[Shajin]

Question #2: In Dr. Sulmasy’s NY Daily News editorial refers to several of the ethical theories presented in B&Cs textbook. Sulmasy insists on some while rejecting others. Analyze his admonitions to the people and health-care workers of NYC during the epidemic found in his editorial:

I found this article very interesting and I can sense that this article must have been a great encouragement during those tough covid times.

I still remember the time when we were managing patients during covid times. It was a very difficult time which made us face a lot of ethical dilemmas. It was quite tough to decide on whom to manage, whom to refer; when we have the last high flow machine remaining, which patient out of the three needing high flow will be given the high flow machine support and many more similar queries.

Some admonitions from his editorial:

1. Be prepared ethically for the next pandemic: While the natural tendency is to be prepared medically, socially and economically, we need to add the ethical component too, in preparing us for the next pandemic.

2. Although we are medical professionals, we do have ethical duties and we should not wash our hands of these ethical duties.

3. Exercise calm but firm leadership. Appeal to the public about the concern for common good.

4. There is an ethical imperative to learn from the covid experience.

[Shajin]

Question #1: How would you evaluate the place of the three quandary-focused theories – utilitarianism, Kantianism and rights theory juxtaposed to the place of virtue ethics in our present medical education system and health system?

The present medical and health system in India has undergone significant changes and these are some of the challenges: Inability to access high quality and affordable healthcare in the remote parts of the country, more so for people from low socio economic strata. Yet another recent development is the mushrooming of medical colleges across the country without adequate teaching faculty to support and train these medical students in the aspects of biomedical ethics, so as to produce doctors – who will also think in ethical angles when they graduate as doctors. Somehow there has been a shift towards the quantity of doctors while neglecting the quality of the medical students undergoing their training.

Applying the principle of utilitarianism, the government needs to strengthen the public health infrastructure and advocate policies so as to cover the healthcare needs of people living in remote and rural areas. Tweak the medical council guidelines thereby orienting the medical students in the principles of biomedical ethics.

Regarding the theory of Kantianism – I think application of the principles of this theory is on the rise in our country. Although the important aspect of this principles under this theory like patient autonomy and informed consenting, giving priority to patient dignity were less followed traditionally in our healthcare setups, streamlining of healthcare system through various guidelines by the government through boards like National Accreditation Board for Hospitals has made sure that the healthcare facilities give importance to these principles and follow the same in their day to day clinical practice.

Rights theory in context to the medical and health system: Right to health (Right to receive good quality and affordable healthcare for all) is a distant reality in our setup. Like the example that I shared in one of our sessions, only one of the states in our country has ever thought of bringing the Right to health act, however they also could not succeed in implementing it in full spirit.

Applying the virtue theory principles has to percolate further and make deep inroads into our healthcare system. As of now, I could say only a scant proportion of the healthcare team follows these principles. Neither it’s very widely practiced in the hospitals, nor it’s not adequately taught in medical schools giving the due importance to it.

[Shajin]

Thanks Kainey for bringing the point on the importance of prioritizing the greatest good for greatest number especially when dealing with limited resources, from the article. I agree with you on this and I think this needs to be practiced in the medical and healthcare system in general in LMIC’s and not necessarily in Pandemic settings alone.

[Shajin]

Hi Rubel, I agree with your response to the 3rd question, about the need for global collaboration, governance, education, awareness campaigns and also about the importance of guidelines from International conventions related to reproductive healthcare and organ transplantation, thereby to promote transparency, accountability, and human rights compliance.

[Shajin]

Question #1: Our society has recently seen much angst over past and persisting injustices, manifesting as inequities and disparities in multiple arenas, including health care. Do you see this as evidence that justice is increasingly seen as the pivot on which all other principles turn? Do you think that in bioethics justice deserves this place, in the sense that it is rights-oriented, practical and prudential? Why or why not?

While Justice is an important component of Bioethics, and has significant bearing on the other components, I don’t think that all other principles boil down to justice eventually at all times. There is no doubt that Justice deserves an important place, however not all problems related to bioethics affect Justice.

