First Year Seminar: Biomedical Ethics

Phil 171

Professor William Seeley, 169 LSP

Office Hours: M/W 11:00 – 12:30 & by appointment

wseeley@fandm.edu

Course Description:

What is biomedical ethics? Biomedical ethics is a branch of applied ethics dedicated to the evaluation of ethical issues in health care. For instance, what is the nature of normal function? Is it a biological or a cultural concept? How do the answers to these questions effect our medical judgments? Does the possibility of neuropharmacological enhancement change these answers? We will discuss these issues along with questions about the ethical foundations of human subjects research, the nature and ethics of genetic screening, informed consent and the physician-patient relationship, the definition of death, and the ethics of stem cell research and cloning. The goal of the class is twofold: to introduce students to the fundamental concepts that frame sound medical practice; and to illustrate the types of philosophical problems that confront practitioners in rapidly changing, technologically flexible medical fields.

Course Goals:

introduce students to a general framework for ethical reasoning

introduce students to the basic concepts and philosophical problems that define the field of biomedical ethics

develop critical reasoning and writing skills necessary to tackle the broad range of intellectual opportunities available in a liberal arts environment.

Texts:

Biomedical Ethics, Walter Glannon (New York: Oxford University Press), 2005 (bookstore).

Electronic resources and eDisk files in the PHI 171 Distribution Folder on EDisk.

A Point of Procedure:

Some ethical issues are controversial. It is critical to the success of class discussion that we all remain open-minded and respectful of the beliefs of others at all times.

Requirements:

The goal of this course is to provide students with critical reasoning skills necessary for college. The only way to master these skills is through practice. This course is, as a result, structured around a series of 8 individual and group projects designed to help students develop critical reading skills, writing skills, and the capacity to publicly express one’s ideas in a coherent and logical manner. Participation in all aspects of the course is mandatory. In particular, it is critical that students keep up with the readings so that they can participate in open discussions in class:

Participation in each of the 6 assigned projects described below (70%).

A cumulative final exam (20%).

Class participation (10%).

All papers must be submitted Both in hard copy and electronically to EDisk.

Late papers will NOT be accepted.

poor attendance will have a deleterious effect on your grade.

Some Miscellaneous Notes and Guidelines:

Moral behavior is the grounds for, and the framework of, a healthy society. In this regard it is each of our responsibility as individuals within the community of our classroom to act responsibly. This includes following the rules and guidelines set out by the College for academic behavior. Plagiarism is a serious matter. It goes without saying that each of you is expected to do his or her own work and to cite EVERY text that is used to prepare a paper for this class. In general philosophy papers are NOT research papers. Your preparations for papers and presentations should focus on material from the syllabus, assigned supplemental readings, and class discussion.

I ask that you not use the internet for your research except as assigned in class.

The six assigned projects are designed to give you a chance to stretch your legs a bit while you learn about biomedical ethics (and to give me a chance to assess your understanding of the material). Your job in each case is to offer a philosophical defense of your take on the issue at hand. However, this does not mean that they are a free forum for opinions. Make sure that your discussions remain focused on the philosophical problems that surround the assigned question or topic.

Finally, the reading list for this class is arranged to guarantee that we keep up with the schedule for our group and individual projects. However there is some flexibility built-in to the reading schedule so that we can spend more time on issues that are of particular interest to you. In this regard, I will occasionally upload supplementary materials to EDisk for students who want to pursue particular issues beyond class discussion. I also reserve the right to modify the syllabus as needed to accommodate our interests as a group.

Schedule of Readings:

Topic 1 : Introduction: A Field Guide for Ethical Theories in Biomedical Ethics

Harmon: “Ethics and Observation” (eDisk)

Pojman: “A Defense of Ethical Objectivism” (eDisk)

First Project:

Do the nature of moral judgments entail ethical relativism?

Topic 2: Disease, Disability, and the Concept of Normal Function

Boorse: "On the Distinction between Disease and Illness" (eDisk)

Wells: “The Country of the Blind” (eDisk)

Daniels: “Justice and Health Care” (eDisk)

Silvers: "A Fatal Attraction to Normalizing: Treating Disabilities as Deviations from ‘Species Typical' Functioning" (eDisk)

Crouch: "Letting the Deaf Be Deaf" (eDisk)

See Movie: “The Sound and the Fury”

Second Project:

What does the case of cochlear implants teach us about the relationship between mode & level of function in treatment judgments?

