarily
on its own merits .
 Gives a clear answer to the question ( what should I do ? )
 Human in this theory is neutral . ( as an object )
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Medical
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Ali

13. CRITICISM OF UTILITARIANISM
 Cannot predict the outcome of actions in advance, thus it is
impossible to set the standers of one’s moral action on the
basis of the act itself
 The notion of utility is very vague. It is very difficult to
determine what the maximal utility would be for all affected
by a situation.
 There is doubt regarding what is the “majority”. Sometimes
its action may benefit the majority at the cost of exploitation
of the minority
 It may sometimes result in unethical and immoral choices
as it judges morality by the results only, and not by the means
 It is very much difficult to foresee the consequences with
accuracy.
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Medical
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Dr.
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Abo
Ali

14. EXAMPLES OF UTILITARIANISM
 Headache : you can find the causes and treat it upon its
cause , or u can give painkiller ( cetacodiene ) and
patient will be happy .
 You get great result of exam even if you cheated ( the
result is the most important , not the way or method ) .
 You gave placebo medicines to treat warts . The patient
believes that it is the best medicine , he might be cured
of warts . The result is the most important thing .
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Medical
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Dr.
Rami
Abo
Ali

15. II. VIRTUE THEORY
 This philosophy stems from Aristotle (384-322 BC. ) and is
based on the virtues of the person making a decision.
 The virtue ethical theory judges a person by his/her character
rather than by an action that may deviate from his/her
normal behavior
 The consideration in virtue ethics is essentially “what makes
a good person,” or, for the purpose of this discussion, “what
makes a good public relations professional?”
 Virtue ethics require the decision-maker to understand what
virtues are good for public relations and then decisions are
made in light of those particular virtues.
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Abo
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16. VIRTUE CONT.
 Examples :
 If the virtue of honesty is the of utmost importance to a good
public relations professional, then all decisions should be
made ethically to ensure honesty is preserved.
 Honesty is good and should be done in all situation even it
hurts some times ( doctor and cancer patient )
 Abortion :
Killing the human being is a crime , the embryo is a human
being , so , according to virtue theory , abortion is considered
a crime and shouldn’t be done even if it is life threatening in
some medical conditions .. But , what if we consider the
embryo is not a human being yet ?!
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Medical
Ethics
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Dr.
Rami
Abo
Ali

17. VIRTUE CONT.
 Strength :
 Depends on appearance of morals more than morals itself (
embryo is a human being ? )
 Multiple and differs from person to another
 Important in medical practicing and for medical students and
doctors ( best character )
 Criticism :
 It does not take into consideration a person’s change in
moral character
 Difficult to analyze , selfish , and character depending .
 Dangerous if it is extreme .
 No middle choice between good and bad 17
Medical
Ethics
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Dr.
Rami
Abo
Ali

18. III. DEONTOLOGY THEORY
 Deontological ethics or deontology from Greek word
deon , “ that which is binding ” or refers to “ obligation,
duty ” which is the normative ethical position that
judges the morality of an action based on rules .
 It is sometimes described as “ duty ” or “ obligation” or
“ rule” based ethics , because rules “ bind you to your
duty” .
 Duties are action that should be done or avoided
regardless of consequences
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Medical
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Ali

19.  Deontological (duty-based) ethics are concerned with what
people do, not with the consequences of their actions.
 Do the right thing.
 Do it because it's the right thing to do.
 Don't do wrong things.
 Avoid them because they are wrong.
 Someone who follows Duty-based ethics should do the right
thing, even if that produces more harm (or less good) than
doing the wrong thing:
 People have a duty to do the right thing, even if it produces a bad
result
 Maybe it will not achieve the best results , but the result will be
morally good and accepted .
( What is built on wrong will be wrong ).
 Opposite of utilitarianism theory
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Medical
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Dr.
Rami
Abo
Ali

20.  Medical Deontology
 Defined as a Set of :
 Ethical standards and principles of behavior of medical
practitioners while executing their professional duties
 Professional ethics of medical workers
 Principles of behavior of medical personnel , directed
towards maximum benefit of treatment of the patient!
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Medical
Ethics
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Dr.
Rami
Abo
Ali

21. STRENGTH OF DUTY-BASED ( DEONTOLOGY ) ETHICS
 Emphasizes the value of every human being , and tend
to focus on giving equal respect to all human beings.
 Says some acts are always wrong
 Provides 'certainty‘
 Deals with intentions and motives
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Medical
Ethics
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Dr.
Rami
Abo
Ali

22. CRITICISM OF DUTY-BASED ( DEONTOLOGY ) ETHICS
 Absolutist : sets absolute rules. The only way of dealing
with cases that don't seem to fit is to build a list of
exceptions to the rule.
 Allows acts that make the world a less good place
Because duty-based ethics is not interested in the
results it can lead to courses of action that produce a
reduction in the overall happiness of the world.
 Hard to reconcile conflicting duties , and it doesn't deal
well with the cases where duties are in conflict. 22
Medical
Ethics
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Dr.
Rami
Abo
Ali

