BIOETHICS

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CURRICULUMSECTION 1: SYLLABUSETHICS EDUCATION PROGRAMME
Sector for Social and Human Sciences
Division of Ethics of Science and Technology

The Bioethics Core Curriculum was developed with theassistance of the Advisory Expert Committee for the
Teaching of Ethics comprising the following members:
Mr Ruben APRESSYAN, Russian Federation (COMEST)
Mr D. BALASUBRAMANIAM, India (TWAS)
Mr Amnon CARMI, Israel (UNESCO Chair)
Mr Leonardo DE CASTRO, Philippines (IBC)Mr Donald EVANS, New Zealand (IBC)
Mr Diego GRACIA, Spain (COMEST-IBC)
Mrs Nouzha GUESSOUS-IDRISSI, Morocco (IBC)Mr Henk TEN HAVE, The Netherlands (UNESCO)Mr John WILLIAMS, Canada (WMA)

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BIOETHICSCORE

CURRICULUMSECTION 1: SYLLABUSETHICS EDUCATION PROGRAMME
Sector for Social and Human Sciences
Division of Ethics of Science and Technology

Design & Production:
Julia Cheftel
SHS/EST/EEP/2008/PI/1 Rev© UNESCO 2008
Version 1.0

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BIOETHICS

CORE

TABLE OF CONTENTSCURRICULUM

Introduction

3

Core Curriculum Content

6

Course Learning Objectives

7

UNIT 1

What is ethics?

89

UNIT 2

What is bioethics?

14
16

UNIT 3

Human dignity and human rights (Article 3)

19
22

UNIT 4

Benefit and harm (Article 4)

22
25

UNIT 5Autonomy and individual responsibility (Article 5)

26
30

UNIT 6Consent (Article 6)

29
33

UNIT 7

Persons without the capacity to consent (Article 7)

33
36

UNIT 8

Respect for human vulnerability and personal integrity (Article 8)

37
40

UNIT 9

Privacy and confidentiality (Article 9)41
43

UNIT 10Equality, justice and equity (Article 10)

44
46

UNIT 11Non-discrimination and non-stigmatization (Article 11)

47
48

UNIT 12

Respect for cultural diversity and pluralism (Article 12)

50
51

UNIT 13

Solidarity and cooperation (Article 13)

53
54

UNIT 14

Social responsibility and health (Article 14)

56
57

UNIT 15

Sharing of benefits (Article 15)

60
61

UNIT 16

Protecting future generations (Article 16)

63
63

UNIT 17

Protection of the environment, the biosphere and biodiversity (Article 17)

66
66

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INTRODUCTION
BackgroundOn 19 October 2005, the 33rd Session of the General Conference of UNESCO adopted
the Universal Declaration on Bioethics and Human Rights (hereafter referred to as the Declaration). The Declaration embodies a set of bioethical principles that has been agreed
upon by 191 Member States of UNESCO after an intense elaboration and consultation
process involving independent and governmental experts from all regions of the world.
This set of bioethical principles provides a common global platform by which bioethics
can be introduced and strengthened within each Member State, and UNESCO is mandated to promote, disseminate and elaborate these principles for practical purposes.
The core curriculum consists of two sections. Section 1 (this document) provides thecore contents with objectives, syllabus and teacher manual for each unit of the curriculum. Section 2 contains the proposed study materials for each unit of the curriculum.

Justification

The UNESCO Bioethics Core Curriculum sets out to introduce the bioethical principles of the Universal Declaration on Bioethics and Human Rights to university students.
Bioethics teaching has not been introduced in many universities in many countries. This
UNESCO Bioethics Core Curriculum can provide an incentive to start introducing suchteaching. Its contents are based on the principles adopted in UNESCO. It therefore
does not impose a particular model or specific view of bioethics, but articulates ethicalprinciples that are shared by scientific experts, policy-makers and health professionals
from various countries with different cultural, historical and religious backgrounds.
The UNESCO Bioethics Core Curriculum furthermore presents a core: it defines whatshould be regarded as the minimum (in terms of teaching hours and contents) for appropriate bioethics teaching. It allows flexible application. It also invites teachers andstudents to expand its contents and approaches in diverse directions.

Objectives

The core curriculum is built upon learning objectives. Each unit starts with specificobjectives. The focus on objectives not only serves to demarcate the contents for each
unit. It also is the basis of the assessment of the program as well as the evaluation of thestudents.

Target groups

The primary target group of the core curriculum is medical students. The teachingshould be implemented before the end of the clinical phase of their medical education.
Although the core curriculum can be introduced in the pre-clinical phase of medical
studies, it will probably be more effective for students who are in the clinical phase.
These students have experienced the need for ethical reflection and they will also moreeasily recognize the ethical dimension of cases and problems.
Nowadays, bioethics teaching is also introduced in other educational programs suchas nursing education, health care sciences, dentistry and public health. Furthermore,bioethics teaching is provided to law, philosophy and social sciences students. The corecurriculum can be used for teaching to these other categories of students. It provides abasic training on the fundamentals and major issues of present-day bioethics.
Students engaged in research with human beings should partake in additional training
beyond the core curriculum.
When bioethics teaching is lacking at all levels of education, the core curriculum canalso be used as the first introduction into bioethics for health care professionals (medical doctors and nurses in particular). It is therefore useful for post-academic training
and continuing education. The curriculum may also be applied in educational programsfor members of ethics committees.

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BIOETHICSCORE

CURRICULUM

Structure of thecurriculum andpossible uses

∆ Units based on principles
The first thing a teacher will notice about the syllabus is its innovative and unconventional structure. Typically, ethics courses in medical schools are organized around specific medical dilemmas such as beginning of life and end of life issues. The core curriculum, however, is designed around the bioethical principles of the Declaration, with each
unit of the syllabus (except for the first two units) elaborating one of the principles. The
primary rationale for this design is firmly rooted in the fact that Member States haveachieved consensus on these bioethical principles, thus establishing an uncontroversial
core curriculum for the teaching of bioethics in all Member States.

∆ Not a complete course but source of inspiration
However, the core curriculum should not be treated as a comprehensive curriculum inbioethics. It is recognized that the content of the core curriculum does not necessarily
cover all aspects of bioethics. Traditional issues that have not been included could be incorporated as examples that are pertinent to one or several of the Declaration’s principles
within the curriculum’s framework. Furthermore, the number of hours proposed for each
unit should be considered as the minimum amount of time to be dedicated to the material. It is preferred that teachers do not deem the proposed time allotment as sufficient,and they should strive to build more hours into their teaching. Although UNESCO hastaken measures to ensure that the curriculum is sensitive to various social, cultural andeconomic contexts, it is emphasized that teachers using the curriculum must still exercise
discretion on the methods employed to convey the content of the curriculum, selecting
contextually relevant materials provided or sourcing other available materials. Therefore,
the core curriculum is intended to be a minimum teaching programme in bioethics withthe possibility of further innovation, expansion and flexible application in different contexts. It is not intended to impose a particular model of teaching but rather is a source ofideas and suggestions on how to approach bioethics teaching.

∆ Flexibility
Teachers are encouraged to build additional modules focusing on traditional and otherrelevant issues around the units of the syllabus, bearing in mind that all units should
be covered, dedicating at least the minimum recommended time. The proposed orderof units could and should be adjusted according to the teaching style of the teacher.
However, it should also be noted that the following units should be taught in conjunction to maintain a logical flow of the syllabus: Units 1 and 2; Units 5, 6 and 7; Units 13,
14 and 15; and Units 16 and 17. Depending on the structure of university education, thiscan imply that some units of the core curriculum will be taught in earlier phases of theuniversity program, and other units in later stages. Implementation of the core curriculum may have many varieties, as long as the appropriate connection between the units
and the coherence among the units is maintained. It is up to individual schools anduniversities to design additional hours into the implementation of the core curriculum,as well as decide how and at what level the core curriculum should be integrated into
the university program.

∆ Wider scope of bioethics
Teachers should keep in mind that the core curriculum is meant to provide them away of getting students to reflect upon the ethical dimensions and human rights considerations of medicine, health care and science, and that the Declaration approaches
bioethics by going beyond the usual individualistic perspective of ethics, widening thescope to include social and community issues. Finally, it is stressed that although abioethics course is important and a prerequisite, ethics needs to be taught as much as
possible throughout the entire university curriculum.

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Introduction
Methods of assessment

As with other courses in university education, bioethics teaching should be evaluated.
Two types of evaluation will be necessary.

∆ Course evaluation
After completion of the core curriculum the teaching should be evaluated. Students aswell as teachers are invited to provide feedback on the implementation of the curriculum. The purpose of this evaluation is to identify how the course and the teaching canbe improved. In order to obtain comparable data about the implementation, UNESCO
will develop a standardized questionnaire for the evaluation of the course.

∆ Student evaluation
The purpose of this evaluation is to assess whether the teaching of the course has resulted in the accomplishment of the objectives in each student. This evaluation is therefore focused on assessing the impact of the course in individual students. Various methods can be used: a written test, a multiple choice test, paper assignments, case analyses,
presentations, essays, oral examinations.
In the future, on the basis of the outcome of the evaluation of the core curriculum, otherassessment methods can be suggested.

FeedbackAs they adapt the curriculum to their teaching styles and contexts, teachers are invited
to submit additional modules they have developed around the core units of the syllabus
as well as additional study materials that are deemed useful. Teachers are also encouraged to provide feedback on the core curriculum to enable UNESCO to improve theproduct.
Please submit all feedback and materials to:
Ethics Education Programme (Bioethics Core Curriculum)
Division of Ethics of Science and Technology
Sector for Social and Human Sciences
UNESCO1, rue Miollis
Paris 75732
FranceEmail: eep@unesco.org

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BIOETHICS

CORE

CORE CURRICULUM CONTENTCURRICULUMUNIT 1

What is ethics?*

2 hours

UNIT 2

What is bioethics?*

2 hours

UNIT 3

Human dignity and human rights (Article 3)

2 hours

UNIT 4

Benefit and harm (Article 4)

2 hours

UNIT 5Autonomy and individual responsibility (Article 5)**

1 hour

UNIT 6Consent (Article 6)**

2 hours

UNIT 7

Persons without the capacity to consent (Article 7)**

2 hours

UNIT 8

Respect for human vulnerability and personal integrity (Article 8)

1 hour

UNIT 9

Privacy and confidentiality (Article 9)

2 hours

UNIT 10Equality, justice and equity (Article 10)

2 hours

UNIT 11Non-discrimination and non-stigmatization (Article 11)

2 hours

UNIT 12

Respect for cultural diversity and pluralism (Article 12)

2 hours

UNIT 13

Solidarity and cooperation (Article 13)***

2 hours

UNIT 14

Social responsibility and health (Article 14)***2 hours

UNIT 15

Sharing of benefits (Article 15)***

2 hours

UNIT 16

Protecting future generations (Article 16)****

1 hour

UNIT 17

Protection of the environment, the biosphere and biodiversity (Article 17)****

1 hour								Content Note

Total: 30 hours(1 hour = 60 minutes)* Units 1 and 2 are tied together.
** Units 5, 6, and 7 are tied together.
*** Units 13, 14, and 15 are tied together.
**** Units 16 and 17 are tied together.
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COURSE LEARNING OBJECTIVESGeneral Objectives

Students should be able to identify ethical issues in medicine, healthcare and life sciences

Students should be able to provide rational justification for ethical decisions

Students should be able to apply the ethical principles of the Universal
Declaration on Bioethics and Human Rights

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BIOETHICSCORE

CURRICULUMUNIT 1

What is ethics?

Unit Learning
Objectives
Students should be able to recognize and distinguish an ethical issue
from other issues
Students should be able to reason about ethical issues

Outline of
the Syllabus

1

The moral point of viewa What is ethics?
b The world of ethics
c The universal experience of dutyd Moral experience is universal, but some moral perceptions and judgements varye Universality and variability of human morality
f Moral statements

2

The nature of moral judgementsa Three types of sentencesb Surface grammar and depth grammarc Moral criteria and moral judgements

3

An ethical method of reasoninga First step: Fact deliberation
i The caseii Deliberation about the facts
b Second step: Value deliberationi Identification of the moral problems
ii Choice of the main problem
iii The values at stakec Third step: Duty deliberation
i Reflecting on the most challenging cases
ii Reflecting on other casesd Fourth step: Testing consistencyBioethics Core i.indd 8

e Fifth step: Conclusion

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UNIT 1

Teacher Manual1

The moral point of viewa What is ethics?
Morality is a unique feature of the life of human beings. It is deeply influenced byseveral cultural factors, such as history, traditions, education, religious beliefs, etc. The
intellectual analysis of this human dimension in all of its complexity is the goal of thediscipline called Ethics. Ethics does not create morality or moral behaviour. The goalof ethics is much more modest: to explore the nature of moral experience, its universality and its diversity. Ethics and morality are generally taken as synonyms, because they
originally had the same meaning: the study of the disposition, character, or attitude of a
specific person, group of people or culture, and ways of promoting or perfecting it.

b The world of ethics
In its development through history, the discipline called Ethics has known different approaches. None of them have obtained, to this moment, a general agreement. There are
ethical systems ordered around the ideas of law, duty, obligation, virtue, happiness, principles, consequences, etc. In an effort to capture the valuable insights of each of these approaches it will be useful to begin by analyzing the universal moral experience of humanbeings. Proceeding this way, two concepts emerge as basic: one is ‘value’ and the other is‘duty’. Values can be identified amongst all peoples and societies and they often provide
unique identifiers of those cultures. Values therefore predate the discipline called ethics,
being promoted by religions, cultural traditions, history, etc. Values are the background ofmany other moral concepts derived from them, like principles, norms, laws, virtues, etc.
One of the most important goals of ethics is the intellectual analysis of values and value
conflicts, in order to define our duties. And duties always involve the values at stake ineach specific situation, promoting them as much as possible.

c The universal experience of duty
We all consider that some things ought to be done and others avoided. We have a duty to act
in certain ways rather than others. The experience of duty is one of the most universal characteristics of human life. There is no human language without the so-called ‘duty-verbs’,such as ‘must’, ‘ought’, ‘shall’, or without imperative moods, in order to express commands,
like: ‘do no harm!’, ‘fulfil your promises!’, ‘do not steal!’, ‘do not lie!’. Similarly, there is no
human society without some rules of conduct, either ‘prohibitions’ or ‘obligations’.

d Moral experience is universal, but some moral perceptions and judgements vary
For instance, morality has been changing all over human history. Moral values are different depending on the place in which one is living, the language one speaks, the culture,
the religions practised. Ask the students to provide examples.

e Universality and variability of human morality
It follows from the previous statements that there are some universal and unchangeable elements in human morality, but others are historically conditioned and particular.
Structurally, morality is always the same, but the contents are, at least to some extent,
variable. In fact, moral values are constantly evolving. But at the same time, some moral
duties remain unchanged, reflecting the logical limits of what counts as part of moral
discourse. For instance, do not harm others, or tell the truth.

f Moral statements
Human beings express, communicate, and exchange human experiences through language. Statements are judgements, propositions or assertions that attribute some predicates to subjects.

