course material

1. Stand-Alone Project County Hospital Director of Public Relations and
Ethics
You have been appointed Director of Public Relations and Ethics at County Hospital.The
hospital is facing several urgent situations regarding the following issues. Your Stand- Alone
Project responses should be both grammatically and mechanically correct and formatted in
the same fashion as the project itself. If there is a Part A, your response should identify a
Part A, etc.1. Abortion2. Germline Experimentation3. Randomized Clinical Research4.
Rationing Health Care5. Organ transplantsPart A White Papers: You are charged with
preparing white papers on these topics. White papers present various positions, explaining
the strengths and weaknesses of each; they do not give or defend the author’ s position.
Using the Required Readings, your textbook, and articles and Web sites you find by doing
your own research, write a two-page paper on each of the topics listed above. Include a
bibliography formatted in APA style.Part B Questions and Rationales: You must also instruct
the hospital’ s Ethics Committee to discuss these issues in depth and revise the hospital’ s
ethics handbook. As part of your work with the Ethics Committee, you must draft three (3)
questions that will guide Ethics Committee deliberations for each of the five (5) topics (15
questions total). For each question provide the rationale for the question.Part C Press
Release Flyers: In addition to the white papers, you are charged with preparing 1-page
summaries of your own position on each of these topics in the form of a flyer that clearly
states hospital policy and the rationale behind it. (In real life, this flyer would state the
position and rationale of your ethics committee.) A suggested outline for these summaries is
as follows:1. State the position clearly in one paragraph.2. Allot one paragraph for each
ethical position, giving reasons for and against each of them.3. Restate your position and
give persuasive arguments for it.4. Indicate that hospital personnel are available to discuss
ethical issues with family members.There was a time not long ago when doctors could offer
only limited help, but they dispensed that help generously to their patients. Today, doctors
have amazing medical resources, but they are limited in supplying them by scarcity and
economics. How, for instance, do they decide whether a patient gets a liver transplant? First,
they have to determine if the patient is a good candidate for organ transfer. Then they have
to locate a liver donor or apply to an organregistry. They also have to consider how the
surgery will be paid for since they will need approximately $100,000 to cover the
expense.What should doctors do? Should they follow the market approach and allot
treatment to those who will pay the most for it? Should they decide on the basis of medical

2. need? Should they depend on a committee to make the decision? Should they depend on a
lottery system or an HMO to make decisions regarding allocating treatment? Or should they
follow the customary approach, which is a bunch of practices that mask the fact that
treatment is being rationed? Eachof these approaches has its advantages and
disadvantages.The market approach is consonant with the free market economy. It
simplifies the choice because the transplant goes to those who can pay for it, either with
their own money or with insurance. Many libertarians feel comfortable with this idea
because people would get the care that they have earned and deserve. Many of us would be
troubled if society followed this option exclusively. It is, however, a component of the
customary approach discussed below.The medical-need approach would allot organs by
giving priority to patients who most need them to stay alive. It would be supported by a
prognosis on the patient’ s likelihood of recuperating to live a healthy life. According to
medical need, a 93-year old man who would almost certainly die with a transplant would
have priority over a 30-year old woman who could live for six months without a transplant.
According to medical prognosis, the woman would receive the transplant.The lottery
approach is another simple approach to rationing transplants that guarantees a kind of
fairness because it treats all seekers of expensive and scarce treatment equally.
This approach may be too simple because it does not take into account the seriousness of
need, the likelihood of success, the length of time on a waiting list, or the person’ s age or
importance to their families and society. On the other hand, everyone would have an equal
chance of receivingtreatment.The committee approach merely moves the decision making
from a doctor to acommittee without dealing with underlying ethical concerns. The
committee is likely to reflect the arbitrary biases of its members. It does, however,
distribute feelings of guilt and gives its members a feeling of justification because one’ s
judgment is supported by one’ s peers. The customary approach, on the other hand, offers
some comfort to the medical establishment. It conceals the reality that people are denied
treatment because of rationing and conceals reasons ofeconomics and bias that shape the
rationing. In short, it does not rock the medical status quo.For these reasons, the customary
approach will remain in place with only minormodifications until situations, interest
groups, and individuals mount campaigns for moretransparency. This is the ordinary course
of democracy: Elites make decisions for their own benefit until people make them decide for
the benefit of ordinary people.One practical decision-making strategy for allotting organ
transplants or other scarce and/or expensive procedures is an explicit or implicit checklist.