ROUGH DRAFT DUE 10/01; FINAL DRAFT DUE 10/12

Topic 3: Neuroethics: Neuropharmacology & the Ethics of Enhancement

Wolpe: "Treatment, Enhancement, and the Ethics of Neurotherapeutics" (eDisk)

Glannon: “Pharmacological and Psychological Interventions”

Topic 4: Informed Consent & the Physician Patient Relationship

Goldman: "The Refutation of Medical Paternalism" (eDisk)

Emanuel and Emanuel: "Four Models of the Physician-Patient Relationship" (eDisk)

Elger: “Beneficence Today, or Autonomy (Maybe) Tomorrow & Commentary”

Chevrolet: “The Severely Demented, Minimally Functional Patient: An Ethical Analysis” (eDisk)

Third Project:

Does informed consent necessarily protect a patient’s rights?

Are there limits to the role of patient autonomy in treatment judgments?

FALL BREAK: 10/12 - 10/15

Topic 5: Assessing Genetic Risk

Andrews et al: “Genetic Testing & Assessment” (eDisk)

Guest Lecture: Dr. Holmes Morton, MD, Clinic for Special Children

Morton: “Through My Window” (eDisk)

Morton et al: “Pediatric Medicine & the Genetic Disorders of Amish and Mennonite People of Pennsylvania” (eDisk)

Strauss et al: “Prevention of Brain Disease from Severe 5,10-methylenetetrahydrofolate reductase deficiency” (eDisk)

Andrews et al: “Social, Legal, & Ethical Implications of Genetic Testing” (eDisk)

McDaniel et al: “Psychosocial Interventions for Patients & Families Coping with …” (eDisk)

Williams & Sobel: “Neurodegenerative Genetic Conditions: The Example of Huntington Disease” (eDisk)

Miller et al: “Psychosocial Processes in Genetic Risk Assessment for Breast Cancer” (eDisk)

Fourth Project:

Do the benefits of genetic testing for untreatable genetic conditions outweigh the costs?

Topic 6: Experimentation on Human Subjects

The Belmont Report: “Ethical Principles and Guidelines for the Protection of Human Subjects of Research” (eDisk)

Hellman & Hellman: “Of Mice but Not Men: Problems of The Randomized Clinical Trial” (eDisk)

Freedman: “Equipoise and the Ethics of Clinical Research” (eDisk)

Miller & Brody: “A Critique of Clinical Equipoise: Therapeutic Misconception in the Ethics of Clinical Trials” (eDisk)

Miller: “Sham Surgery: An Ethical Analysis” (eDisk)

Fifth Project:

Does clinical equipoise resolve ethical conflicts associated with experimentation on human subjects?

Topic 7: Cloning and Stem Cell Research

Kass: “Cloning Human Beings” (eDisk)

NBAC: “Cloning Human Beings: Executive Summary" (eDisk)

Janeisch: “The Biology of Nuclear Cloning and the Potential of Embryonic Stem Cells for Transplantation Therapy” http://www.bioethics.gov/reports/stemcell/appendix_n.html

Topic 8: Life, Death & Choice

PCBE: “Defining Death: A Report on the Medical Legal, and Ethical Issues in the Determination of Death” (eDisk)

PCBE: “The Definition of Death and the Ethics of Organ Procurement from the Deceased”

http://bioethicsprint.bioethics.gov/background/rubenstein.html

Warren: “On the Moral and Legal Status of Abortion” (eDisk

Marquis: “Why Abortion is Immoral” (eDisk)

Thompson: “A Defense of Abortion” (eDisk)

Sixth Project:

Critically evaluate one of the papers from the section on the Life/Choice Debate.

Assignments:

All papers should be double spaced in 12 point font with 1” margins. All papers must be handed in to the eDisk Dropbox folder for our class and my mailbox in the Philosophy Department.

In addition to the projects listed below each student will be asked to lead one class discussion during the semester which will be factored in as half of your class participation grade. We will draw numbers out of a hat on September 5 to assign sessions.

Project 1: First Paper - Ethics & Objectivity (5%) Please write a 3 page (900 word) paper on the following topic. Your paper should be double spaced in 12 point font with 1” margins. The purpose of this assignment is to demonstrate your understanding of the idea of a valid argument & the arguments against ethical relativism in Pojman’s paper.

Paper Topic: Explain the Cultural Differences and Provability Arguments. Does Pojman believe that these arguments suffice to establish Ethical Relativism?