23. EXAMPLES OF DEONTOLOGY
 Hopeless cancer patient asked you is there any hope to live ?
 You shouldn’t say “ yes you will die after 3 months”
 You should say “ your situation is not so bad , we are doing our
best , you should be calm , nobody knows when to die”
 In this case we are not lairs , but we didn’t tell the whole truth ,
we just do our duties toward the patient to make him calm and
comfort .
 Patient need kidney transplantation , I cant do the operation if I know
that this kidney is stolen or they buy it . ( opposite of utilitarianism )
 Diabetic patient come to clinic and afraid of this disease
 Tell him it is simple issue and half of people have this problem ,
happiness ( utilitarianism )
 Tell him he should take the medicine and do pay attention for diet
and medical recommendations to prevent later complications of
this disease . ( deontology )
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Medical
Ethics
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Dr.
Rami
Abo
Ali

24. KANT’S DUTY-BASED ETHICS
 Immanuel Kant (1724-1804) (Kaliningrad,
Russia)
 Represent deontological ethics
 Kant thought that it was possible to
develop a consistent moral system by
using reason.
 If people were to think about this
seriously and in a philosophically rigorous
manner, Kant taught, they would realize
that there were some moral laws that all
rational beings had to obey simply
because they were rational beings, and
this would apply to any rational beings in
any universe that might ever exist
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Medical
Ethics
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Dr.
Rami
Abo
Ali

25. KANT’S CONCEPTS
Morality
The Notion
of Duty
Nature of
Imperatives
Good Will
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Medical
Ethics
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Dr.
Rami
Abo
Ali

26. KANT’S DUTY-BASED ETHICS
 Good Will
 What is good?
 Although Kantian ethics are usually spoken of in terms
of duty and doing the right thing, Kant himself thought
that what was good was an essential part of ethics.
 Kant asked if there was anything that everybody could
rationally agree was always good. The only thing that he
thought satisfied this test was a good will:
 .
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Medical
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Dr.
Rami
Abo
Ali

27. KANT’S DUTY-BASED ETHICS
 The Notion of Duty
 Distinction between “I want” and “I ought”.
 Moral actions are not spontaneous, if I see someone in
need of help, I may be inclined to look the other way,
but I will recognize that my duty is to help.
 Considering only those actions that are seemingly good
according to Kant are actions that seem good by duty,
that are good to my common sense of duty and for that
they are right
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Medical
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Dr.
Rami
Abo
Ali

28. KANT’S DUTY-BASED ETHICS
 The Nature of Imperatives
 Imperatives are commands
 For kant there exist 2:
1. Hypothetical Imperatives
2. Categorical Imperatives
1. Hypothetical Imperatives
 If you want you ought. The ought or the duty is
conditioned by your desires, wants and goals.
 Our goals are grounded in self-interest .
 Example : you should study to succeed the exam ( maybe
you will not succeed in first time , then you change your
methods and study harder to achieve the result )
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Medical
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Rami
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Ali

29. 2. Categorical Imperative
 The general from of Do. (Unconditioned)
 For Kant there is only one imperative command and it is the Moral
Law.
 Example : do emergency treatment to the patient even he is your
enemy .
 Divided in 2 formulations
1. First Formulation
 “Always act in such a way that you would be willing for it to become a
general law that everyone else should do the same in the same
situation..”
2. Second Formulation
 “Act so that you treat humanity, whether in your own person or that of
another, always as an end and never as a mean.”
 See if your actions are using others or affecting others, in the meaning
of never using them as a mean to achieve but always as an end
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Medical
Ethics
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Dr.
Rami
Abo
Ali

30. CONFLICTION OF DUTIES
 Lying or not telling the truth is morally unacceptable , but ,
what if a soldier was captured by enemy , he will have two
choices : to tell the truth and betray his country , or to lie . He is
here in front of tow duties , what will he chose ?
 Lying and betraying are both immoral , but in this case to lie is
better than to betray .
 The rule here is to follow the least damage .
 Another example , breast cancer 2nd stage no lymph nodes
metastases , chemotherapy , radiotherapy , surgery with total
resection , or partial resection . ??
 Deontology theory and the religions both have the rule of
( Necessities allow Prohibitions ) 30
Medical
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Dr.
Rami
Abo
Ali

31.  New deontology theories
1) Rossian duty-based ethics
2) Rawls’s theory of justice
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Medical
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Abo
Ali

32. 1) ROSSIAN DUTY-BASED ETHICS
 The 20th Century philosopher W. D. Ross [Sir David Ross]
(1877-1971) .
 Attempts to incorporate aspects of utilitarianism and
aspects of Kantianism
 Rejected the utilitarian notion that an action is made right
by its consequences alone, but he was also troubled by
Kant’s view, if a rule passed the categorical imperative (and
became a duty to follow), it could have no exceptions, it
was absolute.
 He saw not only that such rules fail to show sensitivity to
the complexities of actual situations, but also that they
sometimes conflict with one another. 32
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Ali