Using such checklists, doctors, committees, and HMOs automatically disqualify certain
groups of people from receiving them.Such people might be excluded on the basis of: age,
criminality, drug or alcohol abuse, mental illness, likelihood of medical failure, quality of life,
low social standing, or lack of insurance.Carl Cohen (as cited in Card, 2004) argues that
there are no special reasons that should automatically deprive alcoholics of liver
transplants, a position with which many Americans disagree as evidenced by the furor that
erupted when Mickey Mantle, an alcoholic, got a liver while those who had not been
alcoholics went without. Daniel Callahan (as cited in Card, 2004) argues that scarce
treatments should not be allocated to people who have completed theirproductive life spans
because society owes people a good life, not a long life, and because giving old people those

3. treatments will deprive younger people of opportunities for a full life. He believes that old
age is meant to be a time of reflection and making peace with inevitable death.George Annas
(as cited in Card, 2004) considers ideas for deciding between prostitutes, playboys, poets,
and other reprobates. He says the process should be “ fair, efficient, and reflective of
important social values” (p. 458). He believes that the initial screening should be based
exclusively on strict medical criteria. The secondary criteria should minimize social
worth criteria and move toward a randomized method of selection, for which he prefers a
modified “ first come, first served” procedure. For example, every prospective kidney
recipient would first be typed with prospective donated kidneys on the basis of
compatibility and likelihood of successful outcomes. After the first selection had been
completed, the prospective recipient who had been on the list the longest would be
awarded the transplant.On controversial measures of distributive justice, such as the
allocation of medical resources, conflicting moral and economic stances prohibit our
assuming any common moral consensus. Rational ethical consensus needs to be
constructed with careful attention to all points of view and the details of particular
situations. General ethical considerations must be balanced against each other in making
such decisions. For these reasons, an ethics committee composed of broadly represented
stakeholders should probably be consulted in the allotment of scarce medical resources. In
such a committee, political considerations would either be sublimated to ethical ones or, at
least, would be balanced among competing interests.A doctor’ s ethical decision making is
more difficult in the United States than it is in the United Kingdom. The British National
Health Service provides universal health care to all citizens, but it makes explicit what
medical procedures will not be supported. More elaborate xray, MRI, and Cat Scans are not
supported, for example, under the justification that their cost would subtract from the care
provided to the remainder of the population. In other words, medical resources are
rationed. Of course, the middle class and wealthy can fly to countries suchas Belgium and
receive any treatment they can afford to pay for, so health care is really only rationed for the
working class and the poor.American doctors are pressured on both sides: by their patients
to provide treatments of questionable worth and by HMOs and hospital administrators to
limit the use of expensive tests and treatments. In the U. S. the cost-containment role is
taken over by a number of organizations such as HMOs that pressure hospitals and doctors
to limit expensive procedures. A doctor risks his livelihood and practice if he or she
continually orders tests and procedures that are discouraged by HMO accountants. Doctors
and hospitals are also financially rewarded if they spend less than the amount set by the
HMO. Thus by means of operant conditioning, they are taught to provide their patients less
service than might be appropriate. Some authors believe that this conditioning turns
doctors into double agents who slight their patients in favor of HMOs and other
institutions.In this connection, an Oklahoma study (Khalig, Broyles, & Robertson, 2003)
found that insurance status, prospective payment, and the unit of payments make a
difference in the length of hospital stays. Medicare-insured, Medicaid-insured, and the
uninsured experience significantly shorter episodes of hospitalization than their
commercially insured counterparts.These shorter stays were found to contribute to
physician-induced (iatrogenic) injury. This study and many others argue that medicine in

4. the United States needs to find a different method of financing. Whatever happens, however,
the chances are that, because of the progress in treating chronic diseases and American’ s
high expectations, the cost of health care will continue to riseno matter who pays for
it. Another reason that medical costs are high in this country is the American tort
system.Premiums got so high in West Virginia because of the thousands of law suits against
doctors that physicians staged a 1-day strike to protest. Worse, so many physicians have
moved out of that state that people in some areas have to drive two or more hours to see a
doctor. Two issues are important here. The first is the many unnecessary lawsuits that
people bring against doctors, lawsuits that frequently cost insurance companies millions of
dollars.On the other hand, doctors, like the rest of us, make mistakes. For example, if a
doctor sews up after an operation and leaves a clamp inside the patient, what should he or
she do?Ignore it and hope for the best? Wait until the patient reacts badly and then reopen?