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CURRICULUM

2

The nature of moral judgementsa Three types of sentences
		 i
		 ii
		 iiib

Mahatma Gandhi was 1.5 metres tall.
Mahatma Gandhi was nice.
Mahatma Gandhi was good.

Surface grammar and depth grammar
The words surface grammar refers to the construction of the sentences in terms ofsubject, verb and complement. The sentences are identical in this respect. As the first
sentence ascribes a property to a subject we might expect the others to do the same.
However when we look at the way we handle the sentences in the case of apparent disagreements about their truth we see that they behave very differently. This shows thatthe depth grammar or the logical character of the sentences varies.
i
How do we resolve a disagreement about the first sentence? It is a matter of			 measurement. Though we might not be in a position to make the measurement
			 we certainly know what it would be like to make it. Our understanding the			 sentence depends on such knowledge. If two people disagree about the claim
			 made by the sentence one of them must be wrong. It is a question of objective
			 fact, an empirical claim.
ii How do we resolve an apparent disagreement about the truth of this sentence?
			 Each speaker might be able to give a reason for their statement. But they do			 not have to be able to do so and might simply say that they just like him. There			 is no logical limit to what people may like or dislike. The lesson is that the			 sentence is not in fact about Gandhi at all but about the speaker who is simply			 expressing a feeling he has about Gandhi. This is not therefore a statement at all			 but an expression of feeling. The speaker might be trying to deceive us but he			 cannot be mistaken.
iii How do we resolve a disagreement about the truth of the final sentence?
			 No-one can say that they have no reason for the claim as it is not a matter of			 whim. Further there are limits to the kind of consideration which can count			 as a proper reason. It has to be a moral reason. Thus the fact that Gandhi
			 was a man of peace who supported non-violent protest would be a justification
			 of the claim. But another observer might consider that opting for non-violent
			 protest is a sign of weakness which hinders the quest for justice. This would be			 a reason for disagreeing with the claim. Thus the same consideration can count			 either for or against the judgement. It follows that relevant criteria are called for			 but they might not guarantee agreement.

cMoral criteria and moral judgements
In the history of ethics we can find two groups of thinkers who have taken different viewsof moral statements depending on which of sentence i or ii most resembles sentence iii.
		 One group have seen passions or emotions as the key element of moral sentences which makes them much like sentence ii. This takes seriously the possibility of noagreement being reachable by the application of reason. However it ignores the fact that
there are logical limits to the feelings relevant to moral statements. It has been pointed
out that we cannot simply experience feelings like pride by just trying hard. Rather
we have to remember some achievement or relation to the object of pride in order toexperience pride. Similarly we cannot experience the moral feeling of shame without
recalling some unworthy event in our lives.
		 It has also been pointed out that no rule of behaviour can count as a moral principle
except it is related to a family of concepts like respect, truthfulness, pride, ostentation,
harm, benefit and so on. These logical limits make moral statements appear to be akin tosentence i. But to overemphasise this similarity suggests that all moral disagreements canbe resolved by appeal to these principles and criteria. But if it were not for moral values
there would be no moral problems for these are created by tensions between those values
in specific situations. Nevertheless reason has its role to play in moral deliberation for the
logical limits we have referred to have to be respected. In many cases reasonable reflection will facilitate agreement but it simply cannot be guaranteed to do so.

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UNIT 13

An ethical method of reasoning
Decision-making and ethics
Ethics is both a theoretical and a practical discipline. The language of ethics refers toduties and values. One goal of ethics is to determine right decisions, and in order to dothat, it is necessary to go step by step, analyzing, first, the facts of the case, second, thevalues at stake, and third, the duties.

a First step: Fact deliberationi

The case

The deliberation process begins always in the same way, with the presentation of aproblem or a case, which is often difficult from the moral point of view. This difficultyis perceived as a conflict, generally called ‘moral conflict’. Conflicts appear when a decision should be taken, and it is difficult to identify the best course of action, because in
all possible actions important values are at stake, and selecting one implies the infringement of other compelling values. The goal of the ethical method of reasoning is always
the same, to help people to resolve these kinds of problems, taking wise or decisions.

ii

Deliberation about the facts

In order to resolve a moral conflict, the first thing we must do is to make a carefulanalysis of the facts of the case, lowering the uncertainty in this field as much as possible and also correcting misperceptions. This is not an easy task, and it usually takes a
lot of time. But at this point, the careful analysis of facts is basic if we want to do things
well. For instance, a careful analysis of medical facts is essential in medicine in order toknow the situation of the patient, the diagnosis, prognosis, and treatment. This is a very
difficult task. We must reduce uncertainties as much as possible, through the processof individual or collective deliberation. Nobody knows all possible facts involved in asituation. Our perception of facts is influenced by our education, cultural background,personal expertise and experience. We might have been trained to perceive some facts,
for instance, the medical ones, but we might not have the same sensitivity to perceive
others, such as the patient’s socio-economic situation, which other people, with othertraining, perceive more readily. Therefore, we should analyze facts carefully, considering
the advice of other people when things are difficult. For instance, in medicine so-called‘clinical rounds’ often take place, in which members of the health care team discuss thefacts of a clinical case, in order to reduce their uncertainty about its diagnosis, prognosis, and treatment. However their considerations should range more widely than the
medical facts and should take account of the patient as a whole.

b Second step: Value deliberationi

Identification of the moral problems

The analysis of a case starts when somebody thinks that he or she has a problem andthinks it is a moral problem. Such cases are often more complex than they at first appear. People ask about a problem, but this does not mean that this is the only problem
the case presents. It is necessary, therefore, to identify and describe the different moral
problems we are able to find in the case, to enable full and unambiguous discussion.

ii

Choice of the main problem

After the identification of all ethical problems at stake in the case, we must choose one
among them, which is to be discussed in the next steps of the analysis. Problems should
be discussed one by one. Only after the discussion of one can we begin the debate aboutanother, and so on. If we mix different problems, reaching a conclusion will be impossible. In any case, we consider that the problem to be discussed first is, of course, thatconveyed by the person who presented the case in step 1. This is the main problem, atleast for him or her, and our duty now is to help him or her to reach a wise decision.
The problem identified by the questioner might be insignificant compared to othermoral problems the case involves. The solution of the major problems might remove theoriginal problem from the scene altogether. For example a doctor might perceive theproblem of whether to choose a more expensive form of treatment for a patient or not
when the major problem might be that he has not enquired whether the patient wants
to be treated at all. Therefore, we should analyse the problem conveyed by the person
who presented the case, and the problems on which it is dependent, if they exist.

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BIOETHICS

CORE

iii The values at stake

CURRICULUM

We have been talking until now of ‘problems’, and ‘moral problems’. We have not given a
precise definition of this expression. ‘Moral problems’ are always concrete, specific. They
are not abstract. When someone has a moral problem, it is because he or she does notknow which moral value should be respected in the situation. We say that the person hasa ‘conflict of values’. Therefore, the specific language of ‘moral problems’ can be translated into the abstract and universal language of ‘values’ and ‘conflict of values’. Values are
special qualities. For instance, justice and truthfulness are values. Values are qualities thathuman beings think important. If we think of a world without justice, or truthfulness, we
can realize that these are important or positive values. There are, of course, opposite values to them, as injustice. Our duty is always and necessarily to implement positive values,
promoting them in our world. And moral conflicts appear when the attempt to implementa specific value infringes the fulfilment of another. In order to solve this conflict, the firstthing to do is to identify the different values at stake; that is, to translate ‘moral problems’into the language of values and ‘conflict of values’.

cThird step: Duty deliberation
A conflict of values can be solved in different ways, and our duty is to identify andchoose the best one, that is, that which promotes best the fulfilment of positive values,or that infringes least upon the values at stake. Therefore, we must identify the different
possible courses of action of the case. And the easiest way of doing that is identifying
first the extreme courses of action.

i

Reflecting on the most challenging cases

It is important for the doctor to be sensitive to the whole range of ethical values in dealing with clinical cases. Such sensitivity, however, will often present challenges which
would otherwise not occur. These challenges are ethical in nature in that it is the tensions between respect for various values which make it difficult to decide what should
be done. There will be more and less demanding challenges of this kind. The most problematic for the doctor to deal with will be those where it seems that whichever alternative course of action is taken he will be doing wrong by failing to respect an importantvalue. These situations are called dilemmas and are rarer than might at first appear.
More often than not careful consideration of all aspects of the case will show that thedilemma is only apparent. The following example is such a case.
		 A Jehovah Witness refuses a blood transfusion for himself in line with his sincere
religious beliefs but at the same time asks for help in saving his life. The two main values
at stake here are respect for his spiritual wellbeing on the one hand, and respect for his
physical wellbeing on the other. We might at first think that we cannot maintain respect
for both of these values in this situation. If we are correct then we shall have choose
between the extremes and sacrifice one value for the other believing that we are doing
wrong whichever option we take. This would constitute a moral dilemma. Our viewmight be that the best outcome of the treatment is the survival of the patient whereas
his view might be that surviving at the cost of being damned forever would be the greatest possible personal disaster.
		 Our first moral duty is to endeavour to respect all values at stake as much as possible. Ideally we need to find a way of saving the life of the patient without ignoring his
religious beliefs. That is, we need to carefully examine our initial belief that we have agenuine dilemma on our hands. There are numerous possible ways of respecting both
values in such cases. For example, around 12% of Jehovah’s Witnesses do not fully agreewith the Watchtower’s blood doctrine. One intermediate course of action is, therefore,to evaluate individual beliefs in respect to blood among Jehovah’s Witnesses patients.
Some of them accept some form of blood or blood products. If we find that our patientis firmly opposed to this option there are other possibilities. One is the use of bloodlesssurgery techniques. Another is the use of transfusion alternatives, like volume expanders, and oxygen therapeutics (Perftec, Hemopure, Oxygent, PolyHeme, Perfloran). And
yet another course of action is avoiding the use blood or any substitute unless the needreally arises. Thus in the case under discussion the apparently contradictory ethicaldemands on the clinician can both be satisfied. Failure to reflect on these matters could
result in serious harms to the patient whichever of the two apparent options is taken.

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UNIT 1
ii

Reflecting on other cases

Most moral problems which face doctors in treatment decisions are less dramatic than
the apparent dilemmas such as the case cited above. They usually take the form of numbers of ethical values calling for attention and making demands on practitioners. These
call for careful consideration but do not suggest that the practitioner is presented with
an impossible task to find an acceptable solution. We might call these moral problems
rather than dilemmas. Nevertheless considerable harms can be caused if the doctor fails
to take the various issues into account. The reflection should involve weighing the various values against each other in the specific situation to facilitate the wisest decision.
That decision will be the one which is least morally objectionable, or, to put it anotherway, involves least disrespect for the values which figure in the case. These reflections
can be complex and different cases might involve details which tip the balance one way
or the other to give priority to a particular value. Sadly neat solutions are not always
available but there are a number of possible outcomes. There are those where eachvalue is compromised somewhat but at no great moral cost, and others where one value
or set of values will be seen to outweigh the others in the specific set of circumstances.
In the latter cases that value or set of values will win out over the other at no moral costfor the duty to act in that situation becomes clear.

d Fourth step: Testing consistency
It is important that moral reflection is consistent. Special pleading involves giving undue
weight to one or more consideration because it is in the interest of the decision maker so to
do. This will always prejudice the decision and undermine the proper role of reason in ethical reflection. We can use a number of techniques to guard against such inconsistency.
i
We can avoid such bad practice by referring to some external measures such			 as the Law. Though the law does not solve ethical problems it does usually			 reflect the moral values of citizens. On some occasion laws might be unjust
			 and not serve us in this way.
ii We can also ask ourselves the question: Would I behave in this way if it was to			 become generally known that I had done so? An honest appraisal in these			 terms would draw our attention to our disregard for the principle which has
			 been extremely important in the history of ethics, namely to act in such a way			 as to be able to wish that mode of behaviour be a universal law.
iii We should not be hasty in drawing conclusions in moral reflection. Once			 presented with moral problems in practice doctors experience a considerable
			 injection of emotions. Such feelings are not unimportant but they might cloud			 any immediate judgement and stimulate rash decisions. Using the time that is			 available, which might also involve consulting with colleagues, allows these			 emotional rushes to recede somewhat and facilitate wiser decisions.

e Fifth step: Conclusion
The desired outcome of all these reflective activities is to arrive at wise decisions. Practical wisdom, the art of making well-thought decisions is the moral virtue par excellence.
Well-thought decisions are not necessarily universally agreed decisions. Serious andresponsible people can disagree on ethical matters. However it has been said that theunexamined life is not worth living and in medicine it is certainly true that the morally
unreflective life is to be deplored.

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BIOETHICSCORE

CURRICULUM

What is bioethics?

UNIT 2

Unit Learning
Objectives
Students should be able to explain the difference between medical
ethics and bioethics
Students should be able to differentiate bioethics, law, culture,and religion
Students should be able to explain the principles of bioethics andhow to balance these principles in practice

Outline of
the Syllabus

The birth of bioethics

1

a The coining of the word ‘bioethics’b Bioethics as bridge between facts and valuescBioethics versus medical ethics

d The idea of Pottere Bioethics as global ethics

2

Health and disease as values
a Health and disease are facts as well as valuesb Health identified with wellbeing

Principles of bioethics

3

a Health care decisions include facts and valuesb The principles of the Universal Declaration on Bioethics and Human RightscMany principles have not been respected throughout history

d Paternalism and ‘informed consent’e Conflicts between bioethical principles. Limits to the autonomy of patientsfLimits of justice and resource allocationg Limits to paternalism

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UNIT 2

Ethics committees

4a Previously, moral conflicts were scarceb Nowadays, many principles need to be respected and they are often in conflictc

The occurrence of conflicts is not negatived The main goal of bioethics is to manage moral conflicts
e To accomplish this goal, bioethics uses deliberationf‘Bioethics committees’ are platforms for deliberationg Different types of committees
h Ethics committees are not legal tribunals

Medical professionalism

5

a Professional ethicsb Changes in medical ethicsc

The unchanging goal of professional ethics

d Professionals strive for excellence

Teacher Manual1

The birth of bioethicsa 		 Bioethics is a relatively new word coined by a biochemist, Van Rensselaer Potter, in1970 in an endeavour to draw attention to the fact that the rapid advances in science hadproceeded without due attention being paid to values. For some time the word referredto the attempt to link scientific facts and values in the area of environmental concerns.
Nowadays it has taken on a more general meaning which includes medical, or more generally, health care ethics. Though there are examples of reflection on ethics in medicine
through the ages the subject of bioethics has mushroomed into sub-discipline of ethics
in the past decades. This growth was stimulated both by abuses of human beings in thecourse of medical research, especially during the Second World War, and by the emergence of medical technologies which have challenged various widely held public values.

b 		 Potter conceived this new discipline, bioethics, as a ‘bridge’ between ‘facts’ and ‘val-

ues’. During the second half of the twentieth century, he said that biological sciences
had been increasing their knowledge and technical power continuously, but reflection
about the values at stake has not progressed in the same proportion. Potter said that hecoined the word bioethics using two Greek words, bíos, life, representing the facts of lifeand life sciences, and éthos, morals, referring to values and duties.

c 		 One profession dealing with life during centuries and millennia, especially with hu-

man life, has been medicine. But today there are many sciences and professions working
in this field. Therefore, bioethics should not be confused with medical ethics, which isonly one of its branches. The field of bioethics is as wide as the facts of life, and its study
is divided in many branches, each one with its specificity: Ecological or environmental
bioethics, Medical bioethics, Clinical bioethics.

d 		 The idea of Potter, and in general of bioethics, is that not all that is technically possible ismorally right, and that some control of our intervention in nature and the environment, on
animals and on human beings, is needed. The future of life and of humankind is at stake.

