PHILOSOPHY 344 ETHICAL ISSUES IN HEALTH CARE SPRING 2000 4 cr.

 

Please note that the list of readings below is incomplete. The completed list will be available soon.

 

Lecture: MW 10:20- 11:40 110 Berkey

Discussion section: F 10:20-11:10 Section 1: 110 Berkey

Section 2: 107 Berkey

 

Instructor: Fred Gifford, 536 S. Kedzie (353-1993), gifford@pilot.msu.edu

Philosophy Dept. (503 S. Kedzie): 355-4490

Office hours: M 12-1 p.m., W 1:30-2:30 p.m., and by appt.

 

Teaching Assistant: Kyungsuk Choi, 539 S. Kedzie (353-8860), choiks@pilot.msu.edu

Office hours: T and Th 2:30 - 3:30, and by appt.

 

This is a course in health care ethics. We will examine a number of the difficult ethical choices that arise in the context of health care, such as the decision to remove life support from a patient, or to subject someone to a medical experiment, or to fail to provide a certain treatment on the grounds that it is too expensive. These questions do not admit of easy answers, because there are often plausible-sounding moral reasons to be given on each side of the matter. In part because of this, there is a tendency to want to set them aside as unanswerable, as just a matter of opinion. Yet they cannot be ignored.

Rather, these questions require that we think hard about them and address them carefully, and that we explore various underlying presuppositions that we often accept uncritically. As a result, this is a course in which we will focus on and practice the skill of critical thinking, and learn to express carefully, verbally and in writing, our reasoning for a given position.

 

REQUIRED TEXTS:

Munson, Ronald, Intervention and Reflection (2000), 6th edition.

Note that there is an online service that comes with this textbook. We will be able to use this to access further readings.

There will also be other articles and websites attached to the course website.

There will probably be reading packet as well. This will be announced in class (as well as on the website).

 

BASIS FOR GRADE:

3 Short Papers (15% each) (45%)

Final exam (35%)

10 Reflection Papers (20%)

 

Adjustments may be made in borderline cases for steady and unmistakable improvement in written work and thoughtful participation in class discussion.

 

PAPERS:

There will be 4 short papers (4-5 pp., typed, double-spaced) assigned. The specific topic will be distributed in class at least 11 days in advance. Each student will choose 3 of these. Papers are due at the beginning of class. Late papers will be accepted without penalty only in unusual circumstances and only if cleared with the instructor in advance. Late papers not cleared in advance will have their grade lowered by 0.5 for each 24 hour period for which the paper is late. The first such period starts at the beginning of class on the day that the paper is due. (If he or she wishes, a student may write all four papers, in which case the lowest paper grade will be dropped.) Students will receive a further handout describing the papers and their evaluation.

 

FINAL EXAM (Wednesday, May 3, 10-12:00 Noon, in the regular classroom):

Students will receive a list of about 10 essay questions several days before the exam (probably by Wed., April 19). At the time of the exam, the instructor will choose a smaller number (perhaps 5) and students will be instructed to write on a smaller number (perhaps 3) of these.

 

"REFLECTION PAPERS": very short (no more than a total of one double-spaced, typed page). In these papers students will respond to each of two different questions:

 

(1) What, to your mind, is the most interesting or important unanswered question raised in or by the class meeting prior to the day the paper is due, and why?

 

(2) What, to your mind, is the most interesting or important point raised in or by the assigned reading for the day the paper is due, and why?

 

These reflection papers will be assigned once a week during 12 of the weeks of the class.

The student must turn in 10 of these assignments. (If he or she wishes, the student may write 11 or all 12 and be evaluated only on the best 10.)

 

Everyone will be assigned a reflection paper for Wed., Jan. 19, and for Mon., Jan. 24.

 

Then, for the 5-week period from Jan. 31 to Mar. 1 (i.e., up until Spring Break):

Students in Section 1 will hand in their Reflection Papers on Mondays, and students in Section 2 will hand in their Reflection Papers on Wednesdays.

