§1. Task& Topic Choice

In a nutshell, you need to provide an argument defending a view about the ethical course of action in a medical ethics case. You then need to consider and respond to an objection to your thesis or argument for it.

• Should a nurse tell other health-care professionals about a patient’s suicide attempt which the patient told the nurse of in confidentiality?
  1. Case Overview:the patient Mr Green is a 57-year-old gentleman with aggressive prostate cancer who is took care of by the nursing team in the oncology department of a general hospital in Brisbane, QLD, Australia. Mr Green was diagnosed with prostate cancer seven years ago but refused medical and surgical treatment at the time. He chose to seek alternative treatment and did not follow up with the urologist over that sevenyear period. Mr Green has now presented with anemia and hypoproteinemia. After several diagnostic tests over a period it was discovered that the cancer had metastasized to his bones, it had spread locally to his lymph nodes and the primary tumor was invading the bladder and partially obstructing the left kidney. Mr Green had several admissions over a two-monthperiod for various reasons. On the last admission Mr Green was told that he may only have 4–6 weeks (previously it was 6–12 months) to live after a cystoscopy showed further extensive growth of the tumor, it was determined that any further surgical/medical intervention would not be appropriate in this case and that a palliative care regimen was the next step. At this point the patient reported to the health care team that he had resigned himself to the fact that he was going to die. Mr Green pulled one of the author’s colleagues aside and confided to the nurse that he planned to kill himself and that is was a secret that the nurse was not to tell anyone.

The major ethical question of this case can be identified as if the nursing staff should tell other health care team members about patient’s suicide attempt without patient’s consent.

§6. Central Tasks

Though there is a fairly large range of topics open to you, each paper—regardless of topic—should accomplish the following things:

• Setup and frame the debate: in order to understand what is going on in your paper it is critical that you first explain the topic. The first part of this is explaining the medical ethics case. Generally, this means paraphrasing the description I gave you. For example, if you were writing about the Dax case, it would be natural to explain Dax’s accident. Then explain his treatments and how they caused him immense suffering, to the point where he wished they were terminated, even knowing this would lead to his death. Once that is in place, your reader can understand the core ethical question in the Dax case: should Dax’s treatments have been stopped? With your own cases, it might often helpful to identify a core question that your argument’s conclusion answers (e.g. “should Joe’s request to have his arm be amputated be honored, even though his arm is healthy?”).

To properly frame the debate you’ll need to do things like define critical concepts, explain how the question differs from related topics it might be confused with. For example, suppose it seems clear that the case raises difficult questions about the principle of autonomy, itself. In such a case, you might lead with a general explanation of the concept of autonomy as self-rule or freedom from interference, then develop more detailed analyses of autonomy as your argument unfolds. For illustration of this point, actually think back to Dr. Terence Ackerman’s argument in his piece “Why Doctors Should Intervene.”

When explaining complex concepts, remember you cannot always rely on the linguistic meaning you think a word has in every day English. A lot of terms that matter for medical ethics are technical terms. Medical ethics is a complex discipline. Not only is it practiced by clinicians working in the heat of the moment, it is also an academic discipline that endeavors to address longstanding ethical issues in medical practice and develop general ethical guidelines. As an academic discipline, medical ethics is an interdisciplinary field that includes material from philosophy, law, medical practice and even religion. Be sensitive to the fact that academic disciplines use words in subtly different, sometimes completely different, ways from everyday English (and from other disciplines!). If you need to define a specifically philosophical term (e.g. “the principle of respect for autonomy”) you should use a source within the discipline of academic philosophy (e.g. your assigned readings).

If you want to do additional research on a specifically philosophical issue there are a lot of resources. The Internet Encyclopedia of Philosophy offers a fairly comprehensive overview of philosophy (https://www.iep.utm.edu/). The Stanford Encyclopedia of Philosophy is often more rigorous than the IEP in terms of its content. However, this also means its content is often less accessible to beginners than the IEP is. The SEP can be accessed at https://plato.stanford.edu/new.html. The IEP and SEP are written by professional philosophers and are acceptable sources for writing in academic philosophy. Non-professional resources (e.g. Wikipedia) are a little more hit and miss in terms of quality. Wikipedia in particular often has very threadbare overviews of topics in academic philosophy. That said, you are not barred from using Wikipedia articles. I am merely offering a word of warning about them, and a stronger word of warning for Wikipedia articles on philosophy.

For medical and scientific details, you should primarily consult academic sources. The Columbia University maintains an excellent library of links to resources for bioethicists here: https://guides.library.columbia.edu/bioethics/databases. This database includes summary links to academic sources on bioethics, but also on scientific and medical details that may be relevant to a case. Also, while Wikipedia is frowned upon as a proper academic source, its articles are often a good place to start: they often include links to academic sources, and you can use these. Though you should check the original scholarly source quickly to confirm the Wikipedia summary of it.

Assume that you’re writing for an intelligent peer—another college student—but one who is not familiar with the material. Your paper succeeds in framing the debate if such a reader could, on reading the paper, understand what you’re debating and your position on it.

