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.
2. Germline Experimentation
3. Randomized Clinical Research
4. Rationing Health Care
5. Organ transplants
Part 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
3. Restate your position and give persuasive arguments for it.
4. Indicate that hospital personnel are available to discuss ethical issues with family
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 organ
registry. 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 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? Each
of 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 receiving
The committee approach merely moves the decision making from a doctor to a
committee 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 of
economics 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 minor
modifications until situations, interest groups, and individuals mount campaigns for more
transparency. 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 their
productive life spans because society owes people a good life, not a long life, and because giving
old people those 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 such
as 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
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 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 rise
no 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 ethical
people admit and correct them as quickly as possible. Honest admission of mistakes is cheaper
than 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 the
behaviors and intentions of other providers. Instead, they should relate only their present
observations of a patient and not assign guilt to anyone. Both the national and state legislatures
are currently struggling to find a solution to medical liability that is fair to both doctors and to
patients 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 told
to do. Wrong was thinking on our own. As adults and professionals, however, we often find that
knowing right from wrong is more problematic because we are called upon to think for ourselves
and 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 our
moral opinions about controversial situations. In medical ethics, we face conflicting arguments
on real-life procedures like abortion, assisted suicide, euthanasia, genetic testing, germline
therapy, stem-cell therapy, research on human subjects, and rationing health care. We move from
a world of black and white into a world of grays. We inhabit a world of competing cultural
imperatives 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 Commandments
4. 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 their
moral assumptions and was eventually asked to commit suicide for being irreligious. His
insistence on asking questions to get to a philosophical truth came to be known as the Socratic
Method. The method is skeptical, conversational, conceptual or definitional, empirical or
inductive, and deductive. Socrates was skeptical of common sense and tested it in conversations
that tried to define key terms. Each proposed definition was tested by applying it to real-life
situations using deduction in the form that says, if that is true, then the following should also be
true. Good examples of the Socratic Method are Euthypro, discussed in your textbook, and
Crito, in which Socrates decides not to escape his death sentence. His method of questioning has
been the driving force of Western ethics, philosophy, and science. His method and arguments
enter into present-day controversies such as voluntary assisted suicide. This method in various
forms 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 is
critical since it leaves itself open to examining and reexamining reasons from all
sources and disciplines. Ethics is reflective in that a conscientious moral agent is
constantly trying to achieve a delicate balance that takes into account the effect of
these 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 nonreflective
person. So, while ethics is a form of morality, a morality is not
necessarily ethical. To consider ethics as a critically reflective morality highlights
the 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 to
inquire. (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 field
of right and wrong, but none of them enlighten the whole field. We have to use all of these lights
to see clearly the relevant aspects of a particular moral controversy.
Seeing many aspects of a problematic situation is the first stage of sound ethical thinking
that sets up a dialogue among contrasting views. In this distance learning course, this ethical
dialogue will be mainly within your own head as you listen and respond to various arguments
presented 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 real
The second stage of sound ethical thinking for us as individuals and as groups seeking
guidance in problematic situations is critical thinking. Just gathering conflicting information in a
controversy will only confuse us unless we can think clearly about that information. Questions
about euthanasia, for example, will remain confusing unless many distinctions are made and
thinking 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 timehonored
strategy of the human race that operates at a mostly subconscious level. This strategy
works for us personally because it reflects what we have been taught and our previous
experiences. It used to work socially because the people around us shared our common-sense
values. When they consulted their consciences, they could be expected to agree with us. This
manner of decision-making has the great virtues of authenticity, clarity, and resolve; in addition,
it primes us for action.
In the present, this strategy is more troublesome in the social arena because the people
around us are likely to disagree with us. When they consult their consciences, they may
advocate courses of action that we see as bad, or conversely, they may see our desired actions as
evil. They might, for example, decide to abort a fetus that has been diagnosed with a crippling
hereditary disease, whereas we might think their decision is wrong. We might decide to
experiment on human subjects, while they might think we are being immoral. In the
controversies that arise in such situations, we need to listen respectfully to one another and
reason our way to a practical—not necessarily a theoretical—consensus. The kind of thinking
required is critical thinking.
When we are thinking critically, we even-handedly evaluate arguments and their
conclusions 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 then
attempting to internalize certain tools to improve your thinking by constantly engaging in
reflection and self-assessment. It is important to note that thinking well is hard work!”
There are two basic forms of argument: deductive and inductive. Deductive arguments
start 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 questioning
the truth of the premises or pointing out flaws of logic. If the major premise or the minor premise
is 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 used
in analyzing arguments:
1. Description, inference, and normative statements
2. Propositions, premises, and conclusions
3. Assumptions, facts, opinions, and ideas
4. Meaning of “and” and “or”
5. Validity and soundness. (47-53)
Inductive arguments do not observe the criteria of validity and soundness as do deductive
ones. They make the more modest claim that the truth of their premises makes it likely that their
conclusions are true. We tend to use inductive arguments often to discern how we are to proceed
in 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 money
back, 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 during
controversial times such as election campaigns. How often do we hear one person assert a point
and 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 evidence
shows that the common belief is unfounded? How often do people invoke the authority of some
well-known person who has no expertise concerning the controversy under discussion? How
many hasty generalizations do we hear? How many ways are statistics spun? How many false
dilemmas are hurled about? How many times do politicians beg a question by assuming exactly
what they are trying to prove? How many times do politicians drop in a red herring to divert
attention from an embarrassing situation? How many times do we argue against change on the
basis that going just one step would put us on a slippery slope to disaster? How often do we
twist the meaning of an opponent’s words (equivocation) in order to gain advantage? And how
often do we argue that the way things are is obviously the way they should be? While we laugh
and gnash our teeth at the blatant use of fallacies in political discourse, we also realize how
effective these fallacies can be—if they are not pointed out.