 

Then, for the 5-week period from Mar. 20 to Apr. 19:

Students in Section 1 will hand in their Reflection Papers on Wednesdays, and students in Section 2 will hand in their Reflection Papers on Mondays.

 

These reflection papers are due at the beginning of class. They will be read, evaluated, and returned at the following class meeting. Late papers will be accepted only in very unusual circumstances and only if cleared with the instructor in advance. Late papers not so arranged in advanced will receive a grade of 0.0.

 

SCHEDULE AND READINGS

 

NOTE: As noted above, this schedule is subject to revision. (Most notably, there will be a number of additions, accessible on the website and/or in a coursepack.) Changes will be announced in lecture and/or discussion section, and you will be responsible for knowing about any changes which have been announced. It will also sometimes be announced in class which parts of the readings you should focus on.

 

The following schedule includes only the Monday and Wednesday classes. There will also be a discussion section every Friday, but there will be no extra readings for discussion section.

 

Classes on Monday and Wednesday will include lectures, but there will also be opportunity for discussion. You are expected to come to class prepared to answer questions about and discuss the readings.

 

Attendance at both lecture and discussion section is required.

 

Jan 10 INTRODUCTION; REFUSAL OF LIFESAVING TREATMENT [VIDEO]

 

Jan. 12 REFUSAL OF LIFESAVING TREATMENT: DAX'S CASE [VIDEO]

CASE PRESENTATIONS:

Dax (378-381)

"The Death of Robyn Twitchell" (387-389)

Cultures in Conflict: Hmong (265-266)

Munson, "Introduction/Autonomy/Paternalism/Informed Consent in Medical Treatment" (389-395, 397-401)

Dworkin, "Paternalism" (402-411)

Cowart and Burt, "Confronting Death" (411-415)

 

[Disc: Dax]

 

 

Jan. 17 MARTIN LUTHER KING HOLIDAY - NO CLASS

 

Jan. 19

COMPETENCY

Drane, "Competency to Give Consent: A Model for Making Clinical Assessments" (415-418)

ETHICAL REASONING: I

Munson's Introduction (2-3), Part II: Major Moral Principles (31-45)

 

[Disc: Competency; ethical reasoning]

 

Jan. 24

ETHICAL REASONING: II

Part I: Basic Ethical Theories [Utilitarianism, Kant, Ross] (3-21)

TRUTH-TELLING

Munson, "Truth Telling in Medicine" (395-397)

Lipkin, "On Telling Patients the Truth" (434-435)

Cullen and Klein, "Respect for Patients, Physicians and the Truth" (435-442)

Brody, "Transparency: Informed Consent in Primary Care" (419-424)

 

AMA Statement on Informed Consent: http://www.ama-assn.org/physlegl/legal/infcons.htm

 

Jan. 26 EUTHANASIA and PHYSICIAN-ASSISTED SUICIDE: I

CASE PRESENTATIONS: Quinlan, Oregon, Cruzan, Kevorkian, Bouvia, Latimer (190-203)

Munson Introduction (203-211)

Rachels, "Active and Passive Euthanasia" (212-215)

 

[Disc: Truth-telling; killing and letting die]

 

Jan. 31 EUTHANASIA and PHYSICIAN-ASSISTED SUICIDE: II

Brock, "Voluntary Active Euthanasia" (215-222)

Gay-Williams, "The Wrongfulness of Euthanasia" (222-225)

Callahan, "When Self-Determination Runs Amok" (225-230)

Munson, "Purposes, Reason, and the Moral Law As Interpreted by Roman Catholicism" (26-31)

http://www.freep.com/suicide/index.htm

http://www.iaetf.org/index.htm

 

Feb. 2 DECIDING FOR OTHERS

Quinlan case (230-232)

Dresser and Robertson, "Quality of Life and Non-treatment Decisions for Incompetent Patients: A Critique of the Orthodox Approach" (233-238)

Gert, et al., "Distinguishing Between Patients' Refusals and Requests" (238-241)

Stoddard, "Terminal, But not Hopeless" (241-242)

 

