[Emma Rehnelt]

Question #1:
I do believe that the idea behind a reflective equilibrium theory is better suited that just choosing one of the other theories presented in chapter 9. I like that this reflective equilibrium is the author’s way of acknowledging that none of the principles or theories laid out in the book can be applied alone and each must be taken into balance with the others with each unique ethical situation. This idea also addresses what to do when viewpoints are at odds with one another. I like the idea that if two people disagree they must work to modify their viewpoints to work towards an equilibrium and overall coherence. I think that this is one way to achieve a more “common morality” as it does not just label someone with a different perspective as wrong.
Question #2:
I thought it was a wonderful point by the author that you cannot praise one group’s different perspectives without acknowledging how/ why those viewpoints were formed. As an example, Dr. Sanders explains that it is not enough to comment on the greater empathy for socio-ethical concerns of the African-American community without also discussing the suffering endured by this community from European-American racism, from which that greater empathy was born. I think that this article is a great call to challenge our standard medical texts to make sure they don’t only include one perspective. Mistakes like this can be avoided by inviting a diverse group of medical professionals working together to add to current knowledge and embracing cultural, geographic and religious differences on their views of ethics and medicine. For example, I was just given access to a dermatology app built by a diverse group of dermatologists that did not only have white skin in its descriptions of various dermatology conditions! I realized that I have never seen what psoriasis looked like on melanated skin! I don’t know if we will ever truly have a “common morality” but I do think that one step closer to broadening the standard ethical guidelines in medicine is to have all viewpoints heard and discussed. I think that the best way to achieve this is to increase diversity and inclusion in medicine as a profession overall.

[Emma Rehnelt]

Nilda, I completely agree that virtue ethics is required in healthcare today and that there are certain situations where the other theories are also important, but that virtue seems to be the leading theory overall!

[Emma Rehnelt]

Question #1:
I agree with the authors that no one theory is inferior to the other and that there are certain circumstances where each theory may lend insight into our moral behaviors, but in all I can see how virtue ethics almost falls into its own category. It does seem to be the dominating principle in medical education and practice that one character trait necessary to be a doctor is virtue. This theory suggests that we should care for people ethically without needing to be told to do so and even without set rules for treating others. This is then compared to the other three theories of utilitarianism, which seems to be the theory that public health acts under, acting to do the greatest amount of good for the most people. We know that this does not work in the clinic, as it automatically ignores those who are not included in that “greatest number.” Next is the rights theory which seems to be more of a guiding moral compass for policy, law and government. In this theory we may see too many conflicting rights in healthcare as discussed in the textbook. For example, a patient may have the right to a procedure that a physician may have the right of refusal. Finally is the Kantianism theory which is grounded in reason, this theory is grounded in the rules. While we all know those strict rule followers in the clinic or hospital, we know that humans as patients are messy and don’t always fit into checkboxes or follow algorithms. We need this moral theory for maintaining order, especially from leadership, but Kantianism is not a moral behavior one can always follow when dealing with the complex and emotional act of healthcare.

Question #2:
On the basis of autonomy, Dr. Sulmasy says that some disabled and elderly people may not desire extreme treatments, and in this case to honor their autonomy and follow their care directives. At the same time, Dr. Sulmasy also implores pandemic workers to not base patient care on their age, social class or disability. He encourages healthcare providers to distribute ventilators if they are valuable treatments for the patient, not if you see a patient as worthy of a particular treatment. Focusing here more on justice, by not discriminating against a particular group. While this oped article is a great call to rally the downtrodden workers at the time, you finish the article with the memories from the start of the pandemic thinking, “Well, that’s great….but what do we DO?” To refrain from treating the sick and elderly using the quality-adjusted life years argument, or do we treat the sick elderly and young the same on a first come first serve basis? I agree with the final paragraph that we should take full advantage of ethics boards in these circumstances and that we were caught off guard with this pandemic, not knowing how to make such difficult ethical decisions.