Cover up the incident? Confer with lawyers to design a defense strategy? Consult with
accountants to see if his or her insurance premiums will skyrocket? Tell the patient and
relatives what happened, apologize, reopen, and correct the mistake?Thurman (as cited in
Card, 2004) says that the barriers to admitting mistakes are:1. The provider’ s difficulty in
confessing mistakes.2. The fear of implicating other providers.3. The possibility of liability
exposure. (p. 484)The first barrier has psychological force but no ethical force. We all make
mistakes, but ethicalpeople admit and correct them as quickly as possible. Honest
admission of mistakes is cheaperthan cover-up because cover-up adds fraud to mere
malpractice and angers the patient or family,who might then sue the doctor or hospital.
Doctors are discouraged from speculating about thebehaviors and intentions of other
providers. Instead, they should relate only their presentobservations of a patient and not
assign guilt to anyone. Both the national and state legislaturesare currently struggling to
find a solution to medical liability that is fair to both doctors and topatients who have truly
been harmed. Some states, like New York and Pennsylvania, exempt“ mere” medical
malpractice from punitive damages.Knowing right and wrong was simple when we were
kids. Right was what we were toldto do. Wrong was thinking on our own. As adults and
professionals, however, we often find thatknowing right from wrong is more problematic
because we are called upon to think for ourselvesand because many of the decisions we are
forced to make are complex and emotionally charged.In addition, we find that other adults
and professionals do not always agree with ourmoral opinions about controversial
situations. In medical ethics, we face conflicting argumentson real-life procedures like
abortion, assisted suicide, euthanasia, genetic testing, germlinetherapy, stem-cell therapy,
research on human subjects, and rationing health care. We move froma world of black and
white into a world of grays. We inhabit a world of competing culturalimperatives and moral
entanglements.Nevertheless, ideal rules for morality are part of every culture and tend to be
universal.We are all familiar with some of them:1. First, do no harm.2. Do unto others as you
would have them do unto you.3. The Ten Commandments4. Mens sano in corpore sano (a
sound mind in a healthy body)Interpretations of these general sentiments, however, vary
widely from culture to culture.These variations can and do lead to conflicts as societies
become more complex.In ancient Greece 2500 years ago, Socrates insisted on questioning
people about theirmoral assumptions and was eventually asked to commit suicide for being

5. irreligious. Hisinsistence on asking questions to get to a philosophical truth came to be
known as the SocraticMethod. The method is skeptical, conversational, conceptual or
definitional, empirical orinductive, and deductive. Socrates was skeptical of common sense
and tested it in conversationsthat tried to define key terms. Each proposed definition was
tested by applying it to real-lifesituations using deduction in the form that says, if that is
true, then the following should also betrue. Good examples of the Socratic Method are
Euthypro, discussed in your textbook, andCrito, in which Socrates decides not to escape his
death sentence. His method of questioning hasbeen the driving force of Western ethics,
philosophy, and science. His method and argumentsenter into present-day controversies
such as voluntary assisted suicide. This method in variousforms underlies most of the
research in this course.Robert Card (2004) describes the relationship between morality and
ethics as follows:Ethics consists in the construction of a critically reflective morality. Ethics
iscritical since it leaves itself open to examining and reexamining reasons from allsources
and disciplines. Ethics is reflective in that a conscientious moral agent isconstantly trying to
achieve a delicate balance that takes into account the effect ofthese reasons on his or her
deepest values. By contrast, a morality, or set of mores,is a set of rules, norms, or
understandings that may be followed even by a nonreflectiveperson. So, while ethics is a
form of morality, a morality is notnecessarily ethical. To consider ethics as a critically