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COREe 		 Bioethics is the first attempt of thinking ‘globally’ in ethics. In fact, one of the books

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written by Potter is titled Global Bioethics (1988). Throughout its history, ethics has not
had a global dimension. The widest criterion introduced in ethics was the Kantian principle of ‘universality’: ‘Act only according to that maxim whereby you can at the sametime will that it should become a universal law’. But the German philosopher ImmanuelKant (1724-1804) probably understood ‘universal’ in a very narrow way, as comprising
only all the actual human beings. On the contrary, the idea of ‘globalization’ includes
not only all actual human beings, but also future generations (called ‘virtual’ human beings), all other living organisms, and also nature, the environment.

f2

Global bioethics includes, therefore:iAll actual human beings (see Units 5–15)
ii Future human beings (see Unit 16)
iii All living organisms and the environment (see Unit 17)

Health and disease as valuesa 		 Health and disease, like life and death, are not bare facts, but also embody values.
Usually health and life are valued and disease and death disvalued. It is also true thatvalues can determine what counts as health itself. Many physicians, especially in theWest, think that health and disease can only be understood as bare facts. Diseases, theysay, are due to the alteration of some tissues or parts of the human body, which can be
determined scientifically. Therefore they conclude that disease is a scientific fact, thesame as the usual facts in physics or in chemistry.

b 		 We think of health as positive as a good and disease as negative, as an evil. Nowadays it isusual to identify health with wellbeing. This is the core idea of the definition of health statedby the World Health Organization (see Unit 4). People think today that they are ill when
they feel some lack of wellbeing, even without any biological alteration. Because of this newconception of health values are important in the concepts of health and disease.

3

Principles of bioethicsa 		 Physicians and other health care professionals have to make health care decisions. Many of
the facts they consider have values built into them, for example that a given condition causes
suffering or threatens a patient’s life or detracts from their wellbeing in some other way.

b 		 Our duties are always the promotion and implementation of values. The duty ofpromoting values is the origin of norms. When these norms are wide and general, they
are called principles. The UNESCO Universal Declaration on Bioethics and Human Rights
identifies fifteen bioethical principles:i Human dignity and human rights
ii Benefit and harm
iii Autonomy and individual responsibility
iv Consent
v Persons without the capacity to consent
vi Respect for human vulnerability and personal integrity
vii Privacy and confidentialityviii Equality, justice and equity
ix Non-discrimination and non-stigmatizationx Respect for cultural diversity and pluralism
xi Solidarity and cooperation
xii Social responsibility and healthxiii Sharing of benefits
xiv Protecting future generations
xv Protection of the environment, the biosphere and biodiversity
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UNIT 2c 		 Many of these principles have not been respected through history. For instance, phy-sicians have traditionally applied their own values and neglected those of patients inmaking clinical decisions. Doctors as experts have considered that they know best what
is good for their patients as fathers know what is best for their children. This historicalapproach has been called ‘paternalism’ and is now seen as inadequate.

d 		 Paternalism is a behaviour that might be taken as morally when societies are homo-

geneous from the point of view of values. This was the case in the past, and might bethought so today in many parts of the world. People in traditional societies shared thesame values. When physicians, therefore, made medical decisions taking into account only
their own values, they could suppose they were respecting also the values of their patients.
But this situation has changed drastically during the last centuries. One of the reasons forthis change has been the continuous mobility of people and the mix of different values,
beliefs, and traditions in modern societies. There may yet be some societies where physicians can assume that patients share their values but they would be very few. Doctors must
therefore take patients’ values into account. This is the origin of the doctrine of ‘informed
consent’, which counters the traditional paternalism of the medical profession. The moral
principles here involved are the following of the previous list: i, iii, iv, vi, vii, and x.

e 		 Professionals must respect the values of patients. But in some cases the values of pa-

tients cannot be honoured by physicians, because they are in conflict with other bioethical principles. One very important duty of health care professionals is expressed by
the traditional saying: ‘do no harm’. Medical interventions are risky, with important side
effects, and many times they hurt people. The balance between benefits and risks is essential in order to determine when medical procedures are harmful or not. A limit to theautonomy of patients is set by the moral principles listed with the numbers ii, ix, and xv.

f 		 Another limit to the values of patients is fairness in the access to health care and the

distribution of resources. The growing technological development of medicine is increasing the price of health care to such an extent that most individuals are incapable of paying
their own bills. This has opened another set of moral problems, all of them related to justice, the right to have health care, and the fair distribution of scarce resources. The moral
principles to deal with these problems are the following: viii, ix, x, xi, xii, xiv and xv.

g 		 Our moral duty is not only not to harm others, but to help and benefit them. This isespecially important for health care professionals since their goal is to do the best forpeople in need. This has always been the main principle of medical ethics but today
what is beneficial for patients and what is not cannot be determined only by health care
professionals; it is also, and primarily, determined by patients. Ignoring this situation
leads to paternalism. To act in the best possible non-paternalistic way: this is the newinterpretation of the moral principles listed with the numbers ii, v, and xiii.

4

Ethics committeesa 		 The situation of present day health care is much more conflict laden than ever before. Traditional medical ethics used to work with the moral principle of beneficenceand non-maleficence, understood in a paternalistic way. The only decision maker was
the professional, and the only moral principle to be taken into account was beneficenceand non-maleficence. Therefore, the possibility of moral conflict was very remote.

b 		 On the contrary, there are different moral principles and values to be respected ineach specific situation. Often, these principles conflict with each other. There are potential conflicts between all of them.

c 		 The number of conflicts is not related to the morality of a society, or of a profession. In

fact, conflicts arise when people are entitled to decide and take part in decision-making
processes. When only one person has the power to decide and the unique moral duty of
all others is obedience, conflicts are quite impossible. Conflicts are part of human life, andthey are more frequent as respect for human freedom and moral diversity increases.

d 		 The problem is not the existence of conflicts; the problem is the will to respect and resolve them. This is the main goal of bioethics, to train people in the management of moral
conflicts, in order to take wise decisions and, in this way, improve the quality of health care.

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COREe 		 In order to reach this goal, bioethics uses deliberation as the way of approaching and

CURRICULUM

thinking about moral conflicts. People can work individually with this procedure, especially when problems are not very complex. But when conflicts are difficult, or when
they involve many people, deliberation should be done collectively.

f 		 There are some areas outside specific treatment decision making where special bio-

ethics bodies have been created to build respect for values into health care provision.
This is the origin of so-called ‘bioethics committees’. They are platforms for deliberations in order to take wise decisions and to make policy recommendations. There aredifferent types of ethics committees, as described in the UNESCO Guides Establishing
Bioethics Committees and Bioethics Committees at Work: Procedures and Policies:i
Policy-Making and Advisory Committees (PMAs)
ii Health-Professional Association (HPA) Bioethics Committees
iii Health Care Ethics Committees (HECs)
iv Research Ethics Committees (RECs)g 		 Each of these committees has its own characteristics, as described in the UNESCO

documents. For instance, HEC committees do important work in clinical bioethics. They
consist of physicians, nurses, social workers, and lay members, both men and women.
Different backgrounds, expertise and experiences allow a better understanding of cases,
enriching all the individual perspectives and facilitating decision-making.

h 		 HEC committees are not judicial bodies with the responsibility of sanctioning wrong
conduct and imposing disciplinary measures. This is one of the biggest differences between ethics committees and legal tribunals. The goal of ethics is not to compete withlaw, but to promote wise decisions among people and professional excellence. Bioethics
does not look for what is legally right but for what is humanly best. The goal of bioethics
is to promote the best possible action.

5

Medical professionalisma 		 Professionalism refers to the conduct, aims, or qualities that characterize or mark aprofession or a professional person. The project ‘Medical Professionalism in the New
Millennium: A Physician Charter’ defines professionalism as the basis of medicine’s
contract with society. ‘It demands placing the interests of patients above those of thephysician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of
medical professionalism must be clearly understood by both the profession and society.
Essential to this contract is public trust in physicians, which depends on the integrityof both individual physicians and the whole profession’. (Annals of Internal Medicine
2002; see http://www.annals.org/cgi/content/full/136/3/243) Professionalism is, therefore,
directly related with ethics. Its ethical expression is called Professional Ethics. Some ofits formulations are the Codes of Professional Ethics.

b 		 Throughout the history of medicine, many changes have occurred in medical ethics.
The influence of paternalism has decreased, to the same extent as respect for autonomy
has increased. There have also been important changes related to access to health careservices and the distribution of scarce resources.

c 		 But there is one thing that has remained unchanged in professional ethics all overits history, which is the moral duty of professionals not only not to do harm but to do
the best for their patients. This is a primary goal of professional codes of conduct which
each professional is obliged to observe.

d 		 Professionals must strive for excellence. They have in their hands the most valued

things people have: life and health, and their duty is to do the best for them.
		At the beginning of the Nicomachean Ethics Aristotle wrote: ‘There is some end of the things
we pursue in our actions which we wish for because of itself, and because of which we wish for theother things; […] clearly this end will be the good, i.e. the best. Then surely knowledge of this goodis also of great importance for the conduct of our lives, and if, like archers, we have a target to aim
at, we are more likely to hit the right mark’. (Nicomachean Ethics I 1: 1094 a 18–26)

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UNIT 3

Human dignity and human rights (Article 3)

UNIT 3

Unit Learning
Objectives
Students should be able to explain and apply the concepts of humandignity and human rights
Students should understand the relevance of these concepts in the context of bioethics

Outline of
the Syllabus

Concepts of dignity in the history of ideas

1a Classical antiquity
b World religions traditionscModern philosophy

d Contemporary humanitarian law
i The Universal Declaration of Human Rights
ii The European Convention on Human Rights and Biomedicine

2

Human dignity as an intrinsic value of the person capable (at least potentially or
as a member of natural kind) of reflection, sensitivity, verbal communication, freechoice, self-determination in conduct and creativity
a Human dignity is an end in itself
b Equality in dignity of all human beingscRespect and cared The interests and welfare of the individual are prior to the sole interest of societye Human dignity as a foundational concept

3

The diverse understandings of human dignity in different cultural and moral traditions (Buddhist, Confucian, Judeo-Christian, Muslim, communitarian, liberal) anddifferent types of societies

4

A person’s dignity and rights entail others’ obligation to treat a person respectfully

5

Ethical aspects of health care provider-patient relations in regard to human dignity
and human rights
a The problem of paternalismb In treatment of children, elderly persons, and mentally handicapped individualsc

In palliative treatment of terminal patients and patients in ‘vegetative state’d In treatment of embryos and foetuses
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Teacher Manual

There are several concepts of dignity in the history of ideas:1a Classical antiquity. Common understanding of dignity as deserving of honour and es-

teem according to personal merit, inherited or achieved. In ancient Greek philosophy,
particularly of Aristotle and the Stoics, dignity was associated with human abilities ofdeliberation, self-awareness, and free decision-making.

b In many world religions human dignity is considered to be predetermined by the creation of human beings in the image of God; those who are weak in body and soul havedignity equal to those who are robust and sturdy.

cModern philosophy proposed secular understanding of human dignity and progressively associated this concept with the idea of human rights. In different teachings humandignity was presented as an aspect of personal freedom (Giovanni Pico della Mirandola)or an embodiment of one’s public worth (Thomas Hobbes), or as universal virtue, unconditional and incomparable worth determined by one’s autonomy rather than origin,wealth, or social status (Immanuel Kant). One of Kant’s basic principles of ethics – to treat
any other person always at the same time as an end, never merely as a means (categoricalimperative) – has been accepted by moral and political philosophy as the actual basis forthe conception of human rights and in this sense it is a foundational concept.

d In contemporary international law, national constitutions, and other normative documents, human dignity is strongly connected with human rights.
i
According to Art. 1 of the Universal Declaration of Human Rights (1948),		
			 ‘all human beings are born free and equal in dignity and rights.’ The Declaration			 establishes human rights (like freedom from repression, freedom of expression
			 and association) on the inherent dignity of every human being.
ii The European Convention on Human Rights and Biomedicine in Art. 1
			 declares protection of ‘the dignity and identity of all human beings and			 guarantees everyone, without discrimination, respect for their integrity and			 other rights and fundamental freedoms with regard to the application of			 biology and medicine’ as its main purpose.

2

The notion of human dignity expresses the intrinsic value of the person capable(at least potentially or as a member of natural kind) of reflection, sensitivity,
verbal communication, free choice, self-determination in conduct, and creativity.
a Unlike material values, or financial prices, human dignity has no external equivalent;
it is an end in itself. Unlike merit as an embodiment of publicly recognized personal
achievements, a person is dignified as a human being as such.

b All human beings are equal in dignity irrespective of gender, age, social status or ethnicity.
c

Recognition of a person’s dignity presupposes active respect for her human rights,
self-esteem and self-determination, as well as care for her privacy, protecting her fromillegitimate intrusions and preserving her valid public space.

d A society or a community should respect each of its members as a person or a moral

agent on the basis of the notion of human dignity. This notion also requires that theinterests and welfare of the individual are considered as prior to the sole interest ofsociety, community, or any particular kind of publicly wholesome activity. The emphasison ‘the sole interest of science or society’ is important. It implies that because of his/herhuman dignity, the individual should never be sacrificed for the sake of science (as has
happened in medical experiments during the Second World War) or for the sake of society (as has happened in totalitarian regimes). But ‘sole’ also implies that there might be
exceptional circumstances in which the interest of others or the community as a whole
are so important that infringing upon the interests of individuals is unavoidable in order to save others or the community. An example is the threat of a deadly pandemic.

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UNIT 3e Human dignity is a foundational concept and it is theoretically and normatively inap-

propriate to reduce it to functional characteristics of person’s activity, ability to decision-making or to taking into account her autonomy. Respect for dignity means recognition of other’s intrinsic worth as a human being.

3

In a comparative view, human dignity has diverse forms in different cultural and ethicaltraditions (for example, Confucian, Judeo-Christian, Muslim) and is respected in various
ways in different types of societies (traditional, modern, totalitarian, democratic). It isless respected in totalitarian societies and more respected in modern and democraticsocieties. Regardless cultural, confessional, and political varieties human dignity is universally based on the person’s self-awareness and appropriate respectful treatment towards her. As it is emphasized in Declaration, the regard to cultural diversity is ‘not to
be invoked to infringe upon human dignity, human rights and fundamental freedoms’(See Article 12).