For example, the Indian government brought an order to prescribe generic drugs across the healthcare facilities in the country, especially in Government healthcare facilities. While this move was to make sure the poor get access to the medicines, as generic medicines are cheaper, there was a lot of resistance from the various groups (more from healthcare professionals and pharmaceutical companies) arguing that generic drugs may be less effective or of inferior quality compared to the branded drugs. The primary concern is about the well-being of the patients by getting continuous access to the medicines in view of the subsidized price. The predominant principles involved in this issue is Beneficence (doing good by providing affordable medicines to the people) Vs Non-maleficence (doing no harm by ensuring the quality & efficacy of drugs) and not necessarily justice.

Question #2: Which among the theories identified by B&C do you think is most operative in our present health care system in the US? With which one do you resonate most and why?

I think I would want a healthcare system which gives importance to all the theories mentioned here. (Theory of Utilitarian, Libertarian, Communitarian and Egalitarian).

Many states in India have adopted a free mid-day meal program in many of their government schools. This program has several advantages: Tries to provide a nutritious meal & balanced diet at least once a day, among the poor children living in rural / urban areas. This goes a long way in reducing malnutrition. Another advantage is, this program encourages parents to send them to school thereby reducing child labor. This is an example of Utilitarian justice in action.

Right to education act was implemented in our country, which states that every child between the age of 6 and 14 years should be given free and compulsory education. Education empowers both men and women, reduces child marriages, and above all gives the people a sense of priority towards health. This is an example for Egalitarian justice, however I should accept that it’s yet to get implemented in full spirit across the country.

India is a vast nation and it has gross inequalities in many aspects more so in the healthcare space. Although India has a significant number of private healthcare facilities, a large proportion of people still go to the government hospitals for their healthcare needs. The government started bringing health and wellness centres to enable people from low socioeconomic strata to get access to high quality preventive and therapeutic healthcare services. I see this as an example of Communitarian justice in action, but these centres are yet to take off to an expected level.
So, I would want a system, giving importance to all the four theories.

Question #3: Principles of Biomedical Ethics, Chapter 7, writes of seeing theories of justice globally or seeing them as “statist” or only locally-applying (p 276 in 7th edition and p 297 in 8th edition). The disparities in the application of theories of justice at a global level are pointed out in the assigned article, which presents the realities of global reproductive tourism, reproductive trafficking, and human organ trafficking. What are some ways in which, in our increasingly globalized world, issues of more equitable application of justice can be ensured in the arenas discussed in the article? What principles need to be greater emphasized at a global level for this to happen?

Ways for equitable distribution of justice:
I am remembered of this particular incident:
A doctor was arrested last week in the national capital from a reputed hospital, for getting involved in a kidney racket. People from Bangladesh were asked to come to India to donate a kidney in exchange for money.

This is just one example, but there may be several similar incidents happening across the globe. There are various reasons for this problem:
Poverty existing among victims, Greediness of the doctors / healthcare team, Loopholes in the legal system under which the culprits in these offences are tried, dire need for an organ for a patient (awareness of organ donation is low hence the availability is low in the pool),

Some ways to address this:
Poverty eradication, Intergovernmental coordination, Support from NGO’s working in this field – especially in the area of human trafficking, Forming ethical and sound guidelines on surrogacy and finding out ways to implement it effectively, Increasing the awareness of organ donation within the nations and to follow the rules of organ transplantation act.

Principles that need to be emphasized: Beneficence, Non-maleficence and justice are most important principles that need to be stressed upon to address these issues globally.

[Shajin]

Question #1: Principles of Biomedical Ethics, Chapter 6, states that “principles of beneficence are not sufficiently broad or foundational, in our account, that they determine or justify all other principles” (p.203 in 7th edition and 218 in 8th edition). Do you agree or disagree? How might one’s view of “the good” lead to differing conclusions about the prioritization of the principles?