reflective morality highlightsthe fact that ethics is a method of discovery and not strictly a
body of knowledge.Ethics does not consist of knowing the answers but instead of knowing
how toinquire. (pp. 44-45)Your textbook describes major theories that try to systematize
ethical decision-making,including relativism, divine command, psychological egoism,
utilitarianism, Kantianism, virtuebased,and Rawl’ s theory of justice. Each of these theories
sheds some light on the playing fieldof right and wrong, but none of them enlighten the
whole field. We have to use all of these lightsto see clearly the relevant aspects of a
particular moral controversy.Seeing many aspects of a problematic situation is the first
stage of sound ethical thinkingthat sets up a dialogue among contrasting views. In this
distance learning course, this ethicaldialogue will be mainly within your own head as you
listen and respond to various argumentspresented in the Required Readings. In your life,
the dialogues will also be with family, friends,and co-workers. The work you do in this
course should help you to dialogue effectively in reallife situations.The second stage of
sound ethical thinking for us as individuals and as groups seekingguidance in problematic
situations is critical thinking. Just gathering conflicting information in acontroversy will
only confuse us unless we can think clearly about that information. Questionsabout
euthanasia, for example, will remain confusing unless many distinctions are made
andthinking is directed toward every aspect of a particular situation.How then do we make
practical personal and communal ethical decisions?In the past, we could trust our
conscience, gut, or common sense. This is the timehonoredstrategy of the human race that
operates at a mostly subconscious level. This strategyworks for us personally because it
reflects what we have been taught and our previousexperiences. It used to work socially
because the people around us shared our common-sensevalues. When they consulted their
consciences, they could be expected to agree with us. Thismanner of decision-making has
the great virtues of authenticity, clarity, and resolve; in addition,it primes us for action.In

6. the present, this strategy is more troublesome in the social arena because the peoplearound
us are likely to disagree with us. When they consult their consciences, they mayadvocate
courses of action that we see as bad, or conversely, they may see our desired actions asevil.
They might, for example, decide to abort a fetus that has been diagnosed with a
cripplinghereditary disease, whereas we might think their decision is wrong. We might
decide toexperiment on human subjects, while they might think we are being immoral. In
thecontroversies that arise in such situations, we need to listen respectfully to one another
andreason our way to a practical—
not necessarily a theoretical—
consensus. The kind of
thinkingrequired is critical thinking.When we are thinking critically, we even-handedly
evaluate arguments and theirconclusions on the basis of the truth of their premises and the
validity of their logic. Robert Card(2004) says that critical thinking “ [i]nvolves learning
how to monitor your own thought process.More particularly, it involves learning the
standards for evaluating your own thinking and thenattempting to internalize certain tools
to improve your thinking by constantly engaging inreflection and self-assessment. It is
important to note that thinking well is hard work!” (pp. 46-47)There are two basic forms of
argument: deductive and inductive. Deductive argumentsstart with premises, which are
accepted as true, and, using formal logic, derive conclusions,which then also have to be
accepted as true. (Ex: Major premise: All men die. Minor premise:John is a man. Conclusion:
John will die.) Deductive arguments can be opposed by questioningthe truth of the premises
or pointing out flaws of logic. If the major premise or the minor premiseis false, then the
conclusion will be false, but if both are true, then the conclusion must be true.Card (2004)
spells out the relationships between the following basic terms that are usedin analyzing
arguments:1. Description, inference, and normative statements2. Propositions, premises,
and conclusions3. Assumptions, facts, opinions, and ideas4. Meaning of “ and” and “ or” 5.