• Analyze the case by appeal to the four principles of medical ethics: with the case explained, the next task is to provide your ethical analysis of it. This analysis should be grounded in the four commonly recognized principles of medical ethics: the principle of respect for autonomy, the principle of beneficence, the principle of non-maleficence, and the principle of justice. This analysis ultimately generates an argument with a conclusion about what the ethical course of action would be in the case you are analyzing. You do not need to formalize your argument (e.g. P1…C1.). However, your arguments should be logically valid or inductively strong, depending on the kind of inference you are making.

  Remember how the principles of medical ethics work, as explained in course lectures and readings like Dr. Raanan Gillon’s “Medical Ethics: Four Principles, plus attention to scope.” The principles do not algorithmically determine what ought to be done in each case, as if you were simply doing a basic problem in arithmetic. Rather, they guide you to look for certain kinds of considerations, e.g. patient well-being is relevant to both beneficence and non-maleficence. But to apply the principle of beneficence you will often need to defend more specific views about what constitutes the patient’s well-being in this or that case, e.g. is their well-being a function of the pleasure they could enjoy, or of fulfilling relationships or career goals? Religious experience? Something else? As an ethicist, your job is partially to look at the details about the patient, and reason your way to what is most important for their well-being. Similarly, the principle of autonomy is not as simple as “do whatever the patient wants.” Instead, you may need to consider whether the patient’s current desire is somehow born of ignorance of incompetence (see Dr. Ackerman’s article). Moreover, you may sometimes need to defend a view about whether autonomy simply generates restrictions against interference, or requires things beyond this. Finally, there are many dimensions to justice, and even within each dimension there might be multiple reasonable conceptions of what justice requires. For example, distributive justice is concerned with justly distributing material goods. But to assess a question of distributive justice you may need to defend a particular view, e.g. libertarianism about justice or egalitarianism about justice, prioritarianism, etc.

Finally, even when you have assessed the case relative to each principle, you will need to defend a view about what to do if it looks like there is a conflict. For example, suppose you concluded that in the famous Dax case there really was a genuine conflict between beneficence and respect for autonomy: respecting Dax’s wishes would kill him, thus probably robbing him of a good life, once he has recovered. In such a case, you would need to defend a view about the priority of either autonomy or beneficence, at least in this case.

• Defend your view from an objection: finally, you must consider and reply to at least one (but up to as many as you’d like) objections to your position or The distinction between your position and your argument is important. Some criticisms you might consider are critical of your thesis: they argue directly for the conclusion that a view opposing yours is correct/your thesis is false. Other criticisms are aimed just at your argument for your position. These kinds of criticisms are silent on the question of whether your position is correct. Rather, they are meant to show that, even if your position is correct, the argument you give for it is simply a bad argument. You may respond to objections of either or both kinds.

  Objections may come from the course (readings, lectures, your peers, etc.). Importantly, if you use someone else’s criticism you need to provide a citation for it. You may also play “Devil’s Advocate” against yourself and try to think of what someone who is critical of your position might say against it. Since such criticisms are your own ideas you do not need to provide a citation for them. Though if you draw on external sources in developing your criticisms you would need to cite those.

Having provided a criticism of your thesis and/or argument you then need to explain why the criticism doesn’t work; don’t just leave us with your argument and a criticism of it! The response to the criticism should itself take the form of another argument, thought-experiment, counter-example, clarification etc. For better or worse, martial metaphors are often helpful for thinking of the interplay of arguments. In this case your opponent is attacking you with a sword thrust (criticism) and you need to block their blade (respond to the criticism). Don’t just let yourself get stabbed!

To be absolutely clear: this requirement is technically two tasks:

1.) articulating a clear and relevant criticism your own position and;

2.) explaining why the objection you presented does not defeat your view.

Only doing the first of these would leave this section incomplete.

To use my running example, suppose I argued that there was a conflict between respect for autonomy and beneficence in the Dax case.[1]I then argued that respect for autonomy trumps beneficence on the general ground patient welfare may depend on patient desires such that we risk violating both principles if we do not treat patient preferences as having priority. A critic might object that there is no such conflict between respect for autonomy and beneficence, because Dax’s pain undermined his capacity for autonomous choice. Note this would be an objection to my argument, not to my ultimate conclusion about whether or not Dax’s treatments should have been stopped. To satisfy this task, I would have to explain this critics’ objection, and then explain why I think it is mistaken, e.g. why I think Dax’s pain did not undermine his capacity for morally relevant autonomous decision making.

[1] Remember, when I say I argued for this, I mean I had offered some kind of support for the claim that there was a conflict, say by first assessing beneficence and then respect for autonomy and noting the conflicting conclusions. For your purposes in this class, an argument is a logically related series of claims that jointly support a conclusion. In every day English, we sometimes say “I argue that X,” without actually providing any supporting ideas. That is just a different use of linguistic symbols, a verbal difference. If you say “I argue that X,” but then do not have any supporting ideas for X, you actually have not argued that X in the logician’s sense. Instead, you have asserted X is true.