[Emma Rehnelt]

Question #1:
After reading Ch.7 I do think that justice should play an important role in medical bioethics. I think that unethical behavior can sometimes be justified by religion or cultural practices that are unethical. For example female genital mutilation, preventing women from receiving education or medical care because of their lesser status in the community and the discrimination of same sex couples have all been justified in communities on the basis of religion or cultural beliefs.
I think that justice principles are less up for interpretation and are more difficult to manipulate for use to harm individuals, especially the global principles of capability and well-being. In contrast, we’ve discussed how other principles, like beneficence, can be warped into paternalism if interpreted incorrectly. Of course, religion and cultural differences in the world should be celebrated and supported, but maybe justice can be an ethical guide to prevent harm because it only protects the rights of an individual as a human without interfering with important cultural or religious differences.

Question #2:
I think, due to the nature of our backgrounds, we will always tend to favor the two theories that are most directly related to health, the capability and well-being theories. Whereas the capability theories focus on what you should have the right to do, live, have bodily integrity, show emotion, play, etc. The well-being theory reminds me of Maslow’s hierarchy and is more broad. It takes into account now only what you should be able to do, but how one must have the right to a body in order to use it. I think that this is the most straightforward and understandable theory, as it suggests that everyone has the right to health, security, knowledge and understanding, respect, relationships and attachments and ability to choose one’s own path. Because the goal of healthcare is to secure these privileges so that people can move on in the world, it then allows them to practice the other 5 theories of justice like capabilities, communitarianism, utilitarianism, etc.

Question #3:
The assigned article does a great job of pointing out important unjust global issues such as reproductive tourism, trafficking and the human organ trafficking market; however, because this article is written for an Evangelical Christian audience, I do think that it is important to read this article with that extreme bias in mind.
The principle here that I believe should be greater emphasized to protect vulnerable people being instrumentalized is the Capability theory. One common theme uniting all vulnerable people being taken advantage of in these situations is that they have no protection by the justice system or their cultural community for bodily integrity, affiliation or for their own health. This was presented as one of the global principles that, in these examples, is not being put into practice. We can protect these women by creating strict laws around the growing field of reproductive technology that look out for the patient but that are not based on cultural beliefs, as the right to make decisions about one’s body is a right that all people, regardless of their religion, should have. Especially in the United States or developed countries, seeking out these alternatives to expensive fertility support should be addressed as the high expenses necessary for an infertile or same sex couple to concieve is the issue driving people to use these unethical alternative by taking advantage of vulnerable women.

[Emma Rehnelt]

Question #1:
I agree with the authors here that no one principle of beneficence can determine/ justify all other principles. As the authors suggest, if this was the case, you may have a system that could be ruled entirely under the guise of “beneficence” but that really becomes a utilitarian system.
Of course doing the most good for the most people are the goals of public health initiatives and often a good thing, but what one person may see as a good act, may not be that same good for the recipient. A common example of this is the unsolicited relief gifts. For example, the tons of donations made to people in Haiti after a major earthquake. The relief donations piled so high that it prevented actual life saving supplies from getting to the people who needed them. Of course, sending food, bottled water and clothing is always a great thing for people who lost everything, but this good turned out to come at a cost to those people needing care. In this way, how we see “good” comes from our own life experiences and being careful to help in a way that actually matches those you are trying to help is only when you can reach true beneficence instead of utilitarianism.
Question #2:
Having processed this request, I would not be able to give this patient the mastectomy she desires. We know that this patient has the right to make this decision, and therefore we should discuss the opportunity for a safer procedure like a breast tissue reduction surgery or perhaps the right to get a second opinion from a different surgeon. As for nonmaleficence, cons of removing an otherwise healthy breast that is currently causing no harm and putting the patient at risk for arm morbidity, phantom breast syndrome, nerve damage, lymph flow damage, skin and nipple necrosis, infection and a large medical bill that may not be covered by health insurance are all reasons why it would be more harmful for her to lose the breast tissue than the pros of the possibility of a better golf game.
Here, the patient’s view of their own good (having less breast tissue in the way of their golf swing) is at odds with both their good as a human person (the potential side effects on their body), ultimate good and biomedical good (this would be a misuse of medical skill). Acting in beneficence, I do not think that this procedure would help the patient more than it hurt, I would like to suggest a training schedule that would better her golf game.
I agree with Alice here that I would ask her to wait while we look into any research that has been done to suggest that a mastectomy does help with a golf game, if so, I would refer her to the physician who had done these successful surgeries in the past with success if she continues to insist.

