I: Autonomy and Paternalism DIPLOMA OF APPLIED SCIENCE (NURSING) STUDIES IN ETHICS, LIFE SCIENCES, AND SOCIALITY

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1 I: Autonomy and Paternalism DIPLOMA OF APPLIED SCIENCE (NURSING) STUDIES IN ETHICS, LIFE SCIENCES, AND SOCIALITY Dr. Alan Bowen-James School of Nursing Kuring-gai College of Advanced Education Eton Road LINFIELD N.S.W AUSTRALIA 1

2 11. STUDIES IN ETHICS, LIFE SCIENCES AND SOCIALITY. The programme of study is intended to provide both a comprehensive academic formation in the study of applied Ethics in the Life Sciences and the field of Sociality at the undergraduate level and a basic preparation for dealing with ethical dilemmas in nursing practice. Though the course is an essential component of the nursing programme, it is believed to be of interest and of practical relevance to people of any professional or academic affiliation who are concerned with the evaluative aspects of issues that confront the community as a result of advancements in modern technology, the biosciences and medicine. The course is designed to present units of study that are fundamentally philosophical in conception, and must be addressed as a part of the process of dealing with ethical problems arising in any context. The philosophical conception allows for the systematic analysis of ethical principles, rules and theories coupled with the essential need to examine a wide variety of actual cases. The course addresses situations where doubt and conflict have arisen in the interest of rendering service to humanity with full respect for the dignity of the human person. The situations range from professional responsibility, public and social policy, clinical issues, experimentation and technological advancement. Without application to cases in these contexts, a systematic analysis of ethical principles and theories would be disembodied and possibly not perceived as relevant to either vocational practice or personal choices. The cases selected for analysis will not only illustrate principles, but also show why and how doubts and conflicts arise in relation to the principles in hard cases. The selected cases will be as representative of current problems as possible, some cases will be drawn from the law and ethics not because they are co-extensive but because legal decisions commonly appeal to moral principles and rules or raise issues that must be handled at least in part by moral deliberation. Preferred cases for analysis are those that both capture the working reality of health care, the business world, professional practice, community life, social and political administration and the ethical dilemmas, and choices that are forced upon the conscientious person. 2

3 AIMS OF THE COURSE (1) To sensitise students to the ethical concerns arising from the whole area of modern biosciences. (2) To promote an increased awareness in students of the ethical dimensions of decision making in the practice of medicine and nursing. (3) To introduce students to the ethical dimensions of decision-making in the health care sector from a legal, economic, political and social perspective. The importance of the conceptual uncertainties and practices in these contexts will be highlighted. (4) While not attempting to take substantive positions on specific ethical problems, it is intended to develop the students intellectual capacity, initiative and creativity with which they can then recognise, integrate and reconcile the various considerations relevant to the resolution of ethical dilemmas. (5) To encourage in students responsible, critical and reflective attitudes, habits of personal research, and a commitment to the study of. ethics that will continue throughout their lives. (6) To enable students to participate in raising community awareness of the issues and consequences of the various alternatives in the face of ethical dilemmas in health care, its delivery and practice. 3

4 ETHICS, LIFE SCIENCES AND SOCIALITY AUTONOMY AND PATERNALISM Semester I Co-requisite - Communication I 3 Class contact hours 6 Week hours OBJECTIVES: 1. To examine the concept of autonomy and the divergent interpretations applied to it. 2. To bring students to an awareness of a moral principle of autonomy and its implications for ethics. 3. To develop students' ability and willingness to protect and defend the well-being, rights, integrity and freedom of every person. 4. To help students accept responsibility for personal effectiveness in social relationships, group activities, and team work. 5. To develop a conscious and critical awareness towards keeping free and honest exchange of ideas with others and reducing prejudices in self. 6. To have students identify conflicting values in several contexts, for example, health care, politics, or the business world, and have them apply a process to value choices. (I) Chooses from alternatives (ii) Chooses after considering alternatives (iii) Chooses freely (iv) Prizes and cherishes own choices (v) Acts on own choices (vi) Acts with repetition and pattern in own choices (vii) Reflects on behaviour, chooses to modify it when appropriate Content: 1. An introduction to a systematic analysis of Mills's essay "On Liberty", a critical evaluation of the argument in support of the principles outlined in the essay. 2. Comparison of Kant's concern for the moral autonomy of the will and Mills's concern for the autonomy of thought and action. 3. Themes associated with autonomy: rights of individual liberty and privacy, free choice, choosing for oneself, being one's own person, creating one's moral position, accepting one's ultimate responsibility for one's moral views. 4