4

From the point of view of ethics, the person’s dignity and rights are proved by others’ obligation to treat a person respectfully, that is to cause no harm, not to abuse, to be fair, notto impose unwelcome models of personal good and happiness, not to treat her merely asa means, and not to consider the interests and welfare of the individual as subordinate toothers’ interests and welfare, to ‘the sole interest of science and society’.

5

Health care provider-patient relations are just one kind of human relations, presupposing all ethical requirements.
a However, historically these relations used to be considered as unequal. A physician

was associated with an active role of decision-maker, providing medical care, taking
responsibility. Hence, he or she was higher in status. A patient was associated with apassive role of recipient, being in need, not responsible for his or condition and, hence,lower in status. In this paternalistic model of health care provider and patient relationship the patient used to be in a dependent position.

b Actual inequality in the status of the health care provider and the patient may be ag-

gravated in special cases when patients are children, handicapped individuals, elderly
persons. Particularly risky are cases of patients who are mentally handicapped.

cSpecial attention in regard to human dignity and human rights is required in palliative
treatment of terminal patients and patients in ‘vegetative state’.

d Though there is no consensus either in public or in the expert community concerning
the ethical and legal status of embryos and foetuses, the latter should be treated withrespect and care.
		The principles manifested in articles 4–15 of the Universal Declaration on Bioethics andHuman Rights give a proper framework to respect patients’ dignity and rights and clarify
the specific context of human rights in bioethics.

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Benefit and harm (Article 4)

UNIT 4

Unit Learning
Objectives
Students should be able to identify harms and benefits in health caresettings
Students should be able to evaluate harms and benefit in health caresettings
Students should be able to justify decisions taking harms and benefits
into accountOutline of
the Syllabus

What is a health benefit?

1

a Problems in determining what is a health benefit; this is not always related to disease statesb A narrow concept of healthc

2

The WHO definition of health as a possible solution of these problems

What is harm?
a Similar problems of identifying what is harmb Ancient notion: ‘above all do no harm’c3

Different types of harm

How do we evaluate benefits and harms in practice?
a Dimensions of comparing harms and benefits in individual patientsb Significance of these dimensions for making treatment choices

Teacher Manual
1

What is a health benefit?
a Begin by analyzing the various interpretations of ‘health benefit’ proposed by the students.
Various possibilities can be mentioned:irelief of sufferingii careiii prevention of disease, illness, disability
iv healthv enhancementvi psychological benefit

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UNIT 4
At first glance it does not seem to be problematic to identify health needs. We are all
only too familiar with the common reasons we have for going to see our doctor. Perhaps
we have an unexplained pain or we are short of breath or we simply feel dreadful andfind we have no energy to do anything. We expect the doctor to diagnose some kindof problem associated with disease, either trivial or serious. We are told that we havean infection, or that our condition demands further investigations which will involve
sophisticated investigative work to determine whether we are developing a malignant
tumour, or rheumatic joints or a stomach ulcer or whatever. There is a standard classification of diseases to which doctors refer when conducting these investigations. It is
tempting therefore to conclude that to be healthy is to be free from any of the diseases
detailed in that list and being unhealthy is to suffer from one or more of them.
		 Once we have determined the disease state of a person then, it seems, we have also
identified their health needs. Absence of disease means no health needs and therefore
no possibility of health benefits; disease means there is a need for treatment and thepossibility of treatment leading to either a cure or the palliation of the effects of thedisease, each of which counts as a health benefit.

b A narrow concept of health
Attractive though the above story is, it is only part of the truth. A cursory glance at thepractice of medicine will show that health benefits are available to people who do notpresently suffer from any disease. These are provided by prophylactic treatments or disease prevention programmes such as vaccination against whooping cough. To be protectedfrom the onset of a disease clearly constitutes a health benefit. Indeed it has been argued
by health economists that these are the cheapest forms of health benefits to achieve. Most
people would also prefer that their health practitioners enable them to avoid suffering
diseases rather than have to treat those diseases when they occur. However, conceding thispoint does not move us far from the disease model of health in that the range of healthbenefits is still exhausted by either the treatment or the avoidance of disease.
		 If we look more closely at health care delivery we will see that non-disease conditions are also part of the remit of medicine and surgery. The most obvious treatments
which go beyond the disease related conditions are bodily dysfunctions arising fromtraumas, such as broken legs and brain injuries. Restoring proper physical functioning
by treating the results of non-disease events are clearly part of the remit of health careprovision. But the practice of health care professionals might go far beyond restoring
normal bodily functions in the face of such events. When such restoration is impossible,
health care professionals might still have a role in providing health benefits to those
who suffer impairments of function. For example, the provision of prostheses to people
who have suffered the loss of arms or legs in accidents is doing nothing to restore normal bodily functioning nor to treat or ameliorate the effects of disease. It is to treat asocial dysfunction insofar as the new limb enables its wearer to engage in a wider rangeof social activity and the affairs of life than would otherwise be possible. No-one would
hold that this was not to provide a health benefit. Such an extension of the definition ofhealth benefits demonstrates that simply widening the disease model of health to one
related to physiological function is also inadequate. Here the social context of a physicalcondition becomes significant.
		 Further reflection will soon bring us to a consideration of mental health problems.
Only a very few people would assert that such problems always originate from or are explicable in terms of physiological functioning. Even though there has been vigorous debate amongst psychiatrists and philosophers about the application of terms like ‘illness’
to mental conditions, it is generally accepted that many behaviours and psychologicalphenomena fall under the umbrella of health. Indeed mental health is a major segmentof health care delivery. Whilst there are some advocates for physiological explanationsof mental problems, including genetic determinists, most practitioners disagree. If, forexample, an apparent psychopathy can be explained by the existence of a brain lesion, aphysiological explanation, then it is described as a ‘pseudo-psychopathy’.

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BIOETHICSCORE

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c

Discuss the WHO definition of ‘health’: ‘a state of complete physical, mental, and social
well-being and not merely the absence of disease or infirmity’iexamples of a wider range of proper clinical activities can be used to demonstrate			 the narrowness of any disease oriented definition of health benefits
ii the example of infertility constituting a health need can be employed to explore
			 the evolution of the character of health interventioniii at the same time, the WHO definition is often criticized for being too wide; it			 is encompassing many situations that are not disease related and that can			 expand the area of work of medical doctors
Given the apparently limitless extension of the boundaries of health and consequentlyof needs and benefits indicated above, can we find some kind of general description
which would secure a manageable range of benefits for which health care should aim?
		 The WHO, fully aware of the dangers of imposing narrow limits on the notion of health,has provided a definition which has been influential for many years. This definition certainly takes account of the extensions of health beyond the boundaries imposed by disease
related and physiological dysfunction related conceptions. It takes the psychological andsocial dimensions of people’s conditions seriously. Insofar as this is the case the definitionis valuable. However it is limited in its usefulness by the sheer immensity of the range of circumstances and conditions for which, by implication, health authorities should be regarded
as responsible. These would include the benefits of the provision of adequate defence capabilities to provide for the security of the population of a country and for the benefits ofthe provision of education to a population. A later amendment includes ‘the ability to leada socially and economically productive life’. However the amended definition remains open
to the same criticism. In addition the amended definition might tempt us to consider that
there are universal objective measures of health and consequently of health benefits. This
would oversimplify the task of identifying and measuring health benefits.
		 So how do we proceed when we want to identify a health benefit? General definitions of health tend to be either too wide or too narrow to fit all cases to be of much assistance. It might therefore be helpful to look at the arguments that have been made forand against the identification of a particular condition as a candidate for being a healthneed and for the identification of the relevant concomitant health benefits attaching to
the treatment of that condition.

2

What is harm?
a It will not be surprising to learn that the task of identifying harms in health care delivery

suffers from the same difficulties as the identification of benefits. It is not necessary tolabour this point and one example of this relationship should be sufficient. Let us imagine
that a surgical procedure to remove an ovarian cyst is carried out successfully on a patient.
In the course of the procedure one of her fallopian tubes is inadvertently damaged andscarred. This damage results in infertility. Has a harm been visited upon that patient? The
answer to this question is that it all depends on the patient. If the patient considers that
she has completed her family and that she will not want any further children, then the inability to conceive will not constitute a harm for her. Of course it might turn out that she
will change her mind about this, given the possible circumstances which could develop in
her life. In such an event she would come to consider that the surgical error did harm her.
In other words we are obliged to consider the context of the surgical mistake in the lifeof the patient before we can determine whether it was harmful or not. The harm that isestablished in relevant cases, however, cannot be divorced from the kind of benefit which
the provision or protection of fertility would constitute for the woman concerned.
		 Proceed with analyzing the various interpretations of ‘harm’; ask the students to
identify what can be harm in the health care setting, for example:i
physical harmii psychological harm
iii moral harm (harm to interests, harm as unfairness, harm as disrespect)iv social/economic harm (consequences for social role, stigmatization)

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UNIT 4b But there remain some interesting issues to consider around the question of identify-

ing and avoiding harms in health care. If the ancient notion which asserts the primum
non nocere (above all do no harm) principle is to be adhered to in practice, how can any
surgical procedure be attempted, or indeed any medication be prescribed, when we cannever know with certainty what the effects in total of that intervention will be in a given
patient? In another context the wound inflicted by the surgeon in an abdominal operation
would constitute a grievous bodily harm. Similarly the administration of cytotoxic drugs
in other situations than in treatments of malignant disease would constitute poisoning.
What justifies them in surgery and chemotherapy is the net balance of benefit over theharm which the treatments inevitably involve. Indeed any clinical intervention has to beundertaken only after the completion of a risk of harm/likelihood of benefit calculation. If
a patient does not stand the chance of benefiting overall from an intervention, then thatintervention is not indicated for him/her. That is, where the risk of harm outweighs possible benefit, then the treatment is not indicated.
		 These calculations are often very difficult to make for not only will the variety ofperceptions of harm and benefit mentioned earlier come into play, but the empiricaland conceptual uncertainties of the possible outcomes will confound the procedure.
With respect to the former uncertainty it has been said that every administration of adrug is an experiment. How one patient will react will not always be a reliable guide to
how another will react. One patient with the same disease as another might respondwell to a drug whereas the other might not be helped. Or one might suffer unpleasant
adverse events whereas the other will tolerate the medication well. Whilst there is hopethat the new technology of pharmacogenomics will increase our levels of confidence
in matching medicines to patients and remove much of the trial and error element ofprescribing, it will never eliminate uncertainty.
		 With respect to conceptual uncertainty we might consider the difficulties of making riskof harm/likelihood of benefit calculations in withdrawing or continuing intensive care treatments. In such circumstances is it the same to ask whether it can be of benefit to a patient
to withdraw life prolonging treatment as to ask whether it can be harmful to continue life
support where it precludes the possibility of a dignified death? We might well find that wecannot easily determine what can count as a harm or benefit in such cases.

c3

In ancient medical ethics, an important moral principle is ‘above all do no harm’. This
notion continues to be used as an important ethical principle in contemporary healthcare. Discuss this principle and answer the following questions:i
Can a physician avoid harm?
ii What is the distinction between expected and unexpected harm?
iii What is positive and negative harm?
iv Who determines what counts as harm?

In health care practice it is important to evaluate benefits and harms
a Explore the difficulties of measuring harms and benefits in individual patients, involving
i
ii
iii
iv

the assessment of degrees of harm and benefit
the incommensurability of harms and benefits
the social context of physical and mental suffering
the subjective nature of sufferingb Treatment choices also have to be made among patients; here an assessment has tobe made between risk of harms and potential benefits for different patients. This will
be particularly important for resource allocation; when time or material resources are
scarce, different priorities can be selected; focusing on patients who are most in needbecause of the harm they are suffering or on patients for whom treatment will produce
the greatest benefit.

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CURRICULUM

Autonomy and individual responsibility(Article 5)

UNIT 5

Unit Learning
Objectives
Students should be able to explain the concepts of autonomy and individual responsibility and to understand their significance for the healthcare provider-patient relationshipStudents should understand the relationship between autonomy andindividual responsibility

Outline of
the Syllabus

The concepts of autonomy and responsibility

1a Autonomy:i Different levels and notions of autonomy
ii Different theoretical approaches to autonomyb Responsibility: its different aspects and dual naturec2

Mutual correlation of autonomy and responsibility in ethics

Decision making in medicine
a Autonomy and patient’s right to self-determination in treatmenti Autonomy and paternalism
ii Autonomy as a right and an obligationb Patient autonomy should be respected by physicianscThe patient’s right to refuse a health care provider’s recommendationd Special measures for protecting the rights and interests of socially and mentally disabled patients3

Patient autonomy and responsibilities in health care. The range of patient responsibilities

4

Evaluation of patient’s abilities to self-motivation and self-control

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UNIT 5Teacher Manual

The concepts of autonomy and responsibility

1a Autonomy – as individual capacity for self-determination, independent decisions,actions, and evaluations.

iDifferent levels and notions of autonomy∆ freedom from paternalistic interference, all the more so, from authoritarian						dictates from any agent, including the state and especially transnational				 corporations; one’s capability to self-determination;			∆ capability to act on the basis of rational principles and rules accepted as				 adequate to one’s understanding of good, personal dignity, and happiness;			∆ capability to reflect upon these principles and rules, to influence their formation				 and transformation through public discourse.
ii
			
			

In the Kantian approach, autonomy is an ability of deliberated self legislation;in the utilitarian approach, autonomy is associated with one’s ability to follow
one’s preferencesb Responsibility is one’s awareness of one’s obligation to make decisions and to act appropri-

ately on the basis of certain commitments (for example, towards an external authority, oneself,
one’s status, engagements, or agreements, respected others, accepted principles and rules).

iDifferent aspects of responsibility∆ spontaneously obtained status or commitments (for example, responsibility							 of parents);∆ consciously accepted status or commitments (responsibility of an officer,				 professional, self-committed person);∆ legal responsibility.

ii
			
			

c

2

Dual nature of responsibility∆ responsibility as accountability,∆ responsibility as personal and universalizable duty.

In ethics, the notions of autonomy and responsibility are mutually related. Responsibility manifests autonomy; there is no autonomy without responsibility; beyond responsibility autonomy turns to arbitrarity, which means that the person in his/her decisions
does not take into consideration the interests of others.

Decision making in medicine
a In medical practice the principle of autonomy underlies the patient’s right to self-determination. As such the principle of autonomy has been recognized in opposition topaternalism, which has been essential for a traditional type of health care provider-patient
relationship. As a condition for the patient’s final decision, autonomy is not merely a rightbut also a responsibility. The patient is autonomous to make responsible decisions.

b So far most patients feel dependent on physicians, the respect for patients’ autonomy

by physicians is crucial; so a discretionary space should be secured for patients to maketheir own decisions with respect to their own dignity.

c

A health care provider is an expert in medicine; a patient is an expert in her/his preferences, beliefs, and values. A patient may refuse a health care provider’s recommendation, but she/he is not entitled to treatment beyond the present medical standards andthe availability of treatment. In other words, patients have a right to refuse treatment but
they cannot claim all treatments.

d Special measures are needed for protecting the rights and interests of persons who
are not capable of exercising autonomy and making responsible decisions concerning
medical care and treatment (see Unit 7).