[Emma Rehnelt]

Question #1:
I agree with Alice that physicians should not be forced to follow through with requests for physician- assisted death, but these services should be allowed with a willing provider in terminal patients. I think that when this decision is made by a competent patient or guardian that assisted death is both ethical and consistent with autonomy and beneficence. My close friend was diagnosed with Huntington’s Disease when we were in college, this is something that we have discussed at length and put in her healthcare directive as her symptoms increase in severity. If a patient is fully aware of the implications of their choices, they should be able to make such decisions for their own health.
Question #2:
I see Jotterands argument that we have lost our sense of medicine as a profession due to patient socio-economic factors controlling our medical decision making. I think it is an interesting call to throw out outdated medical ethics texts like the Hippocratic Oath, as it is too vague and much of it no longer applies to how we practice medicine today. His argument to fill this gap then with a new set of guiding principles of a moral philosophy of medicine, more in line with the times is compelling. With the move toward a capitalistic medical system with the Medicare-Medicaid Act physicians no longer had just their patient to think about, but also the economic implications of their care and no longer could maintain independence in medicine. This I think is where Jotterand thinks that medical professionals lost their respect and individual identities to the broken system of healthcare. Then, we have two options with this great change, go back to the old ways of fee-for-service health care or come up with a new set of principles, as the author suggests, to keep up with the change of the times.
Question #3:
It seems like where B&C fall short is that they make broad generalizations about ethical decision making. To me, it seems like the anthropological approach is a way of making ethical, medical decisions in a more focused way within the cultural context of the group making such decisions. I think that it is important to have broad guiding ethical principles that focus solely on the patient as a fully autonomous person, but I do think that the anthropological approach offers a more focused approach in ethical decision making where a patient’s background and family may come more into play in decision making, especially taking into consideration the different cultures present in the U.S.
I think that the anthropological approach might just hold true in certain contexts. In the ICU in Maasai, it is clear that a patient’s family plays a huge role in end of life decision making. I think it is appropriate to bring in families and take into consideration their religious and personal viewpoints when making decisions for end of life care, for example. Also, in the town where I attended medical school in rural Missouri, we had a large Amish community nearby. Working at the free clinic, we would often make exceptions or give different recommendations in line with their cultural practices. One example of where I think autonomy still rules and it is okay to take a step back from the anthropological approach is in medical decisions about family planning. I think that a competent woman should be able to make decisions about her family planning practices regardless if these agree with her religion or family’s views and be educated on all options.

[Emma Rehnelt]

Question #1:
I remember talking with midwives in a labor and delivery private clinic in Entebbe, Uganda discussing this issue. One problem in low resource countries is that patients often present to a physician or healer with little to no autonomy due to their lack of available health care. For example, a woman experiencing a difficult labor with no easy access to health care has little to no autonomy with the care she does receive, either she accepts that help without judgment, whatever that may look like, or she risks the life or her and her child. In a country with readily available access to healthcare, I do think that patients have more autonomy.
I would absolutely agree that autonomy carries the most weight in the hospital today. Autonomy can either come from a great place, wanting to respect the wishes and decision making of the patient or it can come from fear of legal action by the patient if we do not respect their wishes. For example, yesterday my best friend told me about a patient of hers, a young girl who has spent her whole life in and out of the hospital for neurological complications. When the time came for their daughter to get stitches out, a simple outpatient procedure, both the girl and parents threatened that she needed full sedation or they would sue/leave the neurology clinic because they did not want her to suffer more than necessary. This simple procedure was then done in a fully staffed operating room, with the young girl under potentially risky anesthesia due to her demands of autonomy. This is an extreme case, but highlights how empowered our patients feel to demand what they feel is best in the clinic, making the increased need for education and even at times arguing by doctors extremely frustrating. Other issues such as unwillingness to vaccinate or be weighed at the doctor’s office are other frustrating examples where we might see these services as protecting and helping our patients, but respecting patients decision making, if fully aware of the costs and benefits, we ethically should do nothing.
I agree that beneficence is likely to turn paternalistic or cross ethical lines, as with the example in the textbook of the medical students performing practice pelvic exams on anesthetized patients. Such behaviors have caused a mistrust in medicine over time which we need to fix. Ultimately, I think that patient autonomy should be the foundation of care. The issue then becomes education to patients so that if they do refuse a treatment or demand excessive extra measures of care, they know why we don’t agree with those decisions and are then able to build trust to find a compromise that ultimately improves their health.