Due Date: September 10, 2007 in EDisk & my mailbox in the Philosophy Department.

Project 2: Second Paper - Normal Function & Treatment Judgments (10%) Please write a 4 page (1200 word) paper on the following topic. The purpose of this assignment is to evaluate your understanding of the debate in the literature we have read over the concept of normal function and its role in health care judgments.

The central topic of this set of readings has been the notion of “normal function.” This term is critical to the determination and justification of appropriate treatment judgments. The definition of this term has been shown to be intricately tied to the concept of “personhood,” i.e. to the beliefs, desires, & goals of individuals and the social conventions that define the normal range of needs, interests, and opportunities for individuals in a society. In this context, it has been argued that there are logical and a moral problems associated with the use of cochlear implants to treat hearing loss in prelingually deaf children.

Paper Topic: It has been argued that cochlear implants serve as a case study to demonstrate that concerns about level of function are always more important that concerns about mode of function in treatment judgments. RECONSTRUCT THIS ARGUMENT.

In your paper make sure to pay careful attention the set of following questions: what is the goal of medical treatment; what does it mean to say that normal function is a theoretical concept; what is the role played by “level of function” in determinations of normal “mode of function”; what do cochlear implants treat; what is the goal of cochlear implant surgery; are these consistent.

Rough Draft: due October 1, 2007 in EDisk & my mailbox in the Philosophy Department.

Final Draft: due October 12, 2007 (FRIDAY) @ 3pm in EDisk & my mailbox in the Philosophy Department.

Project 3: Response Paper - Paternalism & Patient Autonomy (10%) Please provide a 4 page (1200 word) argument against either statement (S1) or (S2) below. Your argument should have the form of a reductio ad absurdum. In a reductio one provides a “rational reconstruction” of some argument and then demonstrates that, in its standard form, it leads to a contradiction.

Paper Topics:

(S1): Informed consent necessarily promotes patient autonomy.

(S2): Patient autonomy is the most important consideration in choosing appropriate treatments.

Due Date: October 22, 2007 (Monday) @ 3:30pm in EDisk and my mailbox in the Philosophy Department

Project 4: Group Presentations - Genetic Testing (15%) We will spend one class on each group presentation. All members of each group must participate in the presentation. Each individual member of each group should plan to speak for no more than 10 minutes so there is ample time for discussion. All students are required to hand in a paper version of their presentations (500 words).

Topics:

Group 1: What is genetic testing & what are the Ethical problems associated with it?

Group 2: Present the case study of Huntington’s Disease.

Group 3: Present the case study of Breast cancer.

Group 4:Evaluate the costs & benefits of genetic testing. Are there significant differences between types of genetic conditions? What are the effects of positive results on the personhood & well-being of the patient? What are the effects of positive results on the range of individuals potentially affected by the information delivered? How does this material bear on the debate about the structure of the physician-patient relationship and the value of informed consent?

* Groups are required to meet with me prior to the class before their presentations.

Due Date:

Group 1: October 24

Group 2: October 29

Group 3: October 31

Group 4: November 05

Project 5: Critical Analysis 1 - Clinical Equipoise (15%) Please write a 4-6 page (1200-1600 word) paper on the following topic. Your paper should be double spaced in 12 point font with 1” margins. The purpose of this assignment is to engage with the issues in a current debate in bioethics. In constructing your paper make sure to: clearly identify the question/issue under debate; provide a rational reconstruction of the position that you intend to argue against; demonstrate a flaw in the reasoning, as presented, of that position; evaluate whether the results of this analysis suffices to establish the validity of the opposing position in the debate.

Paper Topic: Does clinical equipoise resolve ethical conflicts associated with experimentation on human subjects?

Due Date: November 16, 2007

Project 6: Critical Analysis 2 - The Life/Choice Debate (15%) Evaluate the argument presented in one of the papers on the reading list about the ethics of abortion. As with project 6 make sure to provide a rational reconstruction of the position presented in the paper, identify any flaws you find in this chain of reasoning, and provide an argument for what you believe this entails for the life/choice debate. Your paper should be 6 pages long (1500-1800 words) double spaced in 12 point font with 1” margins.

Remember: What matters is the internal structure of the argument you choose to evaluate! Do not be distracted by tangential facts or beliefs you may have that run contrary to the position under consideration but lack sound logical support.

Due Date: December 5, 2007

Bibliography:

Topic 1 :Introduction:

Gilbert Harmon, “Ethics and Observation,” The Nature of Morality: An Introduction to Ethics (New York: Oxford University Press), 1977, pp. 3-10.