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3

Patient autonomy and responsibilities in health care
Patient responsibility has the following range:a Responsibility for consequences of freely taken decisions
If individuals are really autonomous and if they decide in all freedom, they have to takeresponsibility for the consequences of these decisions. An example is engagement inrisky behaviours.

b Responsibility to avoid infringement of another person’s autonomy
A limit to the autonomy of an individual is the autonomy of other individuals. We cannot argue that as autonomous persons we have the right to limit the autonomy of otherpersons. If we want our free choices, and thus our values, to be respected, we are obliged
to give the same respect to the free choices, and thus values, of others. An example is thedebate on smoking; we are free to decide to smoke and endanger our own health, but
we cannot endanger the health of others.

4

In cases when a patient’s ability to make autonomous and responsible decisions is notclear, special steps should be taken to evaluate her/his abilities to self-motivate andself-control, to keep commitments and loyalties, to make decisions while taking into
account the given situation, the goals, and the results, and to choose on the basis ofreflective preferences and principles.

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UNIT 6Consent (Article 6)

UNIT 6

Unit Learning
Objectives

Students should be able to explain the meaning of ‘consent’, ‘informed’, and ‘informed consent’; they should be able to define theprinciple of ‘informed consent’Students should be able to explain what the process of informed consent requires
Students should be able to explain how the principle of consent is applied in different interventions, research, and teachingStudents should be able to explain how exceptions to the principle canbe justified

Outline of
the Syllabus

Interconnection of principles

1

a The principle of consent is based on the principle of human dignity and human rights
b The principle of consent is a practical specification of the principle of autonomy and individual responsibilityc2

If the principle of consent cannot be applied, the provisions of Article 7 (‘Persons without the capacity toconsent’) are applicable

What is the purpose of the principle of consent?
a The principle of consent principle aims to achieve several objectives:
i it asserts the patient’s autonomy
ii it protects his/her status as a human beingiii it prevents coercion and deception
iv it encourages the doctor’s self-criticism
v it supports the process of rational decision-making
vi it educates the public at largeb Consent expresses respect for the dignity and rights of each human being

3

Interrelation between consent and autonomy

4

Explanation of the principle
a The article applies to all medical interventionsb What is prior, free and informed consent?
cConsent requires adequate information
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d What is express consent?

CURRICULUM

e Withdrawal of consentf

The patient’s right to refuse and right not to know

g Consent of subjects of scientific research. Compare the provisions for consent in scientific researchwith those for medical interventions
h Consent by individual, group and community

5

Exceptional circumstances for the application of the principle of consent
a Emergency situationsb Minorsc

Mental patientsd Jehovah’s Witnesses
e EuthanasiafHIV patients

Teacher Manual

Introduction

1

Explain how the principle of consent is connected to other principles of the Declarationa Article 3
A person’s basic rights are established on the recognition of his/her human status, theinviolability of his/her life, and the fact that he/she was born and will always be free. Because human dignity and human rights are to be respected, the person concerned needs
to give consent for medical interventions and for participation in scientific research.

b Article 5
Since the autonomy of every person is accepted as an important value, participation indecisions concerning one’s own body or health must be recognised as a right.

c

A decision to treat should be determined by co-operation between the person who
treats and the person who is treated, both parties being linked together by mutual trust
and reciprocity.

d Article 6 of the Declaration states that any medical intervention is only to be carriedout with the prior free and informed consent of the person concerned based on adequate information. The Article also applies to scientific research.

e If the provisions of Article 6 cannot be applied (because consent is not possible), Article 7
applies with special provisions for persons not able to consent (see Unit 7).

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UNIT 6

2

The principle of consent has several objectives
a The purpose of the informed consent principle is to achieve several objectives. It asserts the patient’s autonomy; it protects his/her status as a human being; it prevents
coercion and deception; it encourages the doctor’s self-criticism; it supports the processof rational decision-making; it educates the public at large.

b The principle of consent is also important even if it does not achieve any objective. Ar-

ticle 1 of the Universal Declaration of Human Rights 1948 holds that all human beings areborn free and equal in dignity and rights. They are endowed with reason and conscienceand should act towards one another in a spirit of brotherhood. Consent therefore expresses respect for the dignity and rights of each human being.

3

Explain the relation between autonomy and consent
a Autonomy may be defined as self rule and refers to the right of persons to make authentic
choices about what they should do and what shall be done to them (see Unit 5).

b Autonomous persons can only make decisions and take responsibility for these decisions
if they can consent to interventions that affect their lives.

The provisions of Article 6 are subsequently explained

4

a The article applies to all medical interventions. Medical intervention includes diagnosis, treatment, prevention, rehabilitation and palliation.

b Being informed implies cognition, understanding, willingness, intention, and consideration. Consenting implies freedom (no coercion).

cConsent requires adequate information. The requested information content should concern diagnosis, prognosis, treatment, alternative treatment, risks, benefits, according torelevant circumstances. The information process should specify: by whom; when (in advance); how (oral, writing, expressed); and to whom (patients, relatives, guardians, others).

d Consent might be expressed or implied. Express consent exists when a patient agrees
in verbal or written forms to undergo a medical procedure. Implied consent maybe
concluded or inferred from the surrounding facts and circumstances.

e A patient has the right to withdraw consent to treatment in any stage unless he or she
is not capable of making such a decision.

f

A patient has the right to refuse treatment, unless he or she is not capable of making
such a decision. A patient has the right to be treated without being informed if he or she
is aware of the implications of such a decision.

g Consent of subjects of medical research:
i
ii
iii
iv

The nature of the consent
The adequate information
The withdrawal of consent
The role of domestic and international human rights law

h Consent by the individual and by the community in appropriate cases of research carriedout on a group of persons or a community.

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5

Exceptional circumstances
a There are some circumstances in which the application of the principle is difficult oreven impossible.

b For difficult circumstances special care needs to be given to the application of theprinciple, but it still does apply, even if difficult.

c

If consent is impossible for various reasons, the provisions of Article 7 do apply (see Unit 7).

d Examples of exceptional circumstances:
i
ii
iii
iv
v
vi

Emergency situations
MinorsPatients who are mentally or emotionally incapable of rational decision making
Jehovah’s Witnesses
Euthanasia
HIV patients

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UNIT 7

Persons without the capacity to consent(Article 7)

UNIT 7

Unit Learning
Objectives
Students should be able to explain the meaning of ‘capacity to consent’Students should be able to explain the criteria of capacity to consent
Students should be able to explain how the criteria for consent are applied in different circumstances of treatment and research

Outline of
the Syllabus

Criteria for capacity to consent

1

a Definition of incapacityb Criteria to determine capacity to consent
cArticle 7: special protection is to be given to persons who do not have the capacity to consent

d Give examples of persons who cannot satisfy the criteria; distinguish different categories of persons
not able to consent

2Categories of persons without the capacity to consent
a Different distinctions can be madeb Examples of persons who cannot satisfy the criteriacIllustrative case of mentally ill patient

Legal provisions concerning consent and capacity to consent

3

a The role of domestic legal provisionsb The role of international human rights law

Procedures

4

a Explain Article 7.a.
b How to obtain consent in health care practice?
cSpecial procedures in ethics to construct consent
iii

Determination of appropriate substitute decision-makers
Best interest criterion
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The context of research involving human subjects

5

a Explain Article 7.b.
b Should research been done with persons not able to consent?
cResearch for direct health benefitd Research without potential direct health benefit

Teacher Manual
1

Define incapacity and the criteria for capacity to consent
a Incapacity can be defined as lacking the freedom to make authentic decisions becauseof an inability to make such decisions even when given the opportunity. Various groupsof people have been traditionally labelled in this way. They include people with learning
difficulties, the mentally ill, children, confused elderly and unconscious people. A more
systematic distinction between categories will be made later in this unit.

b Define the criteria for capacity to consent
i
ii
iii
iv
v
vi

c

The ability to understand given information
The ability to appreciate the nature of the situation
The ability to assess the relevant facts
The ability to exercise choice
The ability to use understood information for realistic and reasonable decisions
The ability to appreciate the consequences of giving or refusing consent

Why is it important to make special arrangements for persons without the capacity toconsent, as stated in the first sentence of Article 7?

d Give examples of persons who cannot satisfy the criteria; distinguish different categories
of persons not able to consent

2Categories of persons not able to consent
a Different distinctions
Capacity to consent can be compromised due to various circumstances. Distinctions
should be made between:icategories of practices∆ clinical treatment and research∆ epidemiological research (e.g. use of previously collected data)∆ public health (e.g. vaccination)∆ emergency conditions (e.g. resuscitation)ii

categories of subjects∆ persons not yet able to make their own decisions (e.g. minors)∆ persons no longer able to make their own decisions (e.g. demented persons)∆ persons temporarily unable to make their own decisions (e.g. unconscious

			
			
			
			

			
			
			
				 persons)			∆ person permanently unable to make their own decisions (e.g. severely				 intellectually impaired persons)iii categories of contexts
			∆ disadvantaged economical conditions
			∆ illiteracy∆ socio-cultural circumstances∆ captive audiences (e.g. prisoners, laboratory assistants)
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UNIT 7b Examplesi

Neonates

Neonates cannot think like adults. It is therefore impossible for them to be able to make decisions, to understand information, to process information rationally or to desire reasonableoutcomes. As decisions have to be made about them, the best candidates for this role are
the parents, on the assumption that above all people they will have the best interests of theirchild at heart. However, in some cases parents do not make decisions in the best interests of
their children. In those cases it is possible for the state to step in and remove the decision
making role from them. This is done by making the child a ward of the court.

iiChildren

It might appear that children cannot think like adults. Whilst this is certainly true ofvery young children, as children develop they show marked differences from each other.
The United Nations Convention on the Rights of the Child (UNROC) asserts that children
have the right to say what they think should happen when adults make decisions that
affect them and to have their opinions taken into account (Article 12), have the rightto get and share information (Article 13), have the right to think and believe what theywant and practice their religion as long as they do not stop other people enjoying theirrights (Article 14), and have the right to privacy (Article 16).Research activities involving children are carried out to learn more about the nature of paediatric development,disease and potential treatments. An important safeguard required to minimize loss ofrespect for autonomy is the general rule that where the research can be carried out by
employing adults then children should not be used.

iii Confused elderly patients
Various forms of neurological deterioration including Alzheimer’s disease rob people ofthe powers to make decisions. Relatives or true friends who knew them when well should
be asked to help to build a picture of the patient’s life, the preferences, the values and thewishes in which one can locate the decision that should be made. A hypothetical consent
is a consent which would likely be in accord with the feelings of the patient when well.

iv Patients with learning difficulties
It is important not to confuse intellectual impairment with mental illness. Patients withlearning difficulties represent a wide range of intellectual ability and no simple standard of capacity can be assumed between them. In each case an assessment according
to the criteria outlined above is called for in combination with an awareness of the nature of the decision to be made. Only in extremely serious cases will a person with thisproblem be unable to make a decision about anything. In those cases where either the
impairment is so severe that the decision is too onerous or complex to be grasped by the
person, a best interest judgement on their behalf should be made.

v

Mentally ill patients

As with intellectual impairment so with mental illness, one cannot assume that all persons possess equal capacity or otherwise. On the one extreme, demented people cannot make coherent choices. On the other hand when not in florid state a person withschizophrenia might be quite clear about how he feels about matters of life and how hewould wish to address them.

vi Unconscious patients
Such documents as Advance Directives or Living Wills might be valuable guides but
have inherent weaknesses that should be taken into account. They might be old and outof date, they express hypothetical wishes, and there is always the need to know underwhat circumstances the documents were produced. The documents should be in accordance with domestic law.

cIllustrative case of mentally ill patient
A person who is termed incapable is one whose insanity or mental deficiency deprives
him/her of the ability to control his/her own interests.
iExplain in this case how the criteria for capacity apply
ii Discuss what will be good medical practice for such a patient

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Legal provisions concerning consent and capacity to consent

3

a The role of domestic legal provisionsb The role of international human rights law
The priority of international human rights law over national legislation.

4

Procedures:a Explain Article 7.a.
b Obtaining consent in health care practicecSpecial procedures in ethics to construct consent
iii

5

Determination of appropriate substitute decision-makers
Best interest criterion

The context of research with persons
a Explain Article 7.b.
b Should research been done with persons not able to consent?
cResearch for direct health benefitd Research without potential direct health benefit

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UNIT 8

Respect for human vulnerability and personal integrity (Article 8)

UNIT 8

Unit Learning
Objectives

Students should be able to explain the principle of respect for humanvulnerability
Students should be able to analyse the interrelationship between presentday scientific medicine and human vulnerability and to illustrate the difficulties in this relationship with examples
Students should be able to specify the connections of the principle ofrespect for human vulnerability with the notion of personal integrity
and with care ethics

Outline of
the Syllabus

The notion of ‘human vulnerability’1a Respect for human vulnerabilityb Different aspects of vulnerability
i biologicalii socialiii culturalc2

Implications of the principle: care

The powers of medicine
a The fight against vulnerabilityb Successes and failuresc

Problems with the basic assumption that vulnerability should be eliminatedd Towards sustainable medicine

3

The dilemmas of vulnerability

4

Care ethics
a New approaches in bioethics
b Solidarityc

The duty to care

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5

The notion of personal integrity
a Relation between vulnerability and personal integrityb Personal integrity does not refer to a virtuecPersonal integrity refers to respect for the patient’s understanding of his or her own life and illness,but also for his/her interests and free will

Teacher Manual1

Explain the notion of ‘vulnerability’a The principle of respect for human vulnerability expresses a concern for the fragilityof human beings. As whole and integrated entities their functioning can easily be disturbed and deranged so that their health and even existence can come under threat. The
principle is related to the principle of personal integrity.

b Several aspects of vulnerability need to be distinguished:i			

biological or corporeal vulnerability; this concerns the fragility of the humanorganism originating from:∆ natural threats are coming from our biology: ageing, susceptibility to illness				 and disease, and death∆ environmental and other natural and man-made threats: famine, earthquake,				 hurricanes, pollution and environmental disasters
ii social vulnerability; this concerns the fragility of the human capacity for creating			 coherence in one’s life and for sharing goods and services.
∆ social threats stemming from war and crime, prejudice and discrimination,				 cruelty and indifference∆ persons also become vulnerable due to hospitalization and institutionalization∆ social circumstances and conditionsiii cultural vulnerability; this concerns the fragility of particular traditions and			 conceptions of values that are typical for a community or local cultures.

c2

In ethics, the notion of vulnerability is not just a neutral description of the humancondition but instead a normative prescription to take care of the vulnerability that ischaracteristic for human beings. Ethics is more than respecting individual choices anddecisions; it aims at care for the other. For example, the human face can show the vulnerability of the human person and at the same time appeal for help and assistance.

The powers of medicine
The fight against vulnerabilitya A common idea is that the vulnerability of the human condition should be eliminatedor reduced. Science and technological innovations should be used to overcome the natural threats. Medical research should be focused on eliminating the biological threats tothe human body. The basic assumption behind this fight is that many vulnerabilities of
the human condition are contingent, not inherent.

b This fight has been successful but at the same time has failures. Life expectancy andhealth have improved, poverty and starvation reduced, but at the same time many people die from common diseases, life expectancy is decreasing in many countries, andpoverty is still widespread.