People get elected partially because they convince us with faulty arguments. Similar
misuses of logic occur in medical systems. What we learn in this course will enable us to point
out these abuses of logic when they come up in our lives and workplaces. Ideally, the clarity of
our thinking should lead to constructive changes and personal promotions to more responsible
positions. In reality, we have to learn patience and sharpen our political skills. We need to
remember 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 critical
thinking tools of Chapter Two, you should be able to work your way to reasoned conclusions on
many medical controversies. In the following assignments, you read examples of critical
thinking and construct arguments for your own conclusions. With practice you will master the
tough 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 the
likelihood of birthing children with grave physical disabilities. Still other couples may want to
design a certain kind of offspring. Today and tomorrow, these couples, with the aid of new
medical advances, can achieve their desires. But, what are the ethical concerns in the
development 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 their
The earlier forms of assisted reproductive technologies (artificial insemination, in vitro
fertilization, and different forms of ovarian stimulation, implantation of ova and zygotes) have
been debated and have generally passed medical ethical approval. In this assignment, we explore
the ethics of:
1. Prenatal diagnosis for disease and sex.
2. Whether information should be open to parents and the public, especially insurance
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 who
value prenatal life and traditional and natural processes against progressives who envision a new
and more humane future with less suffering. Historically, new methods of reproduction raise
fear and condemnation that gradually lessen as they prove to be reliable and produce healthy
babies. There may well come a day when cloning and eugenics are accepted practices, but we
must 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 questions
in 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 genetic
predispositions to certain diseases is generated. Some argue that this information should not be
generated or at least not be revealed to either the child’s parents or the public. They believe that
this information will tempt parents and doctors to play God, to try to design the perfect child, and
to have abortions. Others argue that the sex of the fetus should be withheld because of possible
parental sexist preferences. Still others would say that this sensitive information should not be
made public because it could influence the child’s employment possibilities and his or her ability
to obtain affordable insurance later in life.
It should be granted that detailed prenatal diagnosis may result in a higher percentage of
healthy babies and fulfillment for childbearing couples. It should also be granted that this kind
of diagnosis will lead to inevitable abuses in a free society interested in knowledge and profit. It
will be practically impossible to keep this kind of knowledge secret for ordinary people. The
ethical 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 a
defective gene from that population, replacing it with a healthy gene; and returns the geneengineered
cells to the patient. This process should render treatable many genetic diseases that
are caused by a defect in a single gene. This therapy would seem to be ethical because it is
supported by the fundamental moral principle of beneficence: it would relieve human suffering.
Should the same ethical approval be extended to germline gene therapy, which replaces
genes in sperm, ova, and cells that give rise to sperm and ova? This kind of therapy could ensure
that later generations would not inherit a particular disorder, yet some people argue that this
process is unethical because we would be “playing God.” It would, they argue, be a prelude to
eugenics, not only to removing disease, but also to genetic engineering in the service of creating
super people. (Most people are aware of Hitler’s desire to create the Aryan race, but few are
aware that Charles Darwin’s cousin, Francis Galton, introduced the scientific argument for
eugenics or that mentally handicapped adults were sterilized in the United States in an attempt to
keep them from having handicapped children of their own.) Still others argue that the process is
too dangerous. In our present state of knowledge, we could alter the course of embryonic
development, for example, by interfering with the work of nature’s time-tested housekeeping
genes and produce severely handicapped children.
Advocates of germline gene therapy argue that we have always tried eugenics in some
form, as by seeking a desirable mate, and that we have always resisted more aggressive eugenic
efforts in the past. They also argue that our understanding of genetic processes is somewhat
intelligent, 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 that
medicine itself has a prima facie duty to pursue and employ germline gene therapy because it
offers us the chance to rid ourselves completely of many serious genetic diseases for which there
is no effective treatment.