Question #2:
I agree with Pellegrino that paternalism was defended under the guise of beneficence. I also agree that these two are not the same; paternalism overrides the autonomy of the patient in the name of the patient’s best interests. In reality, beneficence is taking into account their preferences and making shared decisions. I think that in an ideal world, autonomy and beneficence should go hand in hand in medical practice. Unfortunately, the long held mistrust from physicians acting of their own accord in the name of “beneficence” has created so much mistrust by our patients in the U.S. healthcare system that we no longer have the privilege of acting on anything but patient autonomy. Especially taking into consideration the mistreatment of people of color in medicine, this is an understandable imbalance and not something we can change overnight. As a physician, I of course will act beneficently, but I think that patient autonomy is still the thing I must respect first and foremost. I do not think that reprioritization of beneficence is possible or defendable as it is viewed today in the U.S.

[Emma Rehnelt]

Alice, your point in Q3 is interesting, combining legal rights with ethical rights. With the decline in religious following, especially by younger people today, I wonder if we will start to look more to laws as guiding moral values instead of our religion. This may also explain some of the ferocity with which many people ascribe to the ideas of their own political parties today. I agree that instead of making laws against abortions, which should ultimately be a decision between a patient and provider like all other healthcare discussions, we should try to prevent the underlying cause for abortions like violence against women and domestic violence through sexual education and public health initiatives.

[Emma Rehnelt]

Question #1: The question of “who counts?” is no small one in bioethics? In chapter 5, Beauchamp and Childress (B&C) present five theories of moral status, with a critique of each. Critique each theory on your own. In your thinking, which theory/theories has/have the greatest coherence? How might some of these theories apply to the ethical decision-making of the difficult situation described in the NEJM article?
The five theories of moral status include everything from granting it to anyone with human DNA, those with the presence of cognition, the ability to act morally, the ability to feel emotion/ pain, or one’s relationships with others as grounds for the right to moral status. For the first theory, one flaw with giving moral status to all humans is that this theory excludes animals as being protected with moral norms. As stated in the text, it also takes issue with human cell lines with human DNA, important for much of our scientific research. One issue with the next theory, giving moral status to those who are conscious, able to act and communicate is that it discredits those important vulnerable populations that deserve to be treated morally but are unable to meet these cognitive criteria like infants and individuals with decreased cognitive abilities. One downside to the theory that all people able to act with moral agency should be held with moral status means that we have to make special considerations for people with mental illness and young children unable to do so. This lack of clarity on this issue can cause the immoral treatment of these individuals by excluding them. One issue with the next theory of moral status is only granting it to individuals who are sentient or who can experience emotions and their effects, is that individuals, like people in a temporary or permanent vegetative state are not given moral status. Finally, one issue with the relationship theory is that if people/ things should be given moral status based on society’s relationship with them, is that if we only consider this theory then we may cause unnecessary harm to those we have no established relationship with or those who we choose to ignore. I agree with B&C that all of these theories need to be considered when granting moral status, as discussed, each of these have important drawbacks where another may offer support to these fallbacks. If I had to choose one of these theories as the most coherent, I would say the sentient theory. I think that minimizing suffering is something that no one can argue with. Some of the other theories are easier to argue; what is human? Can we not harm anything with human DNA? When does life start? How do we measure cognition and how much is enough? To me, the sentient theory is easiest to grasp and easy for all to comprehend its importance.
As for the NEJM article, the line “ethical dilemmas, by definition, have no right answer,” shines through. As these doctors made decisions about their human patients, the first theory is applied to the situation. The presence of cognition may be applied to the situation in the sickest of patients not responding to ventilatory support and unable to respond. When choosing who to provide ventilatory support; either someone who can interact with the providers or not, this may help the team decide who gets the ventilator. In contrast, the sentient theory may work against the cognition theory. For someone who is suffering the most and is the most symptomatic, the team may choose to put this person on a ventilator based on their greater pain and suffering. As for the last theory, I thought it was interesting how the care team looked to outside support for ethical guidance. I can only imagine how the relationships between caregivers and patients would affect decision making at this time. This highlights the necessity for outside guidelines and guidance to make decisions that are not biased or based on patient/provider relationships which may be unethical.