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UNIT 8c

The basic assumption that vulnerability should be eliminated has in itself created problems:i
if vulnerability is regarded as an evil to be eradicated, it cannot be given any
			 positive meaning; we cannot understand human vulnerability and thus			 human suffering
ii religion, alternative medicine and traditional knowledge present different
			 ways of knowing and valuing; because they are open to different perspectives,
			 they can give meaning to vulnerability, but their views are generally not			 accepted by mainstream science or bioethics
iii economic problems; the success of science and technology has created financial
			 difficulties in almost all countries in achieving decent levels of health care for			 the population. Because of its continuous fight against vulnerability, medicine
			 often is not ‘sustainable’iv medical progress itself has created new forms of vulnerability, i.e. chronic
			 illness. This presents continuing vulnerability for a growing populationd An unrestrained fight against human vulnerability generates its own problems. Not

the struggle against human vulnerability is a mistake but the struggle to rid the humancondition of all vulnerability. For a sustainable medicine it is necessary to accept somevulnerability as a permanent part of the human condition.

The dilemmas of vulnerability

3a ‘Taking into account human vulnerability’, as stated in Article 8, requires a balance
between eliminating and accepting human vulnerability. This balance is manifest issome dilemmas:i

disability

Disability is viewed as abnormal and the disabled therefore are by definition vulnerable;at the same time the disabled should not be stigmatized by being treated as abnormal.

ii

death

In medicine the place of death in human life is ambivalent; in palliative care, death isunderstood as being part of life; in some other sectors of medicine death is still treatedas the enemy.

iii depression
Prozac is widely used as an anti-depressant drug, when there are clear clinical symptoms ofdepression; at the same time it is regarded as medication for unhappiness and sadness.

b Human suffering and misery express human vulnerability. They also pose a challenge.
We must at the same time struggle to keep suffering to a minimum and also accept it aspart of life. Human vulnerability cannot be merely regarded as an enemy to be eliminated. Too much emphasis on eradication has led to evils in the name of some supposed
good: the eugenics movement, Nazism to eliminate the socially and ethnically unfit, andtotalitarian regimes to eliminate social injustice.

4

Care ethics
a The challenge of human vulnerability is that it can never be entirely eliminated fromhuman life. Instead, it should inspire new approaches in bioethics

b The human condition requires solidarity; human beings all share common vulnerabilitiesc

Human vulnerability also leads to an ethics of care. Because it is a shared characteristic, it is also a source of concern for others as well as awareness that we rely on others.
It is the basis for the duty to care for those threatened by biological, social and cultural
threats as well as by the power of medicine itself.

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5

The notion of personal integrity
a The principle of respect for human vulnerability is related to the notion of personal
integrity; this is mentioned in the last part of Article 8.

b Integrity concerns the wholeness of an individual. In ethical discourse, integrity is of-ten considered as a virtue, related to the honesty of somebody’s character for example.
But respect for personal integrity in this Article does not refer to somebody’s moral
character or his/her good behaviour. It refers to fundamental aspects of a human lifethat should be respected.

cPersonal integrity refers here to respect for the patient’s understanding of his or her
own life and illness, but also for his/her interests and free will. Each person’s life has acoherence, a narrative whole based on important events in his/her life and by his/herinterpretations and values. What is most valuable to a person is grounded in this narrative whole. It is this personal integrity of human beings that must be protected.

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UNIT 9

Privacy and confidentiality (Article 9)

UNIT 9Unit Learning
Objectives
Students should be able to explain why patient privacy and confidentiality
should be respected
Students should be able to recognise legitimate exceptions to confidentiality

Outline of
the Syllabus
1

Definitions of ‘privacy’ and ‘confidentiality’2

Reasons for respecting privacy and confidentiality

3

Duty of health care providers to protect the privacy of patients

4

Duty of health care providers to maintain confidentiality(also known as ‘professional secrecy’)

5

Confidentiality extends to all personal health information, including genetic data

6

Justified breaches of confidentiality include:a Sharing information for patient careb Using interpreterscTeaching medical students

d Mandatory reportinge Serious danger to othersfGenetic information

g Patient or guardian consent

7

Special circumstances of research

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Teacher Manual1

Begin by defining ‘privacy’ (it is the right of an individual or a group to be freefrom intrusion from others, and includes the right to determine which information
about them should be disclosed to others – see Units 5 and 6) and ‘confidentiality’ (an attribute of personal information requiring that it not be disclosed toothers without sufficient reason)

2

Reasons for respecting privacy and confidentiality:
a Individuals ‘own’ their information: it is essential to their personal integrity.
b For many people privacy is an essential aspect of their dignity (see Unit 4); invading
their privacy against their will is a violation of their dignity.

c

Respect for others requires protecting their privacy and the confidentiality of information
about them.

d Patients are less likely to trust health care providers and confide in them if they thinkthat the health care providers will not keep the information confidential. This can haveserious consequences for the patients’ health and well-being and sometimes for thehealth of others (e.g. family members).

3

Health care providers have a duty to protect the privacy of patients to the greatest
extent possible in the circumstances.
For example, they should ask the patient’s permission to examine him or her unclothedand should ensure that an unclothed patient cannot be viewed by passers-by.

4

The duty of maintaining confidentiality (also known as ‘professional secrecy’) has
been part of Western medical ethics since Hippocrates and preceded the notionthat privacy is a right; ethics courses in non-Western countries should discuss thesource of medical confidentiality in their cultures.

5

Confidentiality extends to all personal health information, including genetic data
UNESCO International Declaration on Human Genetic Data: ‘…all medical data, including genetic data and proteomic data, regardless of their apparent information content,
should be treated with the same high standards of confidentiality’.

6

Justified breaches of confidentiality include:a Sharing information for patient care
In the hospital setting, many individuals need access to the patient’s chart in order toprovide care; however, each of these individuals is bound to maintain confidentiality
to the greatest extent possible; outside the hospital setting, family members may needpatient information in order to provide care and/or to protect themselves;

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UNIT 9b Using interpreters
Where the health care provider does not speak the patient’s language, an interpreter
will be needed who will then have access to information about the patient; interpreters
should be bound to observe confidentiality;c

Teaching medical students
Observation and discussion of patients is a necessary part of medical education; students should be informed of their obligation to maintain confidentiality;

d Mandatory reporting
Health care providers should be familiar with the laws about mandatory reporting of
infectious diseases, suspected child abuse and other conditions in the country where
they practise; normally patients should be informed that their information has to bereported to the appropriate authorities;

e Serious danger to others
For example, in exceptional circumstances and generally as a last resort, health careproviders may need to inform other persons that the patient has threatened to harm
them, whether by violence or by sexual contact when the patient has an transmissible
disease such as HIV;f

Genetic information
There is controversy regarding whether other individuals with the same genetic makeup(usually close family members) have a right to a patient’s genetic information; physicians
should consult their national regulations or guidelines when faced with this situation;g With patient or guardian consent
This should generally be obtained for all breaches of confidentiality and renders thebreach acceptable ethically.

7

Special circumstances of researcha Disclosure of personal health information obtained in the course of a research study
requires the prior consent of the research subject;b There is a great controversy regarding whether anonymized patient information requires

consent for disclosure; researchers should consult their national regulations or guidelines ifsuch exist, otherwise international guidelines such as the Declaration of Helsinki;c

In research, communities as well as individuals have a right to privacy, and information
about them should be kept confidential, especially when its disclosure may be harmful
to the community.

d Scientific publication should respect confidentiality to the greatest extent possible. Consent
is always required when an individual research subject can be identified in a publication.

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Equality, justice and equity (Article 10)

UNIT 10

Unit Learning
Objectives
Students should be able to identify and deal with the ethical issues
involved in allocating scarce health care resources
Students should be able to recognize conflicts between the health care
professional’s obligations to patients and to society and identify thereasons for the conflicts

Outline of
the Syllabus
1

Definitions of ‘equality’, ‘justice’ and ‘equity’2

The different types of justicea Distributive
b ProceduralcRetributived Restorativee Social

The different concepts of distributive justice (the most important types for health care)3

a Authoritarianb Libertarianc

Utilitariand Egalitariane Restorative4

How these different concepts of justice are reflected in the different health caresystems found around the world

5

The right to health care

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UNIT 106

Disparities in health statusa Local disparities
b National disparitiesc7

Global disparities

Roles of health care professionals in establishing health care priorities and allocating
scarce health care resourcesa As government policy makers and officialsb As hospital authoritiesc

As direct health care providers

Teacher Manual
1

Describe or ask the students to identify several issues in allocating health careresources and accessing health care in your area.
Discuss definitions of ‘equality’ (sameness in some respect such as human dignity), ‘justice’ (different types, but generally fairness), ‘equity’ (application of fairness, which may
require unequal treatment).

2

Describe the different types of justice:a Distributive (ensuring that each person receives a fair share of public resources)b Procedural (ensuring a fair process for making decisions and settling disputes)cRetributive (ensures punishment of wrongdoers)d Restorative (attempts to repair harm done in the past)e Social (combination of the previous types as applied to a society in which individuals and groups
receive fair treatment and a just share of the benefits of society).

Describe the different concepts of distributive justice(the most important types for health care)3

a Authoritarian (what the King or other highest authority decrees is just)b Libertarian (what an individual decides to do with his or her own property is just)cUtilitarian (what most contributes to the greatest good of the greatest number is just)d Egalitarian (justice is achieved when everybody has equitable access to the societal resources thatthey need)e Restorative (justice requires favouring previously disadvantaged individuals or groups)
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4

These different concepts of justice are reflected in the different health care systems
found around the world
The Libertarian one is strong in the U.S.A. The Egalitarian one is predominant in many
European countries where the value of social solidarity is recognized. South Africa is attempting to implement a restorative approach. Most economists lean towards the Utilitarian approach. Which predominates in your country?

5

The Constitution of the World Health Organization states that the ‘enjoyment of
the highest attainable standard of health is one of the fundamental rights ofevery human being…’ International statements on human rights, such as theInternational Covenant on Economic, Social and Cultural Rights and the Convention
on the Rights of the Child, support the right to health and require signatory nations
to secure its observance. What does this right to health mean in practice?

6

Health care professionals are faced with many disparities in health status, generally
associated with disparities in wealth/income or with discrimination against women,
minorities or other disadvantaged groups
a Local disparities
b National disparitiesc

Global disparities
What can/should health care professionals do about these disparities?

7

Health care professionals play several roles in establishing health care priorities
and allocating scarce health care resourcesa As government policy makers and officialsb As hospital authoritiesc

As direct health care providers

d As researchers
What concept of distributive justice is most appropriate for each of these roles? Howshould health care professionals deal with conflicts between roles (e.g., between providing expensive curative measures for individual patients in need and vaccination programs for the population)?

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UNIT 11Non-discrimination and non-stigmatization(Article 11)

UNIT 11

Unit Learning
Objectives
Students should be able to explain the concepts of discrimination andstigmatization in the context of bioethics
Students should be able to identify different contexts and bases of discrimination and stigmatization and their implications
Students should be able to identify and deal with situations where exceptions to the principle can be justified

Outline of
the Syllabus

What is discrimination and stigmatization?

1

a The notion ‘discrimination’b The notion ‘stigmatization’2What is positive or reverse discrimination?

3

Grounds of discriminationa Advances in medical technology may create disproportionate disadvantages for some social groups
b The unfair use of genetic testingc

4

Genetic discrimination

Legal context
a Explanation of Article 11b Background for the Article

5

Limitations of the principle:
a Each principle of the Declaration relates to the other principles (Article 26)
b Limiting the application of the principles is regulated in Article 27c

The protection of public health can be a limiting factor

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Teacher Manual

Definition of the notions ‘discrimination’ and ‘stigmatization’1

a The word ‘discrimination’ comes from the Latin discriminare, which means to ‘distin-

guish between’. Thus, to discriminate socially is to make a distinction between people
on the basis of class or category without regard to individual merit, which is an infringement of the ethical theory of egalitarianism based on social equality (see Unit 10).
Distinctions between people which are based just on individual merit (such as personal
achievement, skill or ability) are generally not considered socially discriminatory, contrary to distinctions based on race, social class or caste, nationality, religion, sex, sexual
orientation, disability, ethnicity, height, age or any other ground in violation of humandignity, human rights and fundamental freedoms.

b According to the Encyclopaedia Britannica ‘stigmatization’ is a discrediting process

which strikes an individual who is considered as ‘abnormal’ or ‘deviant’. He or she is
reduced to this single characteristic in other people’s eyes or opinions for whom this‘label’ justifies a range of social discriminations and even exclusion. The social impact
of stigmatization shows a number of negative behaviours toward stigmatized people thatcan end in real discrimination as regards, for example, access to social services such as
health care and education, employment and professional advancement, income leveland domestic life.

2

Positive or reverse discriminationa Discriminatory policies or acts that benefit a historically and socio-politically non

dominant group (typically women and minorities but sometimes majorities), at the expense of a historically and socio-politically dominant group (typically men and majority
races) are called ‘positive or reverse discrimination’ or ‘affirmative action policies’.

b However, whether a given example of discrimination is positive or negative is often a
subjective judgement.

c3

In the field of health care and bioethics, some groups need more protection such as
infants and elderly people, AIDS patients, psychiatric patients and depressed patients.

Grounds of discriminationa Advances in medical technology have the potential to create disproportionate disadvan-

tages for some social groups, either by being applied in ways that harm members of thesegroups directly or by encouraging the adoption of social policies that discriminate unfairly
against them with significant individual, social and legal consequences. For instance, reproductive medicine has developed techniques that enable parents to choose the sex of
their child which raises the concern of discrimination against girls and women in societies
where male children are valued more highly than female children. Similar concerns havebeen raised about the increasing use of abortion as a method of birth control in overpopulated countries where there is considerable social and legal pressure to limit family size andwhere the vast majority of the parents who use it choose to have a boy rather than a girl.

b In the field of genetics, the use of relatively simple tests for determining a patient’s sus-

ceptibility to certain genetically transmitted diseases has led to concerns that the resultsof such tests, if not properly safeguarded, could be used in unfair ways by health-insurance companies, employers, and government agencies. In addition, through genetic
counselling prospective parents can be informed about the chances that their offspring
will inherit a certain genetic disease or disorder; this will enable them to make more
informed decisions about reproduction. This is viewed by some bioethicists and someNGOs as contributing to a social atmosphere considerably less tolerant of disability
than it ought to be. The same criticism has been levelled against the practice of diagnosing, and in some cases treating, congenital defects in unborn children.

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UNIT 11c4

Research on the genetic bases of behaviour, though still in its infancy, is controversial,
because of its potential to encourage the adoption of crude models of genetic determinism in the development of social policies, especially in the areas of education and crime
prevention. Such policies, it is claimed, could result in unfair discrimination against
large numbers of people judged to be genetically disposed to ‘undesirable’ forms of
behaviour, such as aggression or violence.