Cloning humans was once the stuff of science fiction. It is now a real probability. This
probability is proof for many that science has gone too far in its God-playing. The idea of
creating replicas of ourselves raises in our imaginations nightmarish possibilities. How could a
person raise his or her identical twin? Would people use their clones as part shops that they
could dismember at will when their own body parts wear out? Would we sell clones of gifted
people to the highest bidders? How many cloned embryos will have to be discarded because of
serious defects? How do we know that the clones would not have major defects? Wouldn’t
cloning 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 will
be identical. This is not even true of natural identical twins. It would be less true of a clone
because of the different uterine environment, mitochondrial differences, a different growth
environment, and a different will to live. A clone of Michael Jordan might face pressure to be
good 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 are
biologically similar to them. Do they have a right to clone? Cloning might allow couples to
have offspring that are free from hereditary diseases. Cloning might also allow a person to
obtain needed organs or tissue for transplantation. Cloning might allow the duplication of
individuals with great talent. It might also make possible important advances in scientific
knowledge. These are all, arguably, human goods, mostly minor, that could be provided by
It is inevitable that attempts will be made to clone humans. These attempts will probably
result in numerous abnormalities, abortions, miscarriages, and seriously defective people. Each
cloned baby will, however, be a human person entitled to full human rights and respect. These
attempts may also create healthy babies and little or no collateral damage. In that brave new
world, cloning might well become respectable. We must ask ourselves, however, how many
defective clones is an acceptable risk to create one perfect clone? One? Four? Ten?
Another topic that is frequently in the news is stem cell research. While most Americans
have heard of stem cells, most have no real knowledge of what they are or how medical science
uses them. Stem cells have two important characteristics:
1. They are unspecified and renew themselves for long periods through cell division.
2. Under some conditions, they can be induced to become cells with special functions,
such as the beating cells of the heart muscle or the insulin-producing cells of the pancreas.
These characteristics allow scientists to have an unending supply of stem cells to study
the way the body processes stem cells and to try to induce similar processes in the laboratory.
The hope is that this research will yield regenerative cures for diseases ranging from diabetes to
Three types of stem cells have been identified: embryonic stem (ES) cells, embryonic
germ (EG) cells, and adult stem cells. Embryonic stem (ES) cells are generally harvested from
eggs that have been fertilized in vitro in the fourth or fifth day after fertilization. At this time,
they are hollow microscopic balls of cells called blastocysts. The inner cell mass of the
blastocyst is transferred into a plastic laboratory culture dish that contains a nutrient broth called
a culture medium. Early procedures at this point introduced non-dividing mouse cells in order to
stimulate the inner mass cells to proliferate. Newer procedures avoid using mouse cells.
In several days, the inner mass cells proliferate and begin to crowd the culture dish.
When this occurs, they are moved to several fresh culture dishes. This process is repeated many
times for several months. Embryonic stem cells that have proliferated in cell culture for six or
more months without differentiating and appear to be normal are referred to as an embryonic
stem cell line. Batches of this cell line can be frozen and shipped to other laboratories for further
culture and experimentation.
Embryonic germ (EG) cells are removed from the genetic ridge of deliberately aborted
new fetuses in about the second month of pregnancy. They have characteristics similar to ES
cells. Adult stem cells typically generate the cell types of the tissue in which they reside. A
blood-forming adult stem cell in the bone marrow, for example, generally gives rise to red blood
cells, white blood cells, and platelets. Recently, it has been discovered that these adult stem cells
might be able to develop into other forms such as neurons or heart muscle. For more on this
subject, see stemcellresearch.org (www.stemcellresearch.org/facts/miscupdate1.htm).
The ethical questions concerning stem cell research mirror those concerning gene therapy
and cloning. A particular question arises for researchers who may be morally opposed to
abortion. Can they in good conscience experiment on stem cell lines that have been derived
from laboratory blastocysts or aborted fetuses? Is harvesting stem cells from fertilized eggs the
same as aborting a viable human being? If this procedure is legalized, would we then be
committing mass abortion in the name of science? On the other hand, does stem cell research
provide the key to curing currently incurable diseases? If so, would stem cell research be
justified or would bad ethics lead to bad science?
Because of advances in technology, medical professionals can now save the lives of
millions of people who would have died only a decade ago. Despite the many benefits of new
technology, however, these advances have also placed families and physicians in the position of
having to decide when patients are legally dead or when patients should die. For that reason,
Americans now find themselves debating issues such as assisted suicide and euthanasia, knowing
that they themselves will probably have to make decisions about one or the other in their own
Two premises that most ethicists agree on in regard to end-of-life issues are that the
treatment of seriously disabled people should correspond roughly to the nurturance that we are
obliged to provide for our very young and that the compassion shown should respect the
autonomy of the individual. In other words, individuals who are of sound mind should be
allowed to make decisions regarding their medical treatment, including treatments affecting the
end of life.
So, how do both medical professionals and others apply these principles in the course of
their jobs? In the case of someone grievously injured but not yet cared for, such as the man in
the New Testament parable who was attacked on the road from Jerusalem to Jericho, we must
first ascertain whether he wants assistance. If he does, then we most assuredly have some moral
obligation to help him, but we must also decide what we should do if we wish to be Good
Samaritans. What if we want only to be a minimally ethical Samaritan? Then what should we
do? In other words, do we help others to the full extent of our ability, even at a cost to ourselves,
or do we help others only until they are safe from harm? What if the person in need refuses our
assistance, choosing to die, as does the legendary elderly Native American who decides that this
is a good day to die and then heads out to the wilderness? Do family members and medical
professionals have an obligation to keep people alive who profess a desire to die?