33. ROSSIAN DUTY-BASED ETHICS CONT.
 Kantian ethics seems pretty uncompromising and not really
suited to the disordered of many moral choices that people
have to make.
 He suggested that it would be helpful to look at two kinds of
duty:
1. Prima facie duties (Legal term indicating that something
is obvious enough to be considered true until proven
false)
2. Actual duties
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Medical
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Rami
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Ali

34. I. PRIMA FACIE DUTIES
 Are self-evident and obvious duties ( prima facie is a
Latin expression meaning 'on first appearances' or 'by
first instance')
 Can be known to be correct if a person thinks about
them and understands them:
 Should be promoted, "all things considered“
 Can be outweighed by other prima facie duties.
 { when we have reached sufficient mental maturity and
have given sufficient attention to the proposition it is
evident without any need of proof, or of evidence beyond
itself }
 W D Ross, The Right and the Good, 1930
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Abo
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35.  Ross listed The Seven Kinds of Prima Facie Duties:
1. Fidelity
2. Reparation
3. Gratitude
4. Justice
5. Beneficence
6. Self-improvement
7. Non-maleficence (avoiding actions that do harm)
 Calling these 'duties' may be a bit misleading, as they are not
so much duties as "features that give us real (not only obvious)
moral reason to do certain actions".
 Ross later described prima facie duties as "responsibilities to
ourselves and to others" and he went on to say that "what we
should do (our duty proper [our actual duty]) is determined by
the balance of these responsibilities."
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Ali

36. II. ACTUAL DUTIES
 This is the duty people are left with after they have
weighed up all the conflicting prima facie duties that
apply in a particular case .
 the ground of the actual rightness of the act is that,
of all acts possible in the circumstances, it is that
whose prima facie rightness in the respects in which
it is prima facie right most outweighs its prima facie
wrongness in any respects in which it is prima facie
wrong.
 W D Ross, The Right and The Good, 1930 36
Medical
Ethics
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Dr.
Rami
Abo
Ali

37. EXAMPLES OF APPLYING THE PRIMA FACIE DUTIES
 If you are carrying a heavy load into a building and a passer
by holds the door open for you, you can see immediately that
an expression of gratitude is in order. (You are directly
applying the relevant prima facie duty where it is applicable
and discovering your actual duty in the circumstances.)
 If you are an able-bodied passer-by not carrying anything
yourself and you notice someone trying to carry a heavy load
into a building, you might see immediately that you ought to
hold the door open for him or her. (You would be directly
applying the prima facie duty of beneficence.)
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Medical
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Ali

38.  Problems with the Rossian approach
 Ross's idea still leaves some problems:
 How can we tell which prima facie duties are involved in
a particular case?
 How can we compare and rank them in order to arrive at
a balance which will guide us as to our actual duty?
 Ross thought that people could solve those problems by
relying on their intuitions.
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Medical Ethics - Dr. Rami Abo Ali

39. 2) RAWLS’S THEORY OF JUSTICE
 The theory of justice formulated by Harvard philosophy
professor John Rawls (1921–2002) can be understood as
attempting to combine the strengths of utilitarianism
and deontology while avoiding the weaknesses of each
view.
 For Rawls, the central task of government is to preserve
and promote the liberty and welfare of individuals.
Thus, principles of justice are needed to serve as
standards for designing and evaluating social institutions
and practices.
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Medical
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Dr.
Rami
Abo
Ali

40. PRINCIPLES OF JUSTICE
 Rawls’ position has direct relevance to such bioethical issues as
who should have access to health care, how donated organs
should be distributed, and who should pay for society’s medical
costs.
 Rawls argues that there are two essential principles of justice:
1. Each person is to have an equal right to the most extensive
total system of equal basic liberties compatible with a
similar system of liberty for all.
2. Social and economic inequalities are to be arranged so
that they are both
a) To the greatest benefit of the least advantaged
b) Attached to offices and positions open to all under
conditions of fair equality of opportunity.
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Medical
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Ali

41.  For Rawls, these two principles are taken to govern the
distribution of all social goods: liberty, property, wealth,
and social privilege.
 The first principle has priority. It guarantees a system of
equal liberty for all.
 The second principle governs the distribution of social
goods other than liberty.
 Though Rawls’ overall position has relevance to
individual medical decisions, it’s most important
application is to the social institutions and practices of
medical care and research. 41
Medical
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Abo
Ali

42. Ethical theories
Consequence-based
Utilitarian Theory
Virtue Theory Deontology Theory
The old deontology
theory : Kant’s Duty-
based Ethics
The new deontology
theories
Rossian duty-based
ethics
Rawls’s theory of justice
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43. 43
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