Moral and Ethical Issues

The tremendous infusion of technology into the practice of medicine has created a new medical era. Advances in material science have led to the production of artificial limbs, heart valves, and blood vessels, thereby permitting “spare parts” surgery. Numerous patient disorders are now routinely diagnosed using a wide range of highly sophisticated imaging devices, and the lives of many patients are being extended through significant improvements in resuscitative and supportive devices, such as respirators, pacemakers, and artificial kidneys.

These technological advances, however, have not been benign. They have had significant moral consequences. Provided with the ability to develop cardiovascular assist devices, perform organ transplants, and maintain the breathing and heartbeat of terminally ill patients, society has been forced to re-examine the meaning of such terms as death, quality of life, heroic efforts, and acts of mercy, and to consider such moral issues as the right of patients to refuse treatment (living wills) and to participate in experiments (informed consent). As a result, these technological advances have made the moral dimensions of health care more complex and have posed new and troubling moral dilemmas for medical professionals, the biomedical engineer, and society at large.

The purpose of this chapter is to examine some of the moral questions related to the use of new medical technologies. The objective, however, is not to provide solutions or recommendations for these questions. Rather, the intent is to demonstrate that each technological advance has consequences that affect the very core of human values.

Technology and ethics are not foreigners; they are neighbours in the world of human accomplishment. Technology is a human achievement of extraordinary ingenuity and utility and is quite distant from the human accomplishment of ethical values. They face each other rather than interface. The personal face of ethics looks at the impersonal face of technology in order to comprehend technology’s potential and its limits. The face of technology looks to ethics to be directed to human purposes and benefits.

In the process of making technology and ethics face each other, it is our hope that individuals engaged in the development of new medical devices, as well as those responsible for the care of patients, will be stimulated to examine and evaluate critically “accepted” views and to reach their own conclusions. This chapter, therefore, begins with some definitions related to morality and ethics, followed by a more detailed discussion of some of the moral issues of special importance to biomedical engineers

Morality and Ethics: A Definition of Terms

From the very beginning, individuals have raised concerns about the nature of life and its significance. Many of these concerns have been incorporated into the four fundamental questions posed by the German philosopher Immanuel Kant (1724–1804): What can I know? What ought I to do? What can I hope? What is man? Evidence that early societies raised these questions can be found in the generation of rather complex codes of conduct embedded in the customs of the earliest human social organization: the tribe. By 600 BC, the Greeks were successful in reducing many primitive speculations, attitudes, and views on these questions to some type of order or system and integrating them into the general body of wisdom called philosophy. Being seafarers and colonizers, the Greeks had close contact with many different peoples and cultures. In the process, struck by the variety of customs, laws, and institutions that prevailed in the societies that surrounded them, they began to examine and compare all human conduct in these societies. This part of philosophy they called ethics.

The term ethics comes from the Greek ethos, meaning “custom.” On the other hand, the Latin word for custom is mos, and its plural, mores, is the equivalent of the Greek ethos and the root of the words moral and morality. Although both terms (ethics and morality) are often used interchangeably, there is a distinction between them that should be made.

Philosophers define ethics as a particular kind of study and use morality to refer to its subject matter. For example, customs that result from some abiding principal human interaction are called morals. Some examples of morals in our present society are telling the truth, paying one’s debts, honouring one’s parents, and respecting the rights and property of others. Most members of society usually consider such conduct not only customary but also correct or right. Thus, morality encompasses what people believe to be right and good and the reasons they give for it.

Most of us follow these rules of conduct and adjust our lifestyles in accordance with the principles they represent. Many even sacrifice life itself rather than diverge from them, applying them not only to their own conduct but also to the behaviour of others. Individuals who disregard these accepted codes of conduct are considered deviants and, in many cases, are punished for engaging in an activity that society as a whole considers unacceptable. For example, individuals committing “criminal acts” (defined by society) are often “outlawed” and, in many cases, severely punished. These judgments regarding codes of conduct, however, are not inflexible; they must continually be modified to fit changing conditions and thereby avoid the trauma of revolution as the vehicle for change.

While morality represents the codes of conduct of a society, ethics is the study of right and wrong, of good and evil in human conduct. Ethics is not concerned with providing any judgments or specific rules for human behaviour, but rather with providing an objective analysis about what individuals “ought to do.” Defined in this way, it represents the philosophical view of morals, and, therefore, is often referred to as moral philosophy.

Consider the following three questions: “Should badly deformed infants be kept alive?”; “Should treatment be stopped to allow a terminally ill patient to die?”; “Should humans be used in experiments?” Are these questions of morality or ethics? In terms of the definitions just provided, all three of these inquiries are questions of moral judgment.

Philosophers argue that all moral judgments are considered to be “normative judgments”— that is, they can be recognized simply by their characteristic evaluative terms such as good, bad, right, wrong, and so on. Typical normative judgments include the following:

• Stealing is wrong.

• Everyone ought to have access to an education.

• Voluntary euthanasia should not be legalized.

Each of these judgments expresses an evaluation; that is, it conveys a negative or positive attitude toward some state of affairs. Each, therefore, is intended to play an action-guiding function.

Arriving at moral judgments, however, requires knowledge of valid moral standards in our society. Nevertheless, how is such knowledge obtained? The efforts to answer this question lie in two competing schools of thought that currently dominate normative ethical theory: utilitarianism, a form of consequentialism, and Kantianism, a form of nonconsequentialism. Consequentialism holds that the morally right action is always the one among the available options that has the best consequences. An important implication of consequentialism is that no specific actions or courses of conduct are automatically ruled out as immoral or ruled in as morally obligatory. The rightness or wrongness of an action is wholly contingent upon its effects.