I do agree on this. I am reminded of the HPV vaccine trial that happened in India, about two decades ago by PATH. Although it was done with a good intention – of providing Beneficence, there were violations of other basic principles of bioethics which led to an ugly turn of events. So, its important that we view the “good” in all the four main angles of bioethics.

[Shajin]

I like the way you have approached this situation honestly giving her multiple options. I agree that it can be difficult dealing similar situations in real life, in our day to day practice. Looking at the problem in a holistic and larger / long-term perspective, and talking to the patient openly about the pros and cons of various available treatment options would help us deal with these situations.

[Shajin]

Question #2: A middle-aged, wealthy, highly-educated female patient comes to you asking for a unilateral left mastectomy in order to improve her golf swing. The breast size is not excessive and there are otherwise no indications for this procedure. Using principles studies thus far (autonomy, nonmaleficence, beneficence) and Pellegrino’s suggestions on making moral choices based on a four-fold understanding of the patient’s good, how would you process this request ethically? Having processed the request, what would you say to this patient?

Using the principles of bioethics and the Pellegrino’s suggestions on making moral choices based on four-fold understanding of patient’s good, I will not proceed with mastectomy for this woman. Among the four patient’s good that we are discussing, her request is syncing with the third one: patients perception of his own good, but when I look at the larger picture, its not ethical and also not wise for me to perform this procedure for her.

I will talk to the woman in the following manner:
I will greet her, appreciate her for her interest in improving her game by maximizing her golf swing. I will also ask her about how she came to the conclusion of wanting a mastectomy to improve her golf swing, so as to to know her understanding and beliefs. I will tell her that mastectomy by itself is a major surgical procedure which has its own complications and morbidity associated with the procedure. I will discuss with her about involving the sports physician / her coach to find out other ways of improving her golf swing. I will ask her if she wants to know more or if she has any doubts in this regard. I will tell her that I am not keen on performing this procedure considering her overall health and well being.

[Shajin]

Question #1: In the chapter on Nonmaleficence, Principles of Biomedical Ethics presents a view of the goals of medicine as broader than the maintenance of health and the restoration to health, which Kass posits as the telos of medicine. B&C call this an “unduly narrow way of thinking about what the physician has to offer the patient” (p.185, in 7th edition). Instead, they find physician-assisted death as consistent with the principles of autonomy and beneficence. How might Kass’s more traditional telos and B&C’s more contemporary one be perceived in a developing world context such as Kenya, among the Maasai?

Several examples given in the context of Kenya are day to day happenings in India and various other developing countries. I think Kass’s traditional telo’s will sync with the developing world culture like Kenya, whereas the B&C’s contemporary one may appear contradictory to the developing world context.

Question #2: The Kenyan authors of the article assigned find the principlism of B&C’s classic text inadequate for a full understanding of ethical decision-making in their context. What is the anthropological approach? Is it relevant for any context or just for “special” ones, such as working among tribal people such as the Maasai?

The anthropological approach focuses on solving bioethical issues by use of local societal norms and cultural perspectives. As described by Muller in the article, the anthropological approach to solve the bioethical problems involves four dimensions mentioned below:
1. Contextual nature of the bioethical problems
2. Cultural embeddedness of the moral systems
3. Multicultural character of the bioethical dilemma’s and
4. Challenge of examining the field of bioethics as a cultural phenomenon
Anthropological approach is not for the special contexts like in Maasai alone but also it can be applied in general in all the context.

[Shajin]

I liked the way you brought out the point of anthropological culture, not necessarily to be restricted to developing countries or particular tribal groups, bringing the example of differences within the western culture (UK and the US).

[Shajin]

I liked the way you stressed the importance of autonomy for the patient by having their choice to take action on their health, but at the same time, the autonomy should apply to some extent to the treating physician too, so that the physicians too have a choice to be a part of or not to be a part of certain treatment procedures that may go against their values and / or conscience.