Louis Pojman, “A Defense of Ethical Objectivism,”

Supplemental:

Walter Glannon, “History and Theories” Biomedical Ethics (New York: Oxford University Press), 2005, pp. 1 - 22.

Topic 2: Disease, Disability, and the Concept of Normal Function:

Christopher Boorse, "On the Distinction between Disease and Illness" in Eds. James Lindeman Nelson & Hilde Lindeman Nelson, Meaning and Medicine (New York: Routledge), 1999, pp. 16 - 37.

Norman Daniels, “Justice and Health Care,” in Eds. Donald Van DeVeer and Tom Regan, Health Care Ethics: An Introduction (Philadelphia: Temple University Press), 1987, pp. 290 - 325.

Anita Silvers, "A Fatal Attraction to Normalizing: Treating Disabilities as Deviations from 'Species Typical' Functioning," in Ed. Erik Parens, Enhancing Human Traits: Ethical and Social Implications (Washington D.C.: Georgetown University Press), 2000, pp. 95 - 123.

Robert Crouch: "Letting the Deaf Be Deaf,” in Eds. James Lindeman Nelson & Hilde Lindeman Nelson, Meaning and Medicine (New York:

Routledge), 1999, pp. 360 - 370.

“The Sound and the Fury,” dir. Josh Aronson (2001).

Topic 3: Neuroethics:

Paul Wolpe, "Treatment, Enhancement, and the Ethics of Neurotherapeutics," Brain and Cognition 50 (2002), pp. 387 - 395.

Walter Glannon, “Pharmacological and Psychological Interventions,” Bioethics and the Brain (New York: Oxford University Press), 2007, pp. 76-115.

Supplemental Neuroethics:

Walter Glannon, “Neurosurgery, Psychosurgery, and Neurostimulation,” Bioethics and the Brain (New York: Oxford University Press), 2007, pp. 116 - 147.

Topic 4: The Physician-Patient Relationship:

Walter Glannon, “The Patient Doctor Relationship,” Biomedical Ethics (New York: Oxford University Press), 2005, pp. 23 - 46.

Alan Goldman, "The Refutation of Medical Paternalism," in Eds. Bonnie Steinbock, John D. Arras, & Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 56 - 64.

Ezekial Emanuel and Linda Emanuel, "Four Models of the Physician-Patient Relationship," in Eds. Bonnie Steinbock, John D. Arras, & Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 67 - 76.

Topic 5: Genetic Testing, Assessment, & Counseling:

“Genetic Testing and Assessment,” in Eds. Lori Andrews, Jane Fullarton, Neil Holtzman, & Arno Motulsky, Assessing Genetic Risks: Implications for Health and Social Policy (Washington, D.C.: National Academy Press), 1994, pp. 247 - 289.

“Social, Legal, and Ethical Implications of Genetic Testing,” in Eds. Lori Andrews, Jane Fullarton, Neil Holtzman, & Arno Motulsky, Assessing Genetic Risks: Implications for Health and Social Policy (Washington, D.C.: National Academy Press), 1994, pp. 247 - 289.

“Ethical Issues in Pediatric Genetics,” in Eds. Suzanne Miller, Susan McDaniel, John Roland, & Suzanne Feetham, Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives (New York: W. W. Norton), 2006, pp. 486-505.

Susan, H. McDaniel, John S. Rolland, Suzanne L. Feetham, “Psychosocial Interventions for Patients and Families Coping with Genetic Conditions,” in Eds. Suzanne Miller, Susan McDaniel, John Roland, & Suzanne Feetham, Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives (New York: W. W. Norton), 2006, pp. 274 - 319.

Janet K. Williams & Susan Sobel, “Neurodegenerative Genetic Conditions: The Example of Huntington Disease,” in Eds.Suzanne Miller, Susan McDaniel, John Roland, & Suzanne Feetham, Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives (New York: W. W. Norton), 2006, pp. 231 - 247.

Suzanne M. Miller, Mary B. Daly, Kerry A. Sherman, Linda Fleisher, Joanne S. Buzaglo, Laura Stanton, Andrew K. Godwin, & John Scapato, “Psychosocial Processes in Genetic Risk Assessment for Breast Cancer,” in Eds.Suzanne Miller, Susan McDaniel, John Roland, & Suzanne Feetham, Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives (New York: W. W. Norton), 2006, pp. 274 - 319.

