Principles of Bioethics

1. Principles of Bioethics

2. Subjective and Objective Questions • You will be considering subjective and objective questions. • Draw the continuum in their notes

3. Subjective Questions • purely subjective • “What is your favorite ice cream flavor?” • “Do you like to wear sneakers?” • List examples • Write these at the “Purely Subjective” end of the continuum. • Subjective questions usually relate directly to the speaker, often have an emotional component, and are modified by cultural bias.

4. Objective Questions • Purely objective • “What is the capitol of California?” • “How many legs does an arachnid have?” • Write these at the “Purely Objective” end of the continuum. • Objective questions require facts and evidence to answer and are often yes/no or right/wrong answers.

5. Science & Ethics • Individually locate the point on the continuum where you think Science falls and draw it in your notebook. • Individually, ask students to locate the point where they think Ethics falls on the line in their notebook and draw it in your notebook. • Get two sticky notes of different colors. Purple is Science and yellow is Ethics. • Approach the class continuum and attach your sticky notes at the point you think is most accurate.

6. Science • Why Science is not purely “objective”? • While the “facts” of science tend to be objective, the “process of science” is done by humans, and happens in a social context. • For example, values enter into questions about what science to fund, how to conduct science responsibly, and how to apply new scientific discoveries and technologies and use them appropriately

7. Ethics • Why Ethics is not purely “subjective”? • Ethical questions require critical thinking and tools of reasoned judgment. This type of question requires a thoughtful balance on the subjective-objective scale. • Contrary to what many people think, ethics is not purely subjective (“my opinion vs. your opinion”) but has many elements from the objective end of the spectrum. Answering questions involving reasoned judgment requires evidence and logic as well as bioethical analysis. • Answering questions of reasoned judgment, bioethicists rely on a number of ethical perspectives and theories to structure their thinking. • Revisit the continuum in your notebooks and reflect on your original choices.

8. Introduction to the Principles of Bioethics through Skits • Divide the class into six groups. • Give each group of students one of the scenarios a – f • Each group will come to the front of the class to improvise 30-second role-plays of interactions between a parent and child. • Take about 2 minutes to prepare to simulate the following interactions between a parent and child.

9. Skits • Groups ‘a’ and ‘b’ present their skits. • “What code or standard is being honored (or not)?” • “respect” or “right to choose for him/herself.” • One of the bioethical principles is called Respect for Persons. • This principle values the inherent worth and dignity of each individual, and acknowledges a person’s right to make his or her own choices. It means not treating people as a means to an end.

10. Skits • Groups ‘c’ and ‘d’ present their skits. • “What code or standard is being honored (or not)?” • “helping” or “being good.” • Another of the bioethical principles relates to Maximizing Benefits and Minimizing Harms. • Asks how we can do the most good and the least amount of harm. It considers how one would directly help others and act in their best interests, while “doing no harm.”

11. Skits • Groups ‘e’ and ‘f’ present their skits. • “What code or standard is being honored (or not)?” • “fairness” or “equality.” • The third bioethical principle is called Justice. • considers how we can treat people fairly and equitably. It involves the sharing of resources, risks, and costs according to what is “due” to each person. • Distribute Student Handout 2.1

12. Respect for Persons • This principle values the inherent dignity and worth of each person, as well as respecting individuals and their autonomy. It means not treating people as a means to an end. • Autonomy emphasizes the right to self-determination and acknowledges a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs. It emphasizes the responsibility individuals have for their own lives. The rules for informed consent in medicine are derived from the principle of respect for individuals and their autonomy. In medicine, there is also a special emphasis on privacy, confidentiality, truthfulness, and protecting individuals from vulnerable populations

13. Maximizing Benefits/Minimizing Harms • This principle stresses “doing good” and “doing no harm.” To Maximize Benefits one would directly help others and act in their best interests. It requires positive action. Minimizing Harms obligates others to avoid inflicting harm intentionally. It relates to one of the most traditional medical guidelines, the Hippocratic Oath, which requires that physicians “do no harm”—even if they cannot help their patients. “Doing good” is also referred to as Beneficence, and “do no harm” is also referred to as Nonmaleficence.

14. Justice • This principle relates to “Giving to each that which is his due” (Aristotle) or Fairness. It dictates that persons who are equals should qualify for equal treatment, and that resources, risks, and costs should be distributed equitably.

15. Other Considerations • Some ethicists also add Care, which focuses on the maintenance of healthy, caring relationships between individuals and within a community. The principle of care adds context to the traditional principles and can be used alongside them. • Additional considerations include Duties & Responsibilities or taking actions that reflect personal Virtues.

16. Application of the Principles of Bioethics • Think about how you made their decisions about whom to give the vaccine during pandemic flu scenario in Lesson One. • These principles are built upon familiar values respected by many different cultures. They are the result of a long history of humans grappling with how to treat each other in a humane and ethical manner. They provide support for reasoned judgments and help the field of bioethics incorporate more objectivity and rely less on subjectivity.

17. Application of the Principles of Bioethics • Divide the class into six groups • Assign each group a principle: Respect for Persons, Maximize Benefits/ Minimize Harms, and Justice. Larger classes can be • Revisit the pandemic flu scenario from Lesson One. Based on the bioethical principle the group has just been assigned, which one or two people you would save. • 3-5 minutes to discuss your ideas

18. Application of the Principles of Bioethics • One person from each group to share • how their principle can be used to make decisions about who should receive the medication. • For example: • Respect for Persons: By respecting the mother’s choice to forgo medication, we are respecting her autonomy and right to self-determination. • Maximizing Benefits/Minimizing Harms: If we want the highest number of people to benefit, we might choose to save the doctor in hopes that she could, in turn, help to save more lives. • Justice: Drawing straws (distributing the medicine without regard to social status, age, or profession) would be a “fair” way to make the decision.