[Shajin]

Question #1: Edmund Pellegrino points out that historically, until the 1950s, beneficence was the first among the principles in ethical medical practice. In the 1960s, it came to be seen as paternalistic and autonomy came to be first, eclipsing all other moral principles. Though Beauchamp and Childress respond to other’s criticism of the idea of autonomy as first among the four principles in bioethics (p99 and 143), what do you think of the place of autonomy in the actual practice of medicine in the US? For those who have worked internationally, how weighty has autonomy played a role in your experience?

I think autonomy still has a higher place in the United States. It’s one of the most important factors prioritized while deciding the treatment plans for an individual in the US. However autonomy has a different weightage in different countries.

I was in the US in 2019, at a level IV NICU for an international observership. During my short stay there, I came across atleast 5 newborn babies with NAS (Neonatal Abstinence Syndrome). It was a different experience to see the way the attendings dealt with the mothers. The baby has developed a problem as a consequence of the mother’s action in this case. The mothers were approached in a non-judgmental manner (although she should have stayed away from drugs considering her health status and of her baby). They were given all the support including specialized counselling to help them have a less traumatizing perinatal period. Now I am thinking of something similar happening in the Indian context: For example a pregnant woman at term gestation is advised admission, but she decides to come the following day because of some reason. Next day when the baby is born, the baby is depressed at birth and admitted to the NICU. I can’t imagine the pain the mother will have to go through, not only because her baby is sick but the whole system including her family and the healthcare professionals tend to victimize her, for the decision that she took the previous day. So, patient autonomy is still given a diverse importance in different parts of the world.

Question #2: Beauchamp and Childress speak predominantly of patient autonomy in their chapter. Pellegrino writes of the doctor/patient relationship, indeed any ethical relationship, as having two autonomies flowing bilaterally between the parties. Pellegrino also writes of the necessity of a healthy interplay of beneficence and autonomy in the doctor/patient relationship. What do you think of Pellegrino’s critique of his perceived imbalance in modern medicine and his reassertion of the prioritization of beneficence?

I do agree that there should be a balance of beneficence and autonomy in a doctor patient relationship, as rightly mentioned in the article as “a healthy interplay of beneficence and autonomy”. I also feel that the trust of the patient towards the treating physician plays a part in maintaining this balance between beneficence and autonomy. When there is a breach in the trust, there is more likelihood of a tilt in this balance. However modernized the medicine has become and may tend to become in the coming days, the principles of bioethics remain cardinal and it is the moral responsibility of the physician to explain the treatment options and give the autonomy to the patient to choose the treatment option thereby maintaining the balance.

Question #3: How might Sanders perceive the place of autonomy in an African-American context vs a Euro-American one?
I think Sanders perceives the autonomy of Euro American culture as more of individualistic and self-centered, while the autonomy of African American context is more of combined interplay of various factors. So, autonomy in the Euro American context can be quite dominating while that in Afro American context can be less dominating. African American ethos are holistic, inclusive, communalistic, spiritual, theistic, improvisational and humanistic, so Sanders may perceive that the Afro-American autonomy is less materialistic, valuing human life and dignity over material wealth and possessions but the Euro-American autonomy may tend to be more materialistic, giving more importance to wealth and possessions.

[Shajin]

I agree with Kainey about the way she responded to question no:4, to help the society is my duty even at the personal risk, as we have taken a oath and we need to remain truthful to it. Thank you for bringing in the “good Samaritan” in this context.

[Shajin]

Question #1: 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?

Beauchamp & Childress has presented 5 theories and of all the theories presented, the theory which has got the greatest coherence in my thinking is the theory of Sentience, for the following reasons:
1. This theory has a broader scope to include humans and non-humans: especially the animals used in research
2. This theory gives a lot of significance to pain and suffering which is very important for any life.
However, I do consider the fact that theory of Sentience can be considered as the gold standard theory of moral status. I want to bring in issue of impracticability and the same example mentioned by the author about the public health measures requiring vigorous control of pests and pestilence by extermination.

Theory based on Human properties: It’s hard to accept this theory as the main theory of moral status as this theory has excluded the non-humans.