‘Question #2: Do you agree or disagree with B&C’s inclination against using the language of “person”, “personhood” and “respect for persons” in bioethical discussion (p 70-71)? Is it a term we should discard and with what could it be replaced?
I agree with the statement that we should take a step back from using “person” in ethical discussions. Perhaps we could start using a word like “entity” whose definition is a thing with an independent existence. Considering the main ethical debates today like abortion, climate change, energy resourcing, pandemics and war, not all of these are human, yet all affect us and deserve their own consideration in an ethical discussion which may be overlooked if we only take into account how these issues affect human beings. Mainly, I think about climate change. We all can agree that although not human, the earth deserves ethical consideration for its conservation. This of course affects us and animals in turn, but is one example of why this terminology can be changed for a more inclusive ethical discussion.

Question #3: What do you think of B&Cs assertion of the “paramount importance” of moral status (p.88) in light of the critique of bioethicist Tristam Engelhardt that in our contemporary world of pluralistic moralities, morality itself is deflated (week 1’s reading)?
After our weekly discussion, I agree with Engelhardt that we do live in a morally pluralistic world. That being said, how then can we assign one moral status? This would explain the moral differences between groups of people, as they ascribe moral status to one another with a different set of theories or rules. We also discussed that with the decline in religion we also lack moral guidance, this could also mean not a change in the theories we use to guide who we grant moral status to, we instead just have less theories on who we grant moral status to.

Question #4: In B&Cs chapter on the Professional-Patient Relationship, they note that, in the case of epidemics, care for the sick has often been considered praiseworthy and virtuous, but not obligatory? (p 353).Do you consider this to be so? In light of the NEJM article, is the embrace of some degree of risk in caring for the sick inherent to the practice of being in a healing profession?
This question makes me think back to my time working in the emergency department. I think that for people working in health care, caring for the sick is obligatory. Maybe not for everyone outside of the care team, especially in the context of a pandemic, but for those who have always been/ wanted to work in healthcare, from what I have seen it is reflexive and necessary. In times of crisis in the emergency department, if I was put in harm’s way or other members of my team, it was just a part of our job and I never felt the need to leave or quit, we stayed and did what we needed to do. I think care in a pandemic is much the same. Having a job in health care is accepting that every day you are putting yourself at some sort of risk to care for your patients and some days (or years) that risk is higher than others, but for me and the colleagues I have worked with it is just a part of working in healthcare. Risk and difficult decisions are an obligatory part of the job and something that you just face, head on.

[Emma Rehnelt]

Question #1: Do you agree with Beauchamp and Childress that there is a common, universal morality upon which contemporary bioethics can be built? Why or why not?
To agree with Nilda, I do believe that there is a common, universal morality upon which we build contemporary bioethics. From the innate human desire to have community and interpersonal interactions, we must ascribe to a certain set of principles, ideals and virtues. For this reason, we see many of these same rules of a common morality repeated time and time again in all different groups throughout history, from different religions to governing bodies. That being said, as Alice put it, there are always going to be those terrible outliers who stray from what we think of this universal set of values. I wonder if it is nature or nurture that knocks this universal morality out of balance for these individuals? If they have convinced themselves that they are still acting on one set of values while ignoring the rest? I would be interested to learn more.
Question #2: What do you think of Englehardt’s critique of Beauchamp and Childress’s position and of his argument that morality itself is deflated in a morally pluralistic world and that morality and bioethics degenerate into biopolitics?
It is interesting how Englehardt compares clinical ethicists to lawyers. We see countless examples in the news today where the “common morality” and the policy or the dominant ethics of a particular state are not the same. Because of this, I do agree with Englehardt that morality itself has been deflated and has become disarranged into biopolitics. I love Nilda’s example of this, not just in the written law but in the laws of a religion or community group, how that can rule the moral actions of a group of people.
Question #3: Is the de-emphasis on virtues in our contemporary culture, which Beauchamp and Childress lament, a result of what Engelhardt calls the groundlessness of contemporary morality?
I agree with Alice that there has been a shift in our contemporary culture due to the de-emphasis on Christianity, especially in the U.S. I think that this is a positive change as it allows us to make new laws and celebrate other religions and cultures. Because secular morality is no longer a cause for action or policy, I think that this is where we turn to the previously mentioned universal morality as a common ethical ground to stand on. I don’t think that a de-emphasis on one religion means that we become virtuous, rather it gives different people from all religions a voice and a right to agree upon a change in a common conversation.