19. Application of the Principles of Bioethics • Approach 1: Save the Youngest. In choosing this, students are maximizing the life span for the most number of people. This relates to the principle Maximize Benefits and Minimize Harms. • Approach 2: Draw Straws (or any randomization technique). This option values fairness. It relates to the principle Justice. • Approach 3: Save the Weakest. This option considers the special needs of vulnerable populations. It relates to the principle Respect for Persons. • Approach 4: Save the Most Useful. Saving someone who may be able to save others benefits a larger number of people. This relates to the principle Maximizing Benefits and Minimizing Harms. • Approach 5: Respect Relationships. Honoring the dignity of human beings includes acknowledging their relationships. This relates the principle Respect for Persons. This approach also relates to Care, an additional principle which can be used alongside the other principles mentioned.

20. Study Aids or Cognitive Enhancers?

21. How the Brain Works • The human brain is a miraculous organ. Without even realizing it, your brain is allowing you to regulate your breathing, control your heart rate, hear and talk in the classroom, control your movements, and think all at the same time! The nervous system is made up of billions of individual nerve cells that form a system of connections from your head all the way to your toes. These nerves are unique compared to other cells in your body since they can send electrochemical signals. For example, if you step on a pin with your toe, a nerve cell in your toe will feel pain and send a signal up to your spinal cord to move your leg off of the pin and maintain your balance so you do not fall. At the same time, a signal will travel up your spinal cord to your brain so that you know what is happening and can say "Ouch!" Please view this slide show for further information about the components of the nervous system.

22. How the Brain Works • These signals travel both electrically within the nerve cell and then through chemicals called neurotransmitters between the nerve cells. It is this pattern of neurotransmitters that a nerve cell releases that medicines affect. Medicines such as Ritalin and Adderall are normally prescribed to patients with Attention Hyperactivity Deficit Disorder (ADHD), a condition in which they find it difficult to concentrate, in order to boost their attention span. Studies have found that these medicines affect the pattern of neurotransmitters in the prefrontal cortex (PFC). The PFC is an area of the brain that controls attention, decision-making, and impulse control.

23. A Closer Look - Ritalin and Adderall • Each day, millions of people in America drink coffee, tea, or soda for the caffeine jolt to stay energized and focused. Thousands of these people are now turning to Ritalin or Adderall since it has stronger effects on the PFC and can therefore improve concentration and minimize fatigue much more so than caffeine. These drugs are being obtained by people without the diagnosis of ADHD and sold on the black market. In fact, some college campuses report that 3% of their students have abused these prescription stimulants. • So if the medicine increases your ability to study or do well at your job, then what is the problem? Well, first, its illegal to take the medicine without having a prescription from your doctor. Secondly, Ritalin and Adderall are not without their own health risks. Side effects include difficulty sleeping, seizures, high blood pressure, loss of appetite, depression, and many others.

24. What Are Some Of The Ethical Issues Raised? • There is a wide variety of ethical issues that have been raised by the widespread non-prescription use of Ritalin and Adderall. Some of these are: • Cognitive Enhancement • Off-Label Prescribing • Unfair Advantage

25. Cognitive Enhancement • Enhancement was defined by the President's Council on Bioethics as the "use of biotechnical power to alter, by direct intervention, not disease processes but the ‘normal' workings of the human body and psyche, to augment or improve their native capacities and performances." So if medicine is used to treat disease, it is therapy; if not, it is enhancement. An example is erythropoeitin. This medicine increases red blood cells and is used by doctors in patients with kidney disease. However, many athletes have been accused of using it ("blood doping") to increase performance. The first, is therapy. The second, enhancement. • So is the non-prescription use of Ritalin and Adderall cognitive enhancement? • On one hand, it is not being used for its intended purposes of treating ADHD, but instead to increase concentration. • But on the other hand, millions of people use caffeine for the same purpose. So just how far are we willing to go in calling things enhancement?

26. Off-Label Prescribing • Another problematic area is just how these medicines are being obtained. The legal use of Ritalin and Adderall requires a prescription from your physician for the treatment of ADHD or other health conditions. Off-label usage means that a physician prescribes you a medicine for something other than the use for which it was approved by the FDA - in this case, to increase concentration even if you don't have ADHD. • If you were a physician, Would you give out a prescription for Ritalin to a high school that has a big paper due in a week? • Is it wrong for people to sell their pills on the black market? • Do the pharmaceutical companies that make Ritalin and Adderall have a responsibility to strengthen safeguards so that their medicine is not used for off-label uses or sold to others?

27. Unfair Advantage • Since Ritalin and Adderall help increase concentration and decrease fatigue, students are able to study longer and more effectively. • Is this cheating compared to those students that study without this kind of pharmaceutical aid? • Since the drug is being sold, perhaps poorer students are unable to afford the pills - is this fair to these students? • But then again, is it cheating to drink a cup of coffee or is this somehow different?

28. Review Questions • Explain some of the key components of the human nervous system • Discuss how messages move through the nervous system and how Ritalin and Adderall affect this process • Identify three ethical issues raised by the non-prescription use of Ritalin and Adderall and discuss your stance on each of these issues • What is enhancement? Is enhancement always bad? Discuss other technologies that could be considered enhancements. • Discuss some other unfair advantages that exist in the classroom.