Validity and soundness. (47-53)Inductive arguments do not observe the criteria of validity
and soundness as do deductiveones. They make the more modest claim that the truth of
their premises makes it likely that theirconclusions are true. We tend to use inductive
arguments often to discern how we are to proceedin novel situations. They can be based on
statistics, probability, analogy, or cause and effect.For example, if you lent Robert money on
two different occasions, and he never paid the moneyback, you might conclude, based on
the evidence, that Robert doesn’ t pay loans back.Spotting the informal logical fallacies in
arguments is both fun and torture duringcontroversial times such as election campaigns.
How often do we hear one person assert a pointand his or her opponent avoid that point by
attacking (ad hominem) the asserter’ s personality?How often do we hear parties appeal to
common belief as being the truth when ample evidenceshows that the common belief is
unfounded? How often do people invoke the authority of somewell-known person who has
no expertise concerning the controversy under discussion? Howmany hasty generalizations
do we hear? How many ways are statistics spun? How many falsedilemmas are hurled
about? How many times do politicians beg a question by assuming exactlywhat they are
trying to prove? How many times do politicians drop in a red herring to divertattention
from an embarrassing situation? How many times do we argue against change on thebasis
that going just one step would put us on a slippery slope to disaster? How often do wetwist
the meaning of an opponent’ s words (equivocation) in order to gain advantage? And

7. howoften do we argue that the way things are is obviously the way they should be? While
we laughand gnash our teeth at the blatant use of fallacies in political discourse, we also
realize howeffective these fallacies can be—
if they are not pointed out.People get elected
partially because they convince us with faulty arguments. Similarmisuses of logic occur in
medical systems. What we learn in this course will enable us to pointout these abuses of
logic when they come up in our lives and workplaces. Ideally, the clarity ofour thinking
should lead to constructive changes and personal promotions to more responsiblepositions.
In reality, we have to learn patience and sharpen our political skills. We need toremember
that a big ship can be turned only a degree at a time.Using the ethical perspective discussed
in Chapter One of the text and the criticalthinking tools of Chapter Two, you should be able
to work your way to reasoned conclusions onmany medical controversies. In the following
assignments, you read examples of criticalthinking and construct arguments for your own
conclusions. With practice you will master thetough art of critical thinking and gain moral
independence for your own opinions. Couples hope to have healthy babies with an
opportunity for a good life. Unfortunately,approximately 10% of couples in the United
States are infertile. Other couples face thelikelihood of birthing children with grave physical
disabilities. Still other couples may want todesign a certain kind of offspring. Today and
tomorrow, these couples, with the aid of newmedical advances, can achieve their desires.
But, what are the ethical concerns in thedevelopment and use of these medical
technologies? Are the advances ethical? Which ones?What are the personal and societal
consequences of the different procedures? What are theirpossible abuses?The earlier forms
of assisted reproductive technologies (artificial insemination, in vitrofertilization, and
different forms of ovarian stimulation, implantation of ova and zygotes) havebeen debated
and have generally passed medical ethical approval. In this assignment, we explorethe
ethics of:1. Prenatal diagnosis for disease and sex.2. Whether information should be open to
parents and the public, especially insurancecompanies.3. Whether abortions should be
performed on the basis of the babies’ sex or health.4. What genetics can do and should do
to produce healthy and/or exceptional children.In its broadest terms, the controversies
over genetic intervention pit conservatives whovalue prenatal life and traditional and
natural processes against progressives who envision a newand more humane future with
less suffering. Historically, new methods of reproduction raisefear and condemnation that
gradually lessen as they prove to be reliable and produce healthybabies. There may well
come a day when cloning and eugenics are accepted practices, but wemust first evaluate the
ethics of these and other procedures.The general benefits of the new medical technologies
are that:1. They enable couples to have children.2. They enable disease-free children.3. They
promise revolutionary cures for many intractable diseases.The possible downsides of these
new technologies are that they may:1. Weaken people’ s reverence for life.2. Weaken
respect for religious authority.3. Encourage women to have abortions.4. Put society on the
slippery slope to horrors such as eugenics.If new medical advances in human reproduction
are permitted, they raise new questionsin medical ethics:1. For what situations are they