If we agree that we are obligated to assist the injured and ill, then we must ask whether
we are obligated to help all people equally. In other words, are all lives equally valuable? Most
people agree that killing a patient who does not want to be killed is murder and that murder is
always wrong. But what if that patient is a killer who might kill again if he survives and is
released from prison? Are doctors still obligated to save his life? If so, how much time and
money should the medical profession spend trying to save the life of a murderer? Medical
resources are finite, which means that money spent on one life will not be available to another
patient. Utilitarianism says that doctors should save the person who would bring the most good
to the most people, but we have to ask whether we want medical professionals to decide who is
more valuable than whom. What ethical system can help us decide when and how much medical
assistance to give to the sick or injured?
Thus far, we have addressed the ethics of giving aid to those in need; now we must
address two of the most difficult issues we as a society face today. The principal controversies
surrounding the end of life are voluntary active euthanasia (V. A. E.) and assisted suicide.
V. A. E. is the active taking of the life of a patient who persistently and competently asks to be
killed, including patients with diseases that would allow them to live a normal lifespan, albeit in
pain. Dan Brock explains the pros and cons of legalizing voluntary active euthanasia. The good
consequences, according to Brock, are that it would be possible to respect the wishes of
competent patients who want V. A. E. In addition, it would reassure many people that if they
wanted euthanasia, they would be able to attain it and thus be released from severe pain.
According to Brock, once death is accepted, it is often more humane to end life quickly and
peacefully, when that is what the patient wants (in Card, 2004, pp. 216-217).
But V. A. E. might also permit physicians to perform euthanasia, a practice that would be
incompatible with their fundamental moral and professional commitment to care for patients and
protect life. Perhaps worse, patients might come to fear that a medication was intended not to
treat or care, but instead to kill. In other words, patients might actually come to fear their
physicians. In addition, permitting euthanasia would weaken society’s commitment to provide
optimal care for dying patients as people decided that killing seriously ill people would be
cheaper and easier than caring for them. In the end, making a new option or choice available to
people can sometimes make them worse off. Making euthanasia available to people as an option
denies them the alternative of staying alive by default. In the end, legalized euthanasia might
weaken the general legal prohibition against homicide itself (Card, pp. 217-220).
Although legalizing V. A. E. would theoretically show respect for the autonomy of the
individual, studies of the consequences of legalizing of V. A. E. in the Netherlands reveal that
the constraints requiring a patient’s voluntary and persistent requests for euthanasia are easily
brushed aside by doctors who terminate lives without request. It would seem that euthanasia,
which was promoted as a way to counterbalance physician power and to enhance the individual’s
autonomy, has resulted in physicians acquiring even more power over the life and death of
patients (Wikipedia, http://en.wikipedia.org/wiki/Suicide).
Brock does offer suggestions for protecting against abuse of V. A. E.:
1. The patient should be provided with all relevant information.
2. The patient’s request for euthanasia should be stable and enduring.
3. All reasonable alternatives must have been explored for improving the patient’s
quality of life.
4. A psychiatric evaluation should ensure that the patient’s request is not the result of a
treatable psychological impairment. (Card, p. 221)
Assisted suicide is different from euthanasia in that persons kill themselves with the
assistance of another. Assisted suicide is usually undertaken away from health care facilities,
which actively discourage suicide. There are three degrees of assisted suicide. At the lowest
level, one could assist a person in suicide by furnishing them with information about how to do
it, perhaps by giving them access to the works of the Hemlock Society. At an intermediary level,
one can provide the means for suicide by writing prescriptions for lethal amounts of medication.
At the most involved level, one could supervise or directly aid the suicide by inserting an
intravenous line and instructing the patient on how to start a lethal infusion (Watts & Howell in
Card, p. 233).
Actively killing persons in unremitting, untreatable, and terminal pain who ask to die is
forbidden by law, but just as physicians have ended the lives of the terminally ill for centuries,
today they terminate life by administering very high doses of morphine with the professed desire
to alleviate pain. Is this murder? Is there an ethical difference between administering enough
pain medication to cause death and shooting a terminally ill patient, as one mother did her son?
For patients who want to die or have previously indicated their opposition to extraordinary life
support, removing support systems is an accepted practice by the AMA and in U. S. law. This
practice is sometimes called voluntary passive euthanasia. There exists an argument that the
distinction between removing life support and active euthanasia is merely a legalistic one and
that passive euthanasia sometimes inflicts more pain than active euthanasia.
David Watts and Timothy Howell (as cited in Card, 2004) agree with the arguments
against euthanasia and believe that direct participation in suicide by inserting catheters, for
example, goes too far, being a short step from active euthanasia. Such direct participation would
invite “potential abuse of vulnerable persons, mistrust of physicians, and diminished availability
of supportive services for the dying. . . . These arguments [however, are much weaker] when
applied to more limited forms of physician-assisted suicide” (p. 234). Watt’s and Howell’s
reasoning is based on the idea of autonomy. They believe that providing someone with the
means to die and allowing that person to make the decision to end his or her life respects the
autonomy of the individual. It also assumes that the patient is mentally and emotionally capable
of making a clear decision and that the patient is aware of all of his or her options.