[Emma Rehnelt]

Question #1: Develop a routine on how to change the behavior(s) you identified from week 2. Describe the routine and how the other forces of the SCIENCE model can reinforce it.
My routine for setting healthy boundaries is to keep everything on my google calendar, including things like errands or life admin. By doing this I am able to check my calendar when I am asked to do something and I can schedule them in order to never overbook myself. This takes away some of the trouble I have saying “no” when I am asked to do something because I have a concrete reason!
Question #2: Reflecting on your identified behavior(s) change you listed in week 2, use the SCIENCE Model to describe why some changes worked and others did not.
I have used “neurohacks” to try to identify with someone who does not flake out or miss obligations. I have also made this important as I move into clinical rotations and my schedule starts to get busier. One thing I still struggle with is feeling guilty for saying “no” to others, but that is something I am working on!

[Emma Rehnelt]

Question #1: What motivates you to change the identified behavior from week 2? Use both the Quick Fix and Trick Fix to discuss motivations.
My behavior of desired change is to set healthy boundaries with my time. My quick fix for this is my immediate reward, or having the time I need for a given event or task. I often overbook myself and have a hard time saying “no”. A trick fix is to taper off your reward once you are on the set path for a desired change. It is best to taper off your reward over time. I don’t know that this applies as well to my situation, but I do think it is a good practice that I will try in other areas!

[Emma Rehnelt]

Question #1: Discuss the role of friendship, community, and service in living a healthy lifestyle.
If I am being honest, before this year I do not think that I would have considered spending more time with friends and family an important part of my health. This task always seems to be the first thing to go when life gets busy, and for the most part, life was always busy! This year I have started making time with friends a priority again and I can see how it has benefited my health. Spending time with friends helps with emotional health like helping one cope with trauma, boosting self-confidence and increasing self-worth. I have started having bi-weekly dinners or volleyball nights with my co-workers and friends in Missouri as we prepare to move on to the new chapter of medical school, clinical rotations. Having this extra time together makes me feel loved and happier than ever. Plus it has been nice to get outside and be active together as the weather improves.

[Emma Rehnelt]

Dr. Kovac,
I know that this discussion post made me smile, so I am sure that this plan of action will be successful.

[Emma Rehnelt]

Question #1: Choose one of the neurohacks from chapter 6 and apply it to the behavior you want to change. Discuss the neurohacks you chose and integrate them with a previous chapter, like easy to demonstrate how to incorporate each aspect of the SCIENCE model.
“You’d be so proud of me Em, today I put spinach on my turkey sandwich,” my co-worker bragged to me today. I paused at this… all of the sudden the people in my life were starting to report to me when they ate vegetables. How did I become one of those obnoxious people who’s whole identity is tied up in eating salads and tofu?! One of my goals for a long time now has been to improve my diet. I have always struggled with IBS and was constantly physically uncomfortable in college and medical school. This year, I think that I accepted the “identity” neurohack of convincing myself to be a healthy person. I thought that if I could get excited about finally starting to eat better, I might start to feel better! I see now that this trick worked and I hope I can keep it. Instead of worrying that I am bothering my friends and family with my diet choices, I know that I just get excited to tell them about a new delicious recipe that turned out well. In return, while my friends still tease me for eating “all that grass”, we both are enjoying improving our healthy food consumption.

[Author]

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