ethical?2. How can we avoid abuses and slippery slopes?3. How should applications of these
technologies be regulated and/or monitored?When a prenatal diagnosis is performed,
important, sensitive information such as geneticpredispositions to certain diseases is

8. generated. Some argue that this information should not begenerated or at least not be
revealed to either the child’ s parents or the public. They believe thatthis information will
tempt parents and doctors to play God, to try to design the perfect child, andto have
abortions. Others argue that the sex of the fetus should be withheld because of
possibleparental sexist preferences. Still others would say that this sensitive information
should not bemade public because it could influence the child’ s employment possibilities
and his or her abilityto obtain affordable insurance later in life.It should be granted that
detailed prenatal diagnosis may result in a higher percentage ofhealthy babies and
fulfillment for childbearing couples. It should also be granted that this kindof diagnosis will
lead to inevitable abuses in a free society interested in knowledge and profit. Itwill be
practically impossible to keep this kind of knowledge secret for ordinary people. Theethical
question is, How can we foster good uses of prenatal diagnosis and discourage its
abuses?Somatic cell therapy extracts a population of cells from an individual; removes
adefective gene from that population, replacing it with a healthy gene; and returns the
geneengineeredcells to the patient. This process should render treatable many genetic
diseases thatare caused by a defect in a single gene. This therapy would seem to be ethical
because it issupported by the fundamental moral principle of beneficence: it would relieve
human suffering.Should the same ethical approval be extended to germline gene therapy,
which replacesgenes in sperm, ova, and cells that give rise to sperm and ova? This kind of
therapy could ensurethat later generations would not inherit a particular disorder, yet some
people argue that thisprocess is unethical because we would be “ playing God.” It would,
they argue, be a prelude toeugenics, not only to removing disease, but also to genetic
engineering in the service of creatingsuper people. (Most people are aware of Hitler’ s
desire to create the Aryan race, but few areaware that Charles Darwin’ s cousin, Francis
Galton, introduced the scientific argument foreugenics or that mentally handicapped adults
were sterilized in the United States in an attempt tokeep them from having handicapped
children of their own.) Still others argue that the process istoo dangerous. In our present
state of knowledge, we could alter the course of embryonicdevelopment, for example, by
interfering with the work of nature’ s time-tested housekeepinggenes and produce severely
handicapped children.Advocates of germline gene therapy argue that we have always tried
eugenics in someform, as by seeking a desirable mate, and that we have always resisted
more aggressive eugenicefforts in the past. They also argue that our understanding of
genetic processes is somewhatintelligent, and our ability to treat unexpected consequences
is somewhat developed. Therefore,they say, any unforeseen results can be taken care of.
Moreover, these advocates argue thatmedicine itself has a prima facie duty to pursue and
employ germline gene therapy because itoffers us the chance to rid ourselves completely of
many serious genetic diseases for which thereis no effective treatment.Cloning humans was
once the stuff of science fiction. It is now a real probability. Thisprobability is proof for
many that science has gone too far in its God-playing. The idea ofcreating replicas of
ourselves raises in our imaginations nightmarish possibilities. How could aperson raise his
or her identical twin? Would people use their clones as part shops that theycould
dismember at will when their own body parts wear out? Would we sell clones of
giftedpeople to the highest bidders? How many cloned embryos will have to be discarded

9. because ofserious defects? How do we know that the clones would not have major defects?
Wouldn’ tcloning lessen the worth of individuals and diminish respect for life?Much of the
fear of cloning lies in a misperception that persons with the same DNA willbe identical. This
is not even true of natural identical twins. It would be less true of a clonebecause of the
different uterine environment, mitochondrial differences, a different growthenvironment,
and a different will to live. A clone of Michael Jordan might face pressure to begood at
basketball, but he would not be Michael Jordan; he would be himself.In certain
circumstances, a couple might decide upon cloning to have offspring that arebiologically
similar to them. Do they have a right to clone? Cloning might allow couples tohave offspring
that are free from hereditary diseases. Cloning might also allow a person toobtain needed
organs or tissue for transplantation. Cloning might allow the duplication ofindividuals with
great talent. It might also make possible important advances in scientificknowledge. These
are all, arguably, human goods, mostly minor, that could be provided bycloning.