Supplemental: Genetic Testing, Assessment, & Counseling:

“Issues in Genetic Counseling,” in Eds. Lori Andrews, Jane Fullarton, Neil Holtzman, & Arno Motulsky, Assessing Genetic Risks: Implications for Health and Social Policy (Washington, D.C.: National Academy Press), 1994, pp. 146 - 184.

Topic 6: Experimentation on Human Subjects:

Walter Glannon, “Medical Research on Human Subjects,” Biomedical Ethics (New York: Oxford University Press), 2005, pp. 47 - 70

The Belmont Report: “Ethical principles and Guidelines for the Protection of Human Subjects of Research,” in Eds. Bonnie Steinbock, John D. Arras, and Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 738 - 745.

Samuel Hellman and Deborah S. Hellman, Hellman & Hellman, “Of Mice but Not Men: Problems of The Randomized Clinical Trial,” New England Journal of Medicine 324, 1991, 1585-1589.

Benjamin Freedman, “Equipoise and the Ethics of Clinical Research,” New England Journal of Medicine, 317, 1987, 141-145.

Franklin G. Miller & Howard Brody,“A Critique of Clinical Equipoise: Therapeutic Misconception in the Ethics of Clinical Trials,” Hastings Center Report, 33(3), 2003, 19-28.

Franklin Miller, “Sham Surgery: An Ethical Analysis,” American Journal of Bioethics 3(4), 2003, pp. 41 - 48.

Topic 7: Cloning and Stem Cell Research

Leon R. Kass, “Cloning Human Beings,” reprinted in Mappes & DeGrazzia, Biomedical Ethics (New York: McGraw-Hill), 561-564.

National Bioethics Advisory Commission, “Cloning Human Beings” ,” (Rockville, MD: NBAC, June 1997), 564-568

PCBE - Rudolph Janeisch, “The Biology of Nuclear Cloning and the Potential of Embryonic Stem Cells for Transplantation Therapy,” http://www.bioethics.gov/reports/stemcell/appendix_n.html

Supplementary: Cloning and Stem Cell Research

Dan Brock, “Cloning human beings: an assessment of ethical issues pro & con,” in Eds. Bonnie Steinbock, John D. Arras, & Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 631 - 643.

National Bioethics Advisory Commission, “Ethical Issues in Stem Cell Research” (Rockville, MD: NBAC, September 1999).

Rudolph Janeisch, “Human Cloning-The Science and Ethics of Nuclear Transplantation,” New England Journal of Medicine 351(27), 2004, pp. 2787- 2791.

Alexander Meissner & Rudolph Janeisch, “Generation of Nuclear-Transfer Derived Pluripotent ES Cells from Cloned Cdx2-Deficient Blastocysts,” Nature 439(12), 2006, pp. 212 - 215.

Topic 8: Life, Choice, & Death

“Defining Death: A Report on the Medical Legal, and Ethical Issues in the Determination of Death,” President’s Commission for the Study of Ethical Problems in Medicine, 1981, in Eds. Bonnie Steinbock, John D. Arras, & Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 259 - 268.

Alan Rubenstein, Eric Cohen, and Erica Jackson, “The Definition of Death and the Ethics of Organ Procurement from the Deceased,” Staff Discussion Paper, President’s Council for Bioethics. http://bioethicsprint.bioethics.gov/background/rubenstein.html

Mary Warren, “On the Moral and Legal Status of Abortion,” The Monist, 57(1), 1973, pp. 43-61.

Don Marquis, “Why Abortion is Immoral,” Journal of Philosophy, 86, 1989, pp.183-202.

Judith Thompson “A Defense of Abortion” Philosophy and Public Affairs, 1(1), 1971, pp. 47-50,54-66.

Supplemental: Definition of Death:

Robert Veatch, “The Impending Collapse of the Whole -Brain Definition of Death,” Hastings Center Report, 1993. 23(4):18-24.

Baruch Brody, “How Much of the Brain Must be Dead, in Eds. Bonnie Steinbock, John D. Arras, & Alex John London Ethical Issues in Modern Medicine, 6^th edition, (New York: McGraw Hill), 2003, pp. 277 - 282.

Date	Readings	Assignments
08/29	Harmon
09/03	Pojman
09/05	Boorse
09/10	Daniels	First Project Due
09/12	Silvers
09/17	Crouch
09/19	Discussion Day
09/24	Movie: The Sound & The Fury