According to utilitarianism, there are two steps to determining what ought to be done in any situation. First, determine which courses of action are open. Second, determine the consequences of each alternative. When this has been accomplished, the morally right course of action is the one that maximizes pleasure, minimizes pain, or both—the one that does the “greatest good for the greatest number.” Because the central motivation driving the design, development, and use of medical devices is improvement of medicine’s capacity to protect and restore health, an obvious virtue of utilitarianism is that it assesses medical technology in terms of what many believe makes health valuable: the attainment of well-being and the avoidance of pain.

Utilitarianism, therefore, advocates that the end justifies the means. As long as any form of treatment maximizes good consequences, it should be used. Many people, though, believe that the end does not always justify the means and that individuals have rights that are not to be violated no matter how good the consequences might be.

In opposition to utilitarianism stands the school of normative ethical thought known as nonconsequentialism. Proponents of this school deny that moral evaluation is simply and wholly a matter of determining the consequences of human conduct. They agree that other considerations are relevant to moral assessment and so reject the view that morally right conduct is whatever has the best consequences. Based largely on the views of Immanuel Kant, this ethical school of thought insists that there is something uniquely precious about human beings from the moral point of view. According to Kant’s theory, humans have certain “rights” that do not apply to any other animal. For example, the moral judgments that we should not kill and eat one another for food or hunt one another for sport or experiment on one another for medical science are all based on this view of human rights. Humans are, in short, owed a special kind of respect simply because they are people.

These two philosophies may be extended to apply to animal testing in scientific research as well. On the utilitarianism side of the argument for animal experimentation, the health care advancements for humans made possible through animal research far outweigh the majority of arguments against the practice. In contrast, nonconsequentialism would state that maltreatment of innocent and unprotected living beings is morally unjust and as such is an inappropriate means to the ends of better health care for people. Ultimately researchers must decide for themselves, based on their own beliefs and reasoning, which philosophy wins out.

In terms of human experimentation, to better understand the Kantian perspective, it may be helpful to recognize that Kant’s views are an attempt to capture in secular form a basic tenet of Christian morality. What makes human beings morally special entities deserving a unique type of respect? Christianity answers in terms of the doctrine of ensoulment. This doctrine holds that only human beings are divinely endowed with an eternal soul. According to Christian ethics, the soul makes humans the only beings with intrinsic value. Kant’s secular version of the doctrine of ensoulment asserts that human beings are morally unique and deserve special respect because of their autonomy. Autonomy is taken by Kant to be the capacity to make choices based on rational deliberation. The central task of ethics then is to specify what human conduct is required to respect the unique dignity of human beings. For most Kantians, this means determining what limits human beings must observe in the way they treat one another, and this, in turn, is taken to be a matter of specifying each individual’s fundamental moral rights.

These two ethical schools of thought, therefore, provide some rationale for moral judgments. However, when there is no clear moral judgment, one is faced with a dilemma. In medicine, moral dilemmas arise in those situations that raise fundamental questions about right and wrong in the treatment of sickness and the promotion of health in patients. In many of these situations, the health professional usually faces two alternative choices, neither of which seems to be a satisfactory solution to the problem. For example, is it more important to preserve life or to prevent pain? Is it right to withhold treatment when doing so may lead to a shortening of life? Does an individual have the right to refuse treatment when refusing it may lead to death? All these situations seem to have no clear-cut imperative based on our present set of convictions about right and wrong. That is the dilemma raised by Kant: What ought I do?

CASE STUDY: STEM CELL RESEARCH

At the moment of conception—that is, when a sperm penetrates an egg—the process of fertilization occurs. The formation of an embryo is initiated. Once the sperm enters the egg, there is an immediate opening of ion channels, which depolarizes the plasma membrane of the cell and prevents other sperm from fusing with it. DNA replication then begins, and the first cell division occurs approximately 36 hours later. As the process continues, the cell begins to experience cleavage, where the cells repeatedly divide, cycling between the S (DNA synthesis) and M (mitosis) phases of cell division, essentially skipping the G1 and G2 phases, when most cell growth normally occurs. Thus, there is no net growth of the cells, merely subdivision into smaller cells, individually called blastomeres.

Five days after fertilization, the number of cells composing the embryo is in the hundreds, and the cells form tight junctions characteristic of a compact epithelium, which is arranged around a central cavity. This is the embryonic stage known as the blastocyst. Within the cavity exists a mass of cells, which protrude inward. These cells are known as the inner cell mass and become the embryo. The exterior cells are the trophoblast and eventually form the placenta. It is the cells from the inner cell mass of the blastocyst, however, that, when isolated and grown in a culture, are identified as embryonic stem cells.

It is important to note that if cell division continues, determination and differentiation happen. Differentiation occurs when a cell begins to exhibit the specific attributes of a predestined specialized cellular role. Determination is related to differentiation but is somewhat dissimilar

FIGURE 2.1 Using the inner cell mass to form pluripotent stem cells.

When a cell group that has been determined is transplanted, it will not assimilate with the other cells but will grow into cells that comprised the original organ it was destined to become. Since the process of obtaining embryonic stem cells (Figure 2.1) destroys the embryo, the following questions arise:

1. Is the embryo a living human being, entitled to all of the same rights that a human at any other age would be granted? Discuss the answer to this question from a Utilitarian and Kantian point of view.

2. Should any research that is potentially beneficial to the well-being of mankind be pursued? In 2009, President Obama passed ground-breaking legislation entitled “Executive Order 13505—Removing Barriers to Responsible Scientific Research Involving Human Stem Cells.” The order calls for a review of NIH (National Institute of Health) guidelines for stem cell research and, more importantly, removes the requirement of President Action to approve NIH-funded stem cell investigations.

3. Should the federal government support (i.e., use tax dollars to fund) such research? Or, in contrast, should the government be allowed to interfere?