Timothy Quill (as cited in Card, 2004) recounts how he aided a patient who insisted for
her own reasons on committing suicide. His account demonstrates how assisted suicide can lead
to a familial and personal dignified death. Examples such as this point out the essential
difference between private morality and public ethics. A society that sanctions suicide and
euthanasia might well weaken its commitment to life so that even those who have no wish to die
find that they have no control over the termination of their lives. Yet, in the privacy of our
compassionate and loving lives, we may feel justified in performing acts that are forbidden by
the rules of ethics and laws. Public policy reflects this social and personal divide in many ways:
decisions not to prosecute, jury nullification, ignoring the over-administration of morphine drips,
and strictly honoring doctor-patient privacy. Public policy may also legitimize V.A.E. or
physician assisted suicide.
But what about patients who cannot express an opinion because they are in a persistent
vegetative state, an issue that has been on the front page of every paper in America in the past
two years, primarily regarding the Terry Schiavo case in Florida. Actively killing patients who
cannot communicate their wishes is forbidden by the rules of the American Medical Association
(AMA) and by most national and state laws. Nevertheless, courts have allowed family members
to deprive comatose patients of oxygen or food, thereby killing them. The question the court
tries to answer is whether the patient is brain dead. Some Americans, however, have protested
these decisions, including family members who have sued to keep such patients alive. Most of
these cases do not end up in court, however. Physicians admit that many in their profession have
secretly ended the lives of terminally ill patients for millennia. One justification for this
behavior, especially in the days when the doctor/patient relationship was more personal than it is
today, was the virtuous person argument: the virtuous doctor, in consultation with patients and
their families, would make the compassionate and wise decision. In our age of forced
transparency and insistence on rules, however, private decisions to end the lives of comatose
patients often cause public consternation because these cases highlight the complexity of modern
life and the divide between religious and ethical views of Americans. (See, for example, the case
of Robert Latimer www/cbc/ca/news/background/latimer.) And what about patients who request
extraordinary life-prolonging measures yet lack funds to pay for those measures? The larger
questions is, What obligation does society have to pay for medical treatment of those who do not
have the means to pay, even if they lack the means because of the choices they have made
throughout their lives? Who should be allowed to make end-of-life decisions for the comatose or
the indigent? Families? Hospitals? Insurance companies? Governments?
We all want rules to guide us in making decisions. In our law-and-order moments, we
believe that rules must be followed to the letter. In our more liberal moments, we believe that
laws are made to cover the vast majority of cases, but that they do not apply in every situation.
In that liberal mindset, we continue to follow the rules for the good order of society, but retain
the option of bending a rule in certain extreme situations. We keep our rule violations as private
as possible and accept the possible prosecution for our moral independence.
Uncertainty regarding end-of-life decisions can create pain, conflict, and drawn out legal
proceedings. In general, if it can be shown that the patient had expressed a desire not to maintain
extraordinary procedures, then hospitals and courts allow the discontinuance of treatment and
patients are allowed to die a natural death. For that reason, many people now perform advance
directives and do-not-resuscitate orders that clearly state the kinds of life-saving measures that
they do or do not want. Advance directives are of two kinds: a living will and durable powers of
attorney for health care. Living wills describe the kind of treatment people desire in certain
situations, but they do not allow people to select someone to make decisions for them. Durable
power of attorney states whom the patient has chosen to make health care decisions for them. A
do-not-resuscitate order is a request not to have cardiopulmonary resuscitation (CPR) if one’s
heart stops beating (http://familydoctor.org/x1625.xml).
A different kind of controversy arises when a patient who has expressed a desire to have
all available measures used to keep him or her alive is now hopelessly comatose. Are doctors
and hospitals obliged to continue providing measures and care that they deem useless for
restoring a patient to consciousness? How are they to deal with this issue of “futility”?
The abortion controversy exists in a largely unacknowledged evolutionary and historical
context. The particular arguments in this controversy focus on questions such as:
1. When does the fetus get its soul?
2. What is a person?
3. What is human life?
4. When is it legitimate to kill innocent life?
5. What are the demands of nurturance on a pregnant mother?
In our evolutionary past, giving birth was usually an event of unalloyed joy. Because
babies ensured that the tribe would survive, people felt great love for them. This powerful love
for babies has served the human race well. It has implanted in us a deep conviction that babies
are a moral good.
This deeply committed love was not, however, universal because “infanticide was
common in all well-studied ancient cultures, including those of ancient Greece, Rome, India,
China, and Japan. The end of infanticide in the ancient world coincided with the rise of
Christianity. The practice was never completely eliminated and continues today in areas of
extremely high poverty and overpopulation. Female infants, then and now, are particularly
vulnerable. One frequent method of infanticide in antiquity was simply to abandon the infant,
leaving it to death by exposure.” This reality is expressed in a letter from a Roman to his wife in
1 B.C.: “‘If you are delivered (before I come home), if it is a boy keep it; if a girl, discard it’”
(Brainy Encyclopedia, 2004).
Western moral thinking and the march of civilization have increased our respect for life.
As a result, we have gradually limited revenge to legitimate authorities; replaced slavery with
wage labor; guaranteed civil rights to minorities, women, and children; and limited capital
punishment. At the same time, we still condone killing in self-defense, warfare, and collateral
damage. Just as our views on these issues have changed, so have our views on abortion.