Legal context
a Explanation of Article 11, as a theoretical and practical continuation of Articles 3 and10, and continued in discussion of Articles 13, 14, and 15

b Background for the Article:
iii

5Articles 1 and 2 of the Universal Declaration of Human Rights
Article 7 of the International Declaration on Human Genetic Data

Limitations of the principle:
a Article 26 of the Declaration states that the principles should be understood as comple-

mentary and interrelated; the Declaration is to be understood as a whole. This implies
that if a bioethical issue or problem emerges, it is usually the case that several principles
are relevant to the issue or problem and need to be balanced in order to reach a justified
conclusion about what to do.

b Article 27 specifies the limitations on the application of the principles. It mentions
several conditions in which application may be limited:iby law
			∆ laws in the interests of public safety			∆ laws for the investigation, detection and prosecution of criminal offences			∆ laws for the protection of public health			∆ laws for the protection of the rights and freedoms of othersii such law need to be consistent with international human rights lawcWhen therefore public health is at risk, exceptions or restrictions to the non discrimination principle can be necessary either by affirmative actions in favour of some key persons or groups, or by ‘negative’ actions that may infringe upon individual rights. These
exceptions must be publicly discussed and applied with transparency and according to
the national law. They also must be subject to revision according to developments of thesituation and scientific knowledge.

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Respect for cultural diversity and pluralism(Article 12)

UNIT 12

Unit Learning
Objectives
Students should be able to explain the meaning of ‘culture’ and why it
is important to respect cultural diversity
Students should be able to explain the meaning of pluralism and why it
is important in the field of bioethics
Students should be able to deal with cultural diversity and take into
consideration cultural specificities (appropriate approach, positive
inputs and limits) with respect to the fundamental principles of bioethics
and human rights

Outline of
the Syllabus

Background1

a Definition of culture and cultural diversity
b Value of respect for cultural diversityc2

Definition and value of pluralism

Explanation of Article 12a As a theoretical and practical continuation of other articles
b The principle will raise questions concerning:i Discriminationii Infringement of the autonomy principleiii Infringement of national laws

3

Limits to the consideration for cultural specificities
a Human dignity, human rights and fundamental freedoms
b Domestic law, national regulations and international human rights lawscIndigenous knowledge and practicesd Principles set out in the Declaration

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UNIT 12

Teacher Manual

Definitions and background1

a Definition of culture and cultural diversity
i
			
			
			
			
ii
			
			

According to the UNESCO Universal Declaration on Cultural Diversity: ‘Culture
should be regarded as the set of distinctive spiritual, material, intellectual andemotional features of society or a social group, and it encompasses, in addition
to art and literature, lifestyles, ways of living together, value systems, traditions
and beliefs.’
As stated in Article 1 of the above Declaration: ‘Culture takes diverse forms
across time and space. This diversity is embodied in the uniqueness andplurality of the identities of the groups and societies making up humankind.’b Value of respect for cultural diversity
i
			
			
ii
			
			
			
iii
			

c

Definition and value of pluralism
i
			
			
ii
			
			

2

UNESCO considers cultural diversity as the common heritage of humanity
and therefore it should be recognized and safeguarded for the benefit ofpresent and future generations.
As a source of exchange, innovation and creativity, cultural diversity is asnecessary for humankind as biodiversity is for nature and it is essential toensure harmonious interaction among people and groups with plural, variedand dynamic cultural identities as well as their willingness to live together.
Thus, policies for the inclusion and participation of all cultural groups andcitizens are guarantees of vitality, social cohesion and peace.

Pluralism is, in a general sense, the affirmation and acceptance of diversity.
The concept is used in a wide range of issues: politics, science, medicine andmedical practices, religion, philosophy and ethics.
Value-pluralism means that there are several values which may be equally correct
and fundamental, and yet in conflict with each other. These various values andideals have no common character apart from the fact that they are ideals (see Unit 1).

Explanation of Article 12a As a theoretical and practical continuation of Articles 3 and 10, and to be continued in discussion of
Articles 13, 14, and 15
b The principle will raise questions concerning:
i
ii
iii

3

Discrimination
Infringement of the autonomy principle
Infringement of national laws

Limits to the consideration for cultural specificities
a Human dignity, human rights and fundamental freedoms.
i
			
ii
			
			
			

Respect for cultural diversity can never be invoked when it infringes upon
human dignity, human rights and fundamental freedoms.
Cultural value pluralism thus cannot be used as a way of justifying discriminationand stigmatization. Value-pluralism is an alternative to moral absolutism anddiffers also from value-relativism in that pluralism imposes limits to differences,such as when vital human needs or rights are violated. The value of cultural

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diversity may be in conflict with other human rights values. In this case, it isnecessary to analyze and balance wisely the values in conflict.

b Domestic law, national regulations and international human rights lawsiLegal limits

Example: blood transfusion for children in the case of Jehovah’s Witnesses.

ii

Moral and legal limits

Example: sex selection by the use of prenatal and preimplantation genetic diagnosis without any concomitant medical reason but for ‘family balancing’ in some societies. Usuallyused to select male embryos or foetuses, this is considered discrimination (see Unit 11).

c

Risks/benefits of indigenous knowledge and practices
For example practices of traditional healing should be promoted or nationally authorized as long as they are effective and there is no scientific evidence of toxicity or harm.
They should be evaluated by the concerned societies and groups although there aredisputes about the criteria for evaluation.

d Using international declarations/instruments
i
			
			
			
			
			
			
ii
			
			
			
			

Article 4 of the UNESCO Universal Declaration on Cultural Diversity stipulates‘Human rights as guarantees of cultural diversity. The defence of cultural
diversity is an ethical imperative, inseparable from respect for human dignity.
It implies a commitment to human rights and fundamental freedoms, inparticular the rights of persons belonging to minorities and those of indigenous
peoples. No one may invoke cultural diversity to infringe upon human rights
guaranteed by international law, nor to limit their scope’.
Article 4 of the International Declaration on Human Genetic Data: human genetic
data have a special status because: (Paragraph iv) they may have cultural
significance for persons or groups. Due consideration should be given to thesensitivity of human genetic data and an appropriate level of protection forthese data and biological samples should be established.

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UNIT 13

Solidarity and cooperation (Article 13)

UNIT 13

Unit Learning
Objectives
Students should be able to explain the development of the notion ofsolidarity in different societies
Students should be able to describe the difference between solidarity
as an instrumental and a moral value
Students should be able to give examples of solidarity in the context ofhealth care and research

Outline of
the Syllabus

The notion of solidarity

1

a Discuss the notion of solidarity: first associations
b Solidarity in health carec

Opposition to individualism

d Evolution of solidarity in society
i mechanical solidarity
ii organic solidarityiii organized solidarity
e Ethical perspectiveiii

Solidarity as instrumental value
Solidarity as moral value

2

Threats to solidarity in present-day societies

3

Relationship of solidarity, autonomy, and justice4

International research

5

Health insurance – provision of health care to the general population as an end,
health insurance as a means

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Teacher Manual

The notion of ‘solidarity’1

a Discuss the notion of ‘solidarity’
Ask students with what do they associate this notion, for example:imutual respect
ii support of the weak and vulnerable
iii commitment to a common cause or the common good
iv belonging together
v mutual understanding
vi shared responsibilityb Solidarity is applicable in the context of health care systems. In Europe for example, ev-

eryone is obliged to make a fair financial contribution to a collectively organised insurance
system that guarantees equal access to health and social care for all members of society.

c

Solidarity is often considered to be opposed to individualistic behaviour and contrasted with self-centred individualism, as a personal and social concern for vulnerable
groups in modern societies, in particular the chronically ill, the handicapped, politicalrefugees, immigrants and the homeless.

d Sociological analysis shows that solidarity can have different expressions in the evolutionof societies:i
In traditional societies (homogeneous and without much differentiation in social
			 functions) solidarity rests on the social uniformity of beliefs, practices and			 sentiments (‘mechanical solidarity’, ‘group solidarity’ or ‘associative solidarity’);ii During the transition from traditional to modern societies, the form and contents
			 of social ties between individuals are transformed and hence the nature of social			 solidarity. Differentiation and diversification of functions and tasks create			 relations of interdependence between individuals. Division of labour and			 structural interdependence require new rules of cooperation (‘organic solidarity’,			 ‘contractual solidarity’);iii In post-industrial, globalised societies, solidarity takes the form of ‘organised
			 solidarity’. Building new forms of solidarity is an ongoing project. In many			 cases, common interests, interdependencies and personal relations no longer
			 exist. Still ‘solidarity of strangers’ is possible. Modern solidarity functions
			 between non-related and impersonal members of a society.

e From an ethical perspective, solidarity is first and foremost a moral value focused onproviding support to those who need it. Among members of a community mutual obligations exist. This also implies that a fundamental difference should be made between
two forms of solidarity:i

Solidarity as instrumental value

Solidarity as self-interest, reciprocal solidarity. The enlightened self-interest of rationally calculating individuals motivates them to cooperate.

ii

Solidarity as moral value

Group oriented responsibility to care for the weaker and more vulnerable members of
the community. Real solidarity implies that we take care of vulnerable persons even if
it would not be in our interest or even if there is no specific purpose. Human beings
share identity as members of the same collectivity and therefore feel a mutual sense of
belonging and responsibility. Solidarity in this sense is ‘humanitarian solidarity’; it isthe expression of an ethics of commitment, a sense of responsibility towards the mostvulnerable in society. Not self-interest but the interest of others motivates cooperation.

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UNIT 132

Threats to solidarity
a Solidarity in present-day societies is under threat due to various factors.
i
			
ii
			
iii
			
			
iv
			
v
			

Globalisation; more anonymous approach; less connectedness with otherhuman beings;
Increasing demands for expensive treatments, for instance due to the ageingof populations; the range of options for individuals has enlarged;
Changing and more demanding attitudes of clients, related to increasing individualisation of societies with increasing stress on the moral significance ofindividual autonomy;
Shift towards more private financial responsibility and increasing pressure ofmarket ideology;
Erosion of local communities and extended family networks changing
personal and social relationships;b In present-day societies there is a tension between solidarity, personal autonomy andresponsibility. The example of unhealthy lifestyles illustrates this tension. Individuals
are free to choose the lifestyles they prefer but if these are notoriously risky for theirhealth, can they still expect the solidarity of citizens if they fall ill?

3

Relationship of solidarity, autonomy, and justice
Solidarity goes beyond justice. Justice is a matter of obligation from one free individual
to another; it is based on the shared interest of preserving the requisite amount of freedom for all citizens. Solidarity is not necessarily a legal obligation. Solidarity does notnecessarily restrict autonomy.

4

International researcha What do solidarity and cooperation imply?
b Relationship with benefit sharing (see Unit 15)

5

Health insurance
Provision of health care to the general population as an end, health insurance as a means

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Social responsibility and health (Article 14)

UNIT 14

Unit Learning
Objectives

Students should become acquainted with the shared responsibilitiesof the state and various sectors of society in regard to health andsocial development
Students should understand the requirements of global justice and thenotion of the highest attainable standard of health care as a rightStudents should be able to explain that health status is a function ofsocial and living conditions and that the attainment of the highest
attainable standard of health care depends upon the attainment ofminimum levels of social and living conditions
Students should be able to appreciate the urgent need to ensure that progress in science and technology facilitates access to quality health care andessential medicines as well as the improvement of living conditions and theenvironment, especially for marginalized segments of the population
Students should be able to analyze potentially exploitative social practices
or arrangements affecting public health and recommend possible solutions

Outline of
the Syllabus

Highest attainable standard of health as a fundamental human right1

a Universal Declaration of Human Rights
b WHO Constitution

2

Health and the impact of social and overall living conditions
a The need for health care initiatives to take into account the broad development context
b The ethical significance of public and population health initiatives

3

Duty, obligation and responsibility and how these are acquired by individuals,
groups or institutions

4

Responsibilities for governments and various sectors of society
a Responsibilities of governmentsb Social responsibilities of the health sector and the medical professioncSocial responsibilities of the private sector and industry

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UNIT 14

Health and contemporary challenges to global justice5

a Access to essential drugs and health services
b Poverty and the HIV/AIDS pandemiccStandard of care in international health researchd The protection of vulnerable populationse Research prioritizationfProviding health care services across national boundaries

g Organ transplantation and medical tourism

Teacher Manual
1

Highest attainable standard of health as a fundamental human righta Section 1, Article 25 of the Universal Declaration of Human Rights states that ‘everyone

has the right to a standard of living adequate for the health and well-being of himself
and of his family, including food, clothing, housing and medical care and necessary social services . . .’ (1948).

b Moreover, the WHO Constitution provides that ‘the enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition’(1946). The recognitionof the highest attainable standard of health as a fundamental human right establishes aheavy ethical burden on health care and related sectors, especially because of the broad
definition of health as ‘a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity’ (1946). See also Units 2 and 4.

2

Health and the impact of social and overall living conditions
a Ethically-minded players in the health sector appreciate the need for health care ini-

tiatives to take into account the broad development context that includes the reductionof poverty, stewardship of the environment, and assurance of human rights, gender
equity and global security. Such ethical initiatives reaffirm the definition of health as
expressed in WHO’s Constitution, and the recognition of health as both a means toother development goals and as an end in itself.

b This section also highlights the ethical significance of public and population healthinitiatives, as they constitute a dynamic instrument for achieving social and economic
development, justice and security. Whereas health has been conventionally viewed as an
end in itself, the discussion examines the synergistic relationship between health andother aspects of development.
iPoverty defined as the undermining of a whole range of key human capabilities,
			 including health. Ill-health disproportionately afflicts poor people, and sudden			 health problems push people into greater poverty (the ‘medical poverty trap’).
ii The need to reduce the burden of excess mortality and morbidity suffered by			 the poor populations in both poor and rich countries.
iii The sensitivity of health to the social environment and to ‘the social determinants			 of health’.
iv Inequalities between men and women, regions, ethnic groups, rural and urban
			 areas, and in legal status.

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Duty, obligation and responsibility and how these are acquired by individuals,
groups or institutions

3

a Individuals, groups or institutions may be ascribed duties, responsibilities or obliga-

tions in a number of ways. In the case of governments, these may be defined constitutionally, or by the instrument that established the state. These may also be determinedby agreements entered into with other governments, international organizations, or other bodies. In the case of individuals, these may be defined by state laws or by rules andregulations governing membership of a particular group (e.g., professional, religious,interest, or advocacy group). The same applies to groups or agencies established within
the context of national laws or statutes.

b Responsibility may be acquired also in respect of roles that individuals, groups or in-stitutions assume in a particular social-political-economic context. Moreover, in light ofconditions characterized by wide disparities in economic, social and political power, protection of the fundamental right to the highest attainable level of health puts a burden on
individuals, groups and institutions to provide assistance that is within their means. This
notion of responsibility has been specifically referred to as social responsibility.