5 4. The notion that autonomy is a necessary condition for moral agency. Free will and Determinism. 5. An examination of conditions when the assumption that the person possesses the self-contained ability to make choices cannot be the case. 6. The degrees of Paternalism, the justification of Paternalism, and Coercion. When is an act voluntary? 7. The principle of beneficience and the question of whose conception of beneficience should prevail and under what conditions. 8. The elements of consent: (I) Information elements: -Disclosure of Information -Comprehension of Information (ii) Consent Elements: -Voluntary Consent -Competence to consent. 9. Refusal of Treatment 10. Autonomous suicide Definition of suicide The morality of suicide -the principle of human worth or the sanctity of human life. 11. Behaviour modification 12. Questions to be addressed (not exhaustive). -To what extent is it morally required to allow individuals to act in pursuit of their own aspirations? -Does an individual with self-destructive aspirations have the right to autonomy generally enjoyed by others? -Should freedom to act include freedom to follow a foolish or tragic (e.g. suicidal) course of events, or is it justifiable to override another's autonomy paternalistically, as well as for reasons of social benefit? -Does respect for a patient's autonomy require honesty on the part of the physician, even when deception seems medically prudent? -Do government programmes related to public health become coercive if they are based on the provision of powerful incentives? -Under what conditions is coercion justified in medical contexts or political contexts? -Is it ever justified to use coercive drug therapy to promote behaviour modification? 5

6 TEACHING AND LEARNING: Lectures: Students axe required to attend all lectures in Autonomy and Paternalism. The lectures will be taped and held in Closed Reserve, but this service is regarded as an aid to learning, not a substitute for lectures. Students will be tested on lecture content. Tutorials: Required reading is prescribed for each tutorial. Each tutorial will be preceded by a lecture intended to highlight and clarify the major principles and arguments in the prescribed reading. The nature of the dialogue during tutorials is intended to be dialectical, explanatory, questionning, and clarifying in a social climate of tolerance and acceptance in the face of conflict and alternative ideas. As well as becoming informed about the ideas under consideration, the student will be engaged in processes to develop critical thinking and articulation on evaluative issues. found in literature when explaining the application of moral principles. Case Studies: These will be drawn from personal experience in the health care system or other contexts where the notion of autonomy, freedom, paternalism, persuasion and coercion can be explicated. The case study may involve a patient, or a nursing practitioner who is able and willing' to participate. The selection of cases will be a co-operative activity between students and tutor. Abstract analysis is brought to bear on concrete cases, and comparisons drawn between concrete cases and those found in literature. Assessment: Tutorials 15% Case Studies 15% Essay 20% Examination 50% The criteria looked for in student performance during tutorials and case studies are the knowledge based on experience that: (i) they can and do articulate logically, coherently and consistently on evaluative issues (ii) they can and do identify conflicting values, formulate a principled position and support that position with logical arguments (iii) literature (and/or drama) has provided them with insights into human values, purpose and meaning. Students must be successful in each mode of the assessment. 6

7 RECOMMENDED READINGS: TEXTS: Abrams, N. and Buckner, M.D. (ed) Medical Ethics, London: The M.I.T. Press, Beauchamp, T.L. et al. Contemporary Issues In Bioethics, California: Wadsworth Publishing Co, Beauchamp, and Childress. Principles Of Biomedical Ethics, Chap 3 Hospers, J. Human Conduct, New York: Harcourt Brace Jovanovitch Inc, 1972 Hury, P. Plato And Modern Morality, London: Macmillan, 1972, Chapters 1 and 6 Gonsalves, M.A. Fagothey s Right and Reason, St. Louis: C.V. Mosby, 1981, Chapters 3, 14, 19 and 20 Gorovitz, S. et al. Moral Problems In Medicine, New Jersey: Prentice-Hall Inc, 1983, Chapter 2, 'Autonomy and Paternalism', pp Hospers, J. An Introduction To Philosophical Analysis, London and Henley: Routledge and Kegan Paul, 1978, Chapter 17 'Determinism and Freewill'. Mill, J.S. Utilitarianism, London: William Collins Sons & Co, 1979 Murphy, C.P. et al. Ethical Problems In The Nurse-Patient Relationship, Toronto: Allyn and Bacon, Inc, 1983 Veatch, R.M. Three Theories Of Informed Consent: Philosophical Foundations And Policy Implications, Belmont Report, Vol 1, 1978 Bioethics Encylopaedia -Headings -Freewill and Determinism -Informed Consent -Suicide -Life JOURNALS: Hastings Centre Report Journal Of Medical Ethics Journal Of Medicine And Philosophy 7

8 NOVELS: Stryon, W. Sophie's Choice Hardy, T. Tess Of The D'Urbervilles, Hardy, T. Jude The Obscure Hardy, T. The Mayor Of Casterbridge Solzhenitsyn, A. Matryona's House Solzhenitsyn, A. A Day In The Life Of Ivan Denisovitch Solzhenitsyn, A. The Love Girl And The Innocent:. Camus, A. The Myth of Sisyphus, Penguin Modern Classic. Kocan, P. The Treatment and The Cure 8