According to J. Lewis (2004), “In the United States, abortion laws began to appear in the 1820s
forbidding abortion after the fourth month of pregnancy… Most abortions in the US had been
outlawed by 1900… Some early feminists…wrote against abortion…[because it] was an unsafe
procedure for women… and they believed men drove women to abortions.”
The women’s liberation drive to legalize abortion in the 1960s followed the drive to
legalize contraception in the 30s, 40s, and 50s. It arose at the height of the civil rights, anti-war,
and hippie movements. The raging disrespect for white male authority of the times ignited a
cultural war between liberals and conservatives. The Supreme Court’s decision in Roe v. Wade
in 1973 was the last straw for conservatives, who felt that this decision sanctioned rampant
The stage was set for the abortion wars. On the one side were liberals, who identified
with the personal turmoil women felt over the decision whether to terminate a pregnancy and
who were aware of the degradation of back-alley abortions. Feminists saw Roe v. Wade as a
major step in the moral liberation of women from centuries of male-prescribed behavior. They
stoutly defended a woman’s right to decide whether to commit twenty years of her life to serving
a child, and they trusted the woman and her doctor to make this decision conscientiously. On the
other side, conservatives were determined to turn back the wild individuality and immorality of
the 1960s. For them, Roe v. Wade was an abomination that legalized murder of the unborn and
further encouraged young people to engage in sexual relations outside of marriage. Repeal of
that decision became a major plank in their platform to re-establish respect for traditional values.
The two sides of the abortion wars have conflicting “common sense” opinions about the
morality of self-determination and abortion; the liberal side values individual autonomy, seeing it
as a counterbalance to the rights of the fetus. The conservative side sees abortion as murder,
While evolution and history have endowed us with an overwhelming interest in
childbirth, they have also endowed us with a mounting interest in our personal freedom. The
point at which individuals began to consider personal freedom a right is difficult to pinpoint, but
certainly the Enlightenment and the American Revolution were seminal events in this change in
how the individual saw himself in relationship to society. The fact that the Declaration of
Independence and the Constitution of the United States are two of the most important documents
declaring individual rights explain why most Americans refuse to take either extreme in the
abortion wars. Because America was founded by religious people and because most Americans
still profess a belief in God, they are reluctant to sanction a woman’s right to kill a fetus at any
stage. At the same time, their belief in the rights of individuals makes most Americans equally
reluctant to tell a woman that she cannot do what she wants, including having an abortion.
Therefore, many Americans feel that abortion should be legal at least in some circumstances.
One of the primary issues in deciding whether abortion should be legal is the question of
when the soul enters the body. Different cultures at different times have had different views on
1. For Thomas Aquinas, Catholic theologian of the 13th century, following Aristotle,
human life started 40 days after conception.
2. After years of argument, Pope Pius IX in 1869 declared ex cathedra that the soul
entered the body at conception.
3. For Anglicans, the soul enters the body at nidation, when the fertilized egg becomes
implanted in the lining of the uterus.
4. In Judaism, the soul is implanted in boys after 40 days and in girls after 80 days.
5. In Islam, it is implanted after 120 days.
6. In the Greek Orthodox Church, it is implanted 21 days after birth. (Jansen)
In secular Western thinking, the question of ensoulment is replaced with questions about
human life and personhood. Conservatives argue that human life begins at conception and that
abortion is, therefore, murder. Some of them back up this view by arguing that abortion is evil
“because it deprives an individual of a future of value” (Marquis as cited in Card, 2004, p. 68).
In other words, aborted individuals are denied the right to grow up, fall madly in love, get
married, have children, and make the thousands of choices that give meaning to most people’s
Liberal thinkers fasten on the notion of “person.” They argue that persons have certain
qualities like consciousness, reasoning, and self-awareness. Fetuses lack these qualities.
Therefore, they are not persons, and they do not have the rights of persons. Fetuses may be
potential persons; still, their putative rights “could not possibly outweigh the right of a woman to
obtain an abortion, since the rights of any actual person invariably outweigh those of any
potential person” (Warren as cited in Card, 2004, p. 152). (One question those who are against
abortion ask is, What about people whose retardation is so severe that they also lack the ability to
reason and who also seem to be unaware? May we also terminate their lives?)
Other ethicists try to establish a moderate view. Jane English argues that “not all killings
of humans are murders. Most notably, self defense may justify even the killing of an innocent
person” (as cited in Card, 2004, p. 176). Judith Thomson likens the case of a pregnant victim of
rape to being strapped back to back with an unconscious violinist who will die if tubes to his
kidneys are removed. In either case, one could legitimately abort or remove the tubes. Backed
by this reasoning, Thomson believes that abortion is morally wrong in most, but not all, cases.
The exceptions, for her, are cases of rape and contraceptive failure.
L. W. Sumner urges the presence of sentience, the capacity for enjoyment and suffering,
that occurs sometime during the second trimester, as the criterion for deciding when the fetus
should be accorded the rights of a person. Others hold that the criterion should be the
quickening, when the fetus is felt moving in the womb. Still others would urge the criterion of
viability, when the fetus can exist outside the womb. New imaging technology will certainly
have a profound impact on the abortion debate as parents are allowed to see images of the fetus
as early as six weeks. Thus far, many Americans have taken a middle ground on this issue, but
as we have seen, public views on abortion change over time.