Michigan's DPOA - http://www.afss.com/ethics/dpaact.htm

Ten Legal Myths About Advance Directives - http://www.abanet.org/elderly/myths.html

 

[Disc: Physician-assisted death; deciding for others]

 

Feb. 7 ETHICAL THEORY REVIEW

Rawls (21-26), Principles of Distributive Justice (37-40)

 

AIDS

 

Feb. 9 HIV and AIDS: OVERVIEW

CASE PRESENTATIONS (320-322, 325-331)

Intro (331-348)

Mayer, "The Irresponsibility That Spreads AIDS" (349-350)

Bayer, "AIDS Prevention and Cultural Sensitivity: Are They Compatible?" (356-360)

Hunter and Angoff, "Insurers are Right on AIDS Testing" (360-361)

Gifford, "An Insidious Test for AIDS" (361-362)

 

Feb. 14 AIDS and HIV CONFIDENTIALITY

Smith and Martin, "Confidentiality in the Age of AIDS" (350-355)

"Children at Risk/Medical ID Cards" (381-384)

Munson, "Confidentiality" (398-399)

Siegler, "Confidentiality in Medicine -- A Decrepit Concept" (442-445)

Tarasoff case (445-451)

Slater, "AIDS Exceptionalism is No Longer Justifiable" (362-367)

 

GENETICS and REPRODUCTION

 

Feb. 16 GENETICS: INTERVENTION, CONTROL AND RESEARCH

Munson intro (559-593): The Human Genome Project; Gene Therapy; Huntington's Disease; Introduction

 

Feb. 21 GENETICS: INTERVENTION, CONTROL AND RESEARCH: II

Hubbar and Lewontin, "Pitfalls of Genetic Testing" (594-597)

Wachbroit, Disowning Knowledge: Issues in Genetic Testing" (597-601)

Davis, Genetic Testing and the Child's Right to An Open Future" (601-610)

 

(Professional Disclosure of Familial Genetic Information )

http://www.journals.uchicago.edu/AJHG/journal/issues/v62n2/970326/970326.html

 

(Genetic Testing and Screening (Review of literature)

http://www.georgetown.edu/research/nrcbl/scopenotes/sn22.htm

 

(The Human Genome Project (Background Information)

National Human Genome Research Institute )

http://www.nhgri.nih.gov/ELSI/

 

 

Feb. 23 GENETICS: INTERVENTION, CONTROL AND RESEARCH: III

Purdy, "Genetics and Reproductive Risk: Can Having Children Be Immoral?" (611-616)

Kass, "Implications of Prenatal Diagnosis for the Human Right to Life" (617-624))

Munson and Davis, "Germ-Line Gene Therapy and the Medical Imperative" (624-633)

 

Feb 28 CLONING

Munson (647-650, 667-668)

Kass, "The Wisdom of Repugnance" (710-715)

The National Bioethics Advisory Committee, "Cloning Human Beings Ethical Considerations" (715-723)

Jacoby, Entitled to the Embryo?" (724-725)

 

EXPERIMENTATION ON HUMAN SUBJECTS

 

Mar. 1 INTRODUCTION TO EXPERIMENTATION ISSUES [VIDEO]

Tuskegee (255-257)

SOCIAL CONTEXT (463- 473)

HIV Trials in Developing Nations

Cold-War Radiation Experiments

Willowbrook

NY State Psychiatric Institute

Baby Fae

Introduction (473-494)

 

SPRING BREAK

 

Mar. 13 MEDICAL EXPERIMENTATION AND INFORMED CONSENT

Kass, Nancy, et al., "Trust: The Fragile Foundation of Contemporary Biomedical Research" (494-499)

Jonas, "Philosophical Reflections on Experimentation with Human Subjects" (499-508)

Gifford, "An Introduction to Ethical Issues Concerning Randomized Clinical Trials" 

 

Mar. 15 MEDICAL EXPERIMENTATION AND INFORMED CONSENT: II

Golby, et al., "The Willowbrook Letters: Criticism and Defense" (508-511)