Theory based on cognitive properties: As this theory tend to solely depend upon the cognitive properties, there is a sense of excluding a large proportion of humans who lack cognitive capacity and again most of the non-humans (animals), as they don’t possess cognitive property.

Theory based on moral agency: A morally appropriate response from vulnerable people like young children, retarded people, and people with senile dementia can lack moral status as per this theory.

Theory based on relationships: The problem with this theory is its failure to bring out which beings have moral status.

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 (pp 67-68, 7th ed)? Is it a term we should discard and with what could it be replaced?

Yes, I do agree with Beauchamp and Childress (B&C) that the language of “person“, “personhood” and “respect for persons” in bioethical discussion should be used. Human beings can be a better word.

Question #3: In light of Englehart’s critique of moral pluralism, do you think moral status is undermined by moral pluralism?
Yes, I do think moral status is undermined by moral pluralism.

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 325, 7th ed). 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?

The profession of healing is praiseworthy. The article talked about the difficult ethical decisions that they had to take in response to the resource constraints during the peak of the pandemic. These issues are commonly seen in day to day practice and beds / ventilators / other hospital resources are a perennial problem in many resource limited countries like India. But yes, when we deal with situations like the recent covid pandemic and any other epidemics, for that matter, care for the sick becomes obligatory. When we start treating those people with contagious infections, our healthcare team and other sub ordinates also will start caring for them without isolating them or seeing them with a stigma.

[Shajin]

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?
I do not agree with Beauchamp & Childress that there is a common universal morality upon which contemporary bioethics can be built. The concept of morality depends upon various factors and likely to be influenced by numerous local factors. What was considered normal in the west can be an unacceptable and abnormal issue in global south. Moreover, something which was considered moral and acceptable until yesterday may not be so today. For example, Homosexuality was illegal in India until very recently, when it was considered alright in many countries, but the same has been legalised in India now. While I am not talking at the merit of this issue, I am using this example to state how things changes over time, in relation to place and so on, which makes me tell that contemporary bioethics cannot be built upon common universal morality. Having said that, I definitely feel the four foundational principles of bioethics forms the guide light in helping us deal with some of these contemporary issues related to bioethics.

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?
Englehardt mentions that “In the face of intractable moral pluralism, there has also been a radical deflation of traditional morality within the contemporary dominant secular culture, because intractable secular pluralism is a consequence of an absence of foundations”. When we have a morally pluralistic world, it’s very likely that the morality degenerate. The foundation of morality can be shaky if it’s built on pluralism, in contrast to the morality which is built on rational foundation. In a morally pluralistic world, various diverse perspectives can favour or challenge the existing moral principles, which can eventually lead to biopolitics.

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 feel Groundlessness of contemporary morality is multifactorial and de-emphasis on virtues in our contemporary culture is partly adding to it. While it is important to stress on the virtues, it is sadly not given the importance it requires in our contemporary culture. The other factors that could affect the groundlessness of contemporary morality include the significance and priority given for morality, the way morality is practiced in context to the local factors existing within the community and so on. Hence I feel de-emphasis on virtues partly contributes to the groundless of contemporary morality in contemporary culture.

Question #4: African-American ethicist Cheryl Sanders offers her critique of B&C’s principlism from an African-American perspective, noting significant cultural values more characteristic of African-Americans which she contrasts with dominant European-American ones that prevail in B&Cs book. Comment on these values and how they might inform a view of “common morality”?
Cheryl Sanders talks about the values in Afro American community which according to her has been predominantly derived from traditional African cultures. Following are the seven contrasting differences among Afro American and European Americans:
1. Holistic unlike dualistic
2. Inclusive and not exclusive
3. Communalistic not individualistic
4. Spiritual and not secular
5. Theistic not atheistic
6. Improvisational and not forced into fixed forms
7. Humanistic not materialistic
As she mentions, incorporation of these perspectives into the bioethics of dominant culture should happen, which can lead on to development of more humane and less materialistic approaches to healthcare dilemma.

[Author]

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