Shannon Jordan argues that the issue is one of community, urging us to “invert the order
of reasoning to first determine the meaning of moral community, for then we will already
understand who is a person” (Bouchier-Hayes, 2004). The lived reality of our human moral
community requires prescribed patterns of belief, behavior, and relationships so that we can
achieve individual and species survival. In particular, it requires us to nurture our young. We
have a duty to take care of our offspring until they become self-sufficient. It is in these
relationships that we confer personhood on each other.
Marjorie Reiley Maguire and Susan Sherwin build on the idea that community confers
personhood on its members in examining the relationships of a fetus to that community. The
fetus has direct relationships to the moral community only through the mother. In the words of
Maguire, “The fetus cannot become related to the human social community except through the
mediation of the mother. It is the mother who makes the fetus a social being by accepting its
relatedness to her. Thus, it is the mother who makes the fetus a person” (as cited in Bouchier-
Hayes, 2004). In the words of Sherwin (as cited in Card, 2004), “Because of this inexorable
biological reality, the responsibility and privilege of determining a fetus’s specific social status
and value must rest with the woman carrying it” (pp. 161-162).
In the context of our responsibility to nurture our young, Paul Gomberg (as cited in
Bouchier-Hayes, 2004) frames the abortion question in familiar conservative v. liberal terms. If
we accept that a woman’s chief role is to bear and nurture children, then the woman is morally
required to accept her pregnancy from the moment of conception. (Or, if we believe that the
fetus has personhood at conception, then no one, not even the mother, has the right to kill that
fetus.) If, however, we accept that a woman’s chief role is not to bear and nurture children, then
the woman can choose either to accept or reject her pregnancy. Yet, while most of us believe
that early abortions appear to be in line with the morality of nurturance, most of us “believe that
later abortions are morally and emotionally more problematic… It is clear that the morality of
nurturance must apply to the fetus, [and] it is clear that the longer we wait to abort, the more like
a baby is the thing we destroy” (Bouchier-Hayes, 2004).
The question remains: When do a woman’s duties to her offspring take hold? According
to Gomberg, Maguire, Sherwin, and Bouchier-Hayes, the morality of nurturance takes over when
a woman accepts her pregnancy. This maternal acceptance can occur earlier in a pregnancy, but
it can be assumed as the fetus approaches viability. And what if a woman never accepts her
pregnancy? At what point, if any, do the rights of the fetus take precedence over the rights of the
The Tuskegee study of untreated syphilis (1932 -1972) rivals abuses of prisoners by Nazi
scientists. The Nazi experiments prompted adoption of the Nuremberg Code after World War 2.
The World Medical Association (WMA) expanded the prescriptions of Nuremberg in 1964 and
has updated its principles ever since, with its latest revision in 2002. These codes and the laws of
many countries specify the rights of patients and the responsibilities of doctors and scientists
when experimenting on them. They require among other things that:
1. The patient is fully informed of the benefits and risks of a proposed procedure.
2. The patient freely consents to undergo the procedure.
3. A clearly defined medical benefit is reasonably expected from the experiment.
4. Human experimentation should be attempted only after animal experiments indicate a
probability of medical benefit for humans.
5. Physical and mental pain should be minimized.
6. Patients should be protected from even the remote possibility of injury, disability, or
The Tuskegee experiment:
1. Did not inform the indigent black men that they had syphilis.
2. Did not provide penicillin to combat the effects of syphilis.
3. Allowed patients, their wives, and children to suffer the ravages of syphilis.
4. Ignored the Nuremberg and WMA regulations.
5. Did all of this with official United States approval and funding.
In spite of its infamy, the results of this experiment are still being cited as authoritative
sources in scientific discussions about syphilis, but some researchers claim that bad ethics result
in bad science. The use of Tuskegee results seems to show an implicit approval of the
experiment and contributes to the widespread impression among scientists that because they
were the guinea pigs of this study and their pictures accompanied its results, black males are
more infected than white males.
The argument that bad ethics generates bad science does apply to the ways that Tuskegee
was conducted. It does not apply to its findings about the natural course of syphilis, however. It
is understandable and justified, therefore, to use the knowledge provided by Tuskegee.
Nevertheless, presenting those findings without renouncing the research that produced them may
not be ethical. Scientists must protest immoral research in order to prevent its imitation by
The tendency to pursue research in unethical ways continues to manifest itself, especially
among the non-privileged members of society as evidenced in the Willowbrook experiment on
retarded children during a hepatitis epidemic. In this experiment, staff withheld efficacious
treatment from the children and even deliberately fed children infectious hepatitis without
seeking parental consent (Ramsey as cited in Card, 2004, pp. 429-433).