Ramsey, "Judgment on Willowbrook" (511-515)

"Principles of the Nuremberg Code" (515)

Buchanan, "Judging the Past: The Case of Human Radiation Experiments" (524-531)

 

 

Mar. 20 THE CONFLICT BETWEEN PERSONAL CARE AND RCTs:

Hellman, "Of Mice but Not Men: Problems of the Randomized Clinical Trial" (516-520)

Passamini, "Clinical Trials: Are They Ethical?" (520-524)

 

Mar. 22 AIDS TRIALS

"Social Context: AIDS Activism and the Democratization of Biomedicine" (322-325)

 

Mar. 27 RACE, GENDER AND MEDICINE

Tuskegee (255-257)

The Mammography Debate; The Prostate Cancer Epidemic (258-265)

Introduction (266-283)

Goering, Women and Underserved Populations: Access to Clinical Trials" (296-300)

King, "The Dangers of Difference: The Legacy of the Tuskegee Syphilis Study" (300-303)

 

Mar. 29 ANIMAL EXPERIMENTATION

Singer, "Animal Experimentation" (531-538)

Cohen, "The Case for the Use of Animals in Biomedical Research" (538-544)

 

HEALTH CARE AND DISTRIBUTIVE JUSTICE

 

Apr. 3 MICRO-ALLOCATION: INTRO

SOCIAL CONTEXT: Acquiring and Allocating Transplant Organs (737-745)

SOCIAL CONTEXT: Fetal-Cell Implants (745-748)

CASE PRESENTATION: The Drug Lottery (748-749)

CASE PRESENTATION Selection Committee for Dialysis (749-753)

Introduction (753-758)

 

Apr. 5 MICRO-ALLOCATION AND ORGAN TRANSPLANTATION

Cohen, "The Case for Presumed Consent to transplant Human Organs After Death" (773-779)

Kinsley, "Take My Kidney, Please" (779-780)

Kass, "Organs for Sale? Propriety, Property, and the Price of Progress" (781-784)

 

Apr. 10

Rescher, "The Allocation of Exotic Medical Lifesaving Therapy" (758-766)

Annas, "The Prostitute, the Playboy, and the Poet: Rationing Scheme for Organ Transplantation" (785-789)

Cohen, et al., "Alcoholics and Liver Transplantation" (789-793)

 

Apr. 12 MACRO: THE CLAIM TO HEALTH CARE: I

SOCIAL CONTEXTS:

Leftovers from the 1994 Clinton Health Care Plan (805-813)

A Patient's Bill of Rights: Protecting Patients from Managed Care (813-817)

CASE PRESENTATIONS: Canada, Oregon, Hawaii (817-826)

Introduction (827-830)

President's Commission, "An Ethical Framework for Access to Health Care" (830-838)

 

Apr. 17 MACRO: THE CLAIM TO HEALTH CARE: II

Callahan, "Aging and the Ends of Medicine" (838-844)

McDermott, "The Case for a Single Payer Approach" (852-857))

Dirnfield, "The Benefits of Privatization" (857-860)

 

Apr. 19 COST-CUTTING / RATIONING

Angell, "The Doctor as Double Agent" (844-848)

Saturn, "Controlling AIDS/HIV Forever: Guidelines for Using Protease Inhibitors" (367-370)

Fleck, "Just Caring: Managed Care and Protease Inhibitors" (767-773)

Reinhart, "Wanted: A Clearly Articulated Social Ethic for American Health Care" (849-852)

 

Apr. 24 RACE, GENDER AND MEDICINE

Sherwin, "Gender, Race and Class in the Delivery of Health Care (284-289)

Dula, Toward an African-American Perspective on Bioethics" (289-296)

Geiger, "The Demise of Affirmative Action and the Future of Health Care" (303-305)

DeVille, Parties to the Social Contract? Justice and Health Care for Undocumented Immigrants" (306-311)

 

Apr. 26 SUMMING UP AND CATCHING UP

 

EXAM: Wednesday, May 3, 10-12:00 Noon, in the regular classroom.