Other examples abound today in the offshore testing of new drugs upon patients not
protected by the laws of the United States or European countries. Many medical advances of the
past two decades have come from the pharmaceutical industry, which is both competitive and
profit-driven. Speed in getting an innovative drug to market can result in immense profit. Some
researchers find the ethical regulations on experimentation in the developed world to be too
restrictive. For these reasons, some drug research is being done in Third World countries where
there is little protection for subjects of clinical trials. At times, trials are being conducted in
which the control group receives only a placebo. Even the National Institute of Health (NIH) has
urged scientists to employ placebo control groups. Placebos are ethically allowable, however,
only when there is no known effective treatment. The pressures of time and financial gain, the
urging of funding bodies to approve testing with placebos, and the natural enthusiasm of even
altruistic researchers to make an important medical advance all tempt researchers to suppress the
rights of patients and to emphasize the objective of clinical studies. Firms and universities in the
United States are pushing to soften the guidelines on the use of placebos. These current practices
and trends seem to ignore the Nuremberg Code and revive the spirit of the Tuskegee Syphilis
Physicians face inherent ethical challenges when they participate in randomized clinical
trials because they agree to act simultaneously as physicians and scientists. Randomized clinical
trials employ an experimental group and a control group in order to test the efficacy and safety of
new therapies (drugs). Physicians participating in these trials face inherent ethical challenges
because they have to withhold the new therapy from their patients who might be in the control
group. They are agreeing to act simultaneously as physicians and scientists. They are, in effect,
being asked to sacrifice the interests of their patients for the sake of a study that might produce
information of use to the rest of society. The physicians’ duty is always to act in their patients’
best interests, whereas the scientists’ goal is to answer a scientific question whose answer may
help society at large. This conflict of interest compromises:
1. Physicians’ ability to profit from results of trials for the benefit of their patients.
2. Physicans’ ability to utilize their own expertise, including hunches, to help their
3. Kantian categorical imperatives that people be treated as ends and not means.
Physicians in randomized clinical trials are asked to sacrifice concern for their patients, to
withhold what they believe will be beneficial treatment simply because that treatment has not
been rigorously validated. On the basis of arguments like these, some ethicists claim that
randomized clinical trials on human subjects are inherently unethical. They urge alternative
(unspecified) trials that would not compromise the physician-patient relationship.
The typical response favoring physician-scientist participation in randomized trials is the
utilitarian one: The benefits of this research are potentially so great that they far outweigh the
inconvenience visited upon a few patients. The weakness of this response is that it cedes the
moral high ground to the anti-trial argument. It says, in effect, that “X (to honor the physicianpatient
relationship) is ethical, but I will not do X.” This statement merely expresses a weakness
of will and unethical conduct. The utilitarian response could also be understood as saying, “X is
ethical, but one should deny or doubt that one should do X,” which is clearly self-contradictory.
The utilitarian argument would therefore seem to be weak.
A stronger pro-trial response would be, “X is ethical, I will honor X, and I will participate
in randomized clinical trials.” To justify this response, one has to clarify the meaning of both X
and the nature of clinical trials. Key to this clarification is the concept of equipoise.
According to the principle of equipoise, if the physician has no opinion whether a
treatment is acceptable, then random assignment is acceptable. The difficulty with equipoise is
its inherent fragility. As soon as a physician forms an opinion about the efficacy of a treatment,
equipoise is undone. Physicians are bound to have some opinion about the acceptability of a
drug even at the beginning of a randomized trial and certainly as the trial progresses. They will
then be obliged by their professional ethics to withdraw their patients from the trial—destroying
the practice of randomized clinical trials (Hellman & Hellman, as cited in Card, 2004).
The understanding of equipoise in the preceding paragraph, which has been dubbed
“theoretical equipoise,” is conceptually odd and ethically irrelevant, according to some ethicists.
According to these ethicists, theoretical equipoise postulates an oversimplified trial situation that:
1. Gives undue weight to the beliefs and hunches of individual physicians while
minimizing the accumulated wisdom of the medical community.
2. Reduces the complexity of deciding the efficacy and safety of a procedure to a simple
good vs. bad decision of a single doctor.
3. Ignores the complexity of clinical trials.
A more realistic, ethically relevant, and robust notion for evaluating the ethics of
randomized clinical trials is “clinical equipoise,” which takes into account the importance of
medical consensus and the complexity of clinical trials. Clinical equipoise is premised upon a
split within the medical community with some clinicians favoring A and others favoring B, in
which both sides recognize that the opposing side has evidence to support its position. Freedman
(as cited in Card, 2004) says that a “state of clinical equipoise is consistent with a decided
treatment preference on the part of the investigators. They must simply recognize that their less
favored treatment is preferred by colleagues whom they consider to be responsible and
competent (p. 448).
Randomized clinical trials are set up to remove clinical equipoise and establish the
superiority of one therapy over another. Clinical equipoise depends on the consensus of the
medical community, not the preferences of an individual physician. It is a weaker and more
common condition than theoretical equipoise. It is also more robust—not subject to the intuition
of an individual physician. It relieves the ethical difficulties at the beginning and end of a trial.
It changes the discussion with the patient regarding consent into informing the patient about the
honest disagreement among competent clinicians. It allows physicians to inform their patients of
their preference of treatment. It does not conceal information from patients and allows patients
to opt out of trials. In the words of Freedman (2004), “Clinical equipoise serves, then, as a
rational formulation of the approach of many toward research ethics: it does not so much change
things as explain why they are the way they are”
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