Responsibilities for governments and various sectors of society

4This section examines the context within which governments and other stakeholders
have to operate when they try to provide health care and other needs to the population.
The conditions characterizing that context have implications for the specific responsibilities that may be ascribed to the different stakeholders. Ordinarily, the degree of responsibility increases as one’s amount of control over a given situation rises. It is usefulto analyze different situations in order to consider the extent to which stakeholders may
be adjudged to have a responsibility, and to identify the specific initiatives that may be
identified as falling within the sphere of their ethical obligations.

a Responsibilities of governments
The government or the state has the primary duty to uphold and protect the rights of its
citizens. It is also charged with the responsibility to provide the environment that could
maximize the contributions of other sectors to the promotion of fundamental rights.

b Social responsibilities of the health sector and the medical profession
The Physician’s Oath contained in the Declaration of Geneva (1948, 1968, 1983, 1994, 2006)
and the WMA International Code of Medical Ethics (1949, 1968, 1983, 2006) enumerate theduties of medical practitioners. Nurses, dentists, caregivers and other workers in the healthcare community have similar or corresponding responsibilities. This section examines the
responsibilities that arise in relation to professional roles as well as to the gaps in healthservice that cannot be sufficiently filled by referring to such roles.

cSocial responsibilities of the private sector and industry
Regardless of the nature of the products they produce or services they offer, industries havean ethical responsibility to promote the interests of society. The responsibility ought to beshared in accordance with relevant principles of justice and fairness. In many countries,
the pharmaceutical industry observes codified regulations that include provisions for social
responsibility. A study of the regulations could reveal certain gaps that need to be filled.

5

Health and contemporary challenges to global justice.
The wide disparities in the provision of health care experienced globally give rise toquestions of equality and global justice.

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UNIT 14a Access to essential drugs and health services
More than 33% of the global population has no access to essential drugs and more thanhalf of this deprived population lives in the poorest regions of Africa and Asia. The development of drugs for tropical diseases has progressed very little and even when drugs
are available, they are often inaccessible to those who need them the most.

b Poverty and the HIV/AIDS pandemic
HIV/AIDS spreads more quickly in poor countries and amongst poor people. This highly
visible and paradigmatic example illustrates the inevitable connection between poverty anddisease in general. Poverty itself is one reason for such an exacerbated effect; thus, the fightagainst HIV/AIDS (and disease in general) requires progress in the elimination of poverty.

cStandard of care in international health research
Developing countries attract researchers from the affluent parts of the world. Many pharmaceutical companies are testing their drugs in developing countries. While these countries
urgently need research to help address the enormous burden of disease they carry, the inequalities in resources pose a real risk of exploitation in the context of externally-sponsoredresearch. It is of great importance to develop local expertise in the provision of health careand come up with research hosting protocols. Researchers on the other hand should follow
an ethical framework guided by duties to (1) alleviate suffering, (2) show respect for persons,(3) be sensitive to cultural differences, and (4) not exploit the vulnerable.

d The protection of vulnerable populations
The 2005 World Summit Outcome adopted by the United Nations General Assembly expresses the resolve of UN member states to ‘continue making progress in the advancementof human rights of the world’s indigenous peoples’ (Sec. 127), to ‘pay special attention to thehuman rights of women and children and undertake to advance them in every possible way’
(Sec. 128), and to recognize the need for persons with disabilities to be guaranteed full enjoyment of their rights without discrimination (Sec. 129). Member states also noted that the promotion and protection of the rights of persons belonging to national or ethnic, religious andlinguistic minorities contribute to political and social stability and peace and enrich the cultural diversity and heritage of society (Sec. 130). Persons without capacity to consent, prisoners and refugees also deserve special attention as vulnerable populations. These and similargroups ought to receive special consideration for a number of important ethical and historical reasons, specifically those give rise to various forms of exploitation (See also Unit 8).

e Research prioritization
Global health research funding has been heavily tilted in support of the needs of theaffluent minority, leaving a mere 10% of research resources to address the needs of thedeveloping world. It is important to promote responsive, fair and equitable initiatives
in this area. Research projects carried out in poor countries should be relevant to theirneeds. Participants should also be considered as major stakeholders in the research
projects. This section looks at illustrations and case studies in developing countries.

f

Providing health care services across national boundaries
The migration of medical doctors and other health care workers has reached alarming
proportions. Developing countries are continuously losing their health care workers todeveloped countries that provide higher remuneration and benefit packages. This section examines the experience from a global perspective and traces responsibility to thevarious institutions involved, including the highly developed countries that draw valuable health care personnel away from the environments where they are most needed.

g Organ transplantation and medical tourism
The global income disparity is also manifest in the ongoing practice of transplanting
organs from the poor to the rich. The medical tourism industry has provided a smokescreen that serves to disguise the injustices associated with transnational exploitation.
This section examines the ethical issues involved and some of the measures that havebeen offered to curb unethical and illegal practices.

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Sharing of benefits (Article 15)

UNIT 15

Unit Learning
Objectives

Students should be able to understand the need for ensuring that scientific knowledge contributes to a more equitable, prosperous and sustainable world
Students should be able to explain that scientific knowledge has become a crucial factor in the production of wealth, but at the same time
has perpetuated its inequitable distribution
Students should be able to explain the reality that most of the benefitsof science are unevenly distributed among countries, regions and socialgroups, and between the sexes
Students should be able to analyse efforts that have been undertaken atvarious levels to promote the sharing of the benefits of scientific knowledge
and research and to explore novel initiatives that may be undertaken
Students should be able to identify and assess potentially undue or
improper inducements in different research settings/situations

Outline of
the Syllabus
1

Global justice as basis for sharing the benefits of science and scientific research

2International instruments on benefit sharinga International Declaration on Human Genetic Data (2003)b Bonn Guidelines on Access to Genetic Resources and Fair and Equitable Sharing of the Benefits Arisingout of their Utilization (2002)
c Doha Declaration on the TRIPs Agreement and Public Health (2001)
d Human Genome Organization (HUGO) Committee Statement on Benefit Sharing (2000)
e Universal Declaration on the Human Genome and Human Rights (1997)3

Models of benefit-sharing agreements
a Fair and equitable options for research subjects
b Biopiracy and fair sharing of benefits of genetic resourcescPatents and intellectual property

d Valid options for promoting fair and equitable access to new diagnostic and therapeutic modalities or
to products stemming from them

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UNIT 15

4Integration of capacity-building components to externally funded research andother initiatives

5

Prohibition of using improper inducements to participate in research

Teacher Manual
1

Global justice as basis for sharing the benefits of science and scientific research
Many benefits of science are unevenly distributed, as a result of structural asymmetries among countries, regions and social groups, and between the sexes. As scientificknowledge has become a crucial factor in the production of wealth, so its distribution
has become more inequitable. Principles of global justice should take central place inscientific endeavours. This can be actualized through the long-term commitment of all
stakeholders, public and private, through greater investment, the appropriate review ofinvestment priorities, and the sharing of scientific knowledge.

2

International instruments on benefit sharing
International agreements and other documents have been drafted under the auspices
of international bodies committed to enhancing opportunities to share the benefits ofscientific advances and research. Article 19 of the International Declaration on Human
Genetic Data (2003); the Bonn Guidelines on Access to Genetic Resources and Fair and Equitable Sharing of the Benefits Arising out of their Utilization (2002); the Doha Declaration on
the TRIPs Agreement and Public Health (2001); the Human Genome Organization (HUGO)
Committee Statement on Benefit Sharing (2000); and the Universal Declaration on the
Human Genome and Human Rights (1997) are just a few examples.

Models of benefit-sharing agreements

3This section examines different models for benefit-sharing agreements and the lessons
that may be learned from successful and unsuccessful initiatives. Proper assessment
should reveal which measures governments could take in order to ensure that the benefits of science and research are made available to the poor.

a Fair and equitable options for research subjects
Agreements for sharing the medical and scientific benefits arising from the involvementof human subjects in health research projects.

b Biopiracy and fair sharing of benefits of genetic resources
The human genome is part of the common heritage of humanity. It is incumbent upon
scientists, governments and industry to find ways for the achievements in scientific andtechnological research to contribute to economic and social progress to developing
countries and not only to developed ones.

c

Patents and intellectual property
There is a need to create ways of protecting intellectual property rights and at the sametime making discoveries and innovations available and accessible to the public, particularly to those populations who need them the most. The Doha Declaration, for example,

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affirms that the WTO TRIPS Agreement can and should be interpreted and implemented
in a manner supportive of WTO members’ right to protect public health and, in particular,
to promote access to medicines for all.

d Valid options for promoting fair and equitable access to new diagnostic and therapeutic modalities or
to products stemming from them
To ensure the availability of new products and innovations, continuous, time-specified
or needs-based supply, local version manufacturing, patent and licensing agreements
are just some of the ways that can be explored.

4

Integration of capacity-building components to externally funded research andother initiatives
Apart from access to material results of research, efforts should be dedicated to improving
health systems by strengthening local health research capacities. Higher levels of skills
and ability to perform research will prove useful in addressing local needs and concerns.

5Prohibition of using improper inducements to participate in research
While participants should benefit from the research, there is a strong case for the prohibition of inducements that may unduly compromise informed consent or erode autonomy.

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UNIT 16

Protecting future generations (Article 16)

UNIT 16

Unit Learning
Objectives
Students should be able to explain the principle of protecting future
generations
Students should be able to evaluate the possibilities and difficulties in
the application of the principle in practical settings

Outline of
the Syllabus
1

Why care about the future?
a Contexts of concernb Contemporary sensibility towards future generations

2

The scope and limits of future related responsibilities
a Intergenerational; distant generations, all unborn generations?
b Human or non-human species?

3

Do we have obligations to the possible people of the future?

4

How to represent the future in present decision-making?

5

Health care and future generations
a Prescription of medication without any rationale (e.g. antibiotics, etc.) is a threat to future generations– long-term effects of medicine
b Xenotransplantationc

Genetically modified foodd Germ-line genetic interventions

6

Precautionary Principle

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Teacher Manual1

Why care about the future?
a Start by exploring in what contexts the concern for future generations has emerged
i
			
			
			
			
			
			
ii
			
			
			
			
iii
			
iv
			
			
			
			

Many countries are rapidly developing. At the same time, economic growth
has consequences such as increasing inequity or environmental degradation.
Economic growth is often based on natural resources (such as oil or wood)that are diminished, destroyed or consumed. If present trends continue, theworld will be more crowded, more polluted, less stable ecologically and more
vulnerable to disruption. In this context, the notion of ‘sustainable development’(see Unit 17) or ‘development without destruction’ has been introduced.
The 1987 Report of the World Commission on Environment and Development(with the title Our Common Future) defines sustainable development as‘development that meets the needs of the present without compromising theability of future generations to meet their own needs’. The key idea is that theneeds of present and future generations must be taken into account.
Responsibility for future generations has been endorsed in many international
documents. An example is the 1992 Rio Declaration on Environment and Development.
The ethical context of the principle is articulated in the Declaration on the
Responsibilities of the Present Generations towards Future Generations, adopted by
UNESCO in 1997. Article 4 of this Declaration states that ‘The present
generations have the responsibility to bequeath to future generations an Earththat will not one day be irreversibly damaged by human activity’.

b It is argued (see, for example, Agius, 2006) that three factors are responsible for thecontemporary sensibility towards future generations:itechnology has altered the nature of human activity which is now impacting
			 on not only the lives of people living now but of those who will live in			 the future;ii present-day reality is interdependent and interrelated; for example, environ			 mental disasters in one region will affect other regions and			 other generations;iii the increasing awareness of the finitude and fragility of our existence and			 ‘our one and only Earth’, as the UN Secretary General said in 1998.

2

The concept of moral responsibilities towards future generations is also related tothe concept of intergenerational justice
It implies that the activities of present generations are limited by the obligation to take
into account and safeguard the development and needs of future generations. Traditionally, justice has been defined as ‘giving to everyone his or her due’. By promoting obligations to future generations as a matter of justice, a new discourse of intergenerational
justice has been introduced.

3

Arguing that we have responsibilities to posterity or obligations of justice towards
future generations is, however, problematic
Does it make sense to claim that we have responsibilities towards persons who do not
yet exist? What exactly do we mean if we speak about ‘future generations’: our children
or grandchildren who have just been born, human beings who are not yet born and who
we cannot even consider as individual persons, or all distant generations, human andnon-human, who will inherit the earth from us? Two positions are usually defended:

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UNIT 16a We only have a moral relationship with generations of the immediate future
Our obligations only extend to the succeeding one or two generations. Crucial here is the viewthat it makes only sense to talk about moral responsibility if there are moral relationships;

b All future generations can claim that we take them into accountWe therefore have responsibilities to even far-distant future generations. Central here isthe concept of ‘common heritage’; that which belongs to all humanity cannot be considered simply as unexplored and unclaimed territories suitable for expropriation and exploitation on a first-come, first-served basis. Earth’s resources belong to all generations.

4

How do we represent the future in present decision-making?
a Even if we agree that moral concern for future generations is necessary, what kind of

obligations do we have to people who do not yet exist or who might even not ever exist?
We do not know what will be the needs of future generations since their identity is dependent or contingent on many factors. Future generations can, by definition, not haveany claims upon us because they are not present to make them.

b A solution to this last problem is to have others who act on their behalf. Some haveproposed the establishment of an office of guardian to represent future generations at
national, regional and international levels. It is a matter of justice to give voice to thevoiceless. Institutional mechanisms should therefore be created to make our responsibilities towards future generations a reality. Discuss this option. Take the example of
the Commission for Future Generations, created in one Member State of UNESCO.
Discuss whether and how a similar approach could be realised at international level, forexample by creating a UN Commission. Analyse the advantages and disadvantages.

5

In health care, there are several examples of technological and scientific progressthat have serious impact on future generations
Discuss the case of xenotransplantation, genetically modified food or germ-line genetic
interventions.

6

One principle that is often used in this context is the Precautionary Principle
Where a threat to health or the environment is serious and imminent, we cannot afford
to wait for a high degree of proof before acting to prevent damage. If we wait too long,especially the interests of future generations will be irreversibly damaged. Examine thisprinciple, its definitions and applications.

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Protection of the environment,
the biosphere and biodiversity (Article 17)

UNIT 17

Unit Learning
Objectives

Students should be able to explain how bioethics is related to environmental issues
Students should be able to analyse environmental issues from anthropocentric, biocentric and ecocentric ethical perspectives
Students should be able to describe sustainable development

Outline of
the Syllabus

Ethics and the environment: views of nature1

a The relation of bioethics and environmental issues
b Background2

Ethical perspectives
a Anthropocentric environmental ethics: human centred ethicsb Non-anthropocentric environmental ethicsiiicBiocentric: other living organisms have intrinsic value
Ecocentric: ecosystems have intrinsic value as well

Basic principles of environmental ethics
i environmental justiceii intergenerational justiceiii respect for nature

3

Notion of sustainabilitya A new ethics of conservation and stewardshipb What is sustainable development?

Teacher Manual
1

Ethics and the environment: views of nature
a Ethical concerns with the environmenti

Characteristics of such concerns:∆ extend the scope of ethical concerns beyond one’s community and nation to				 include also animals and the whole of nature

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UNIT 17∆ interdisciplinary∆ plural: different approaches∆ global: the ecological crisis is a global issue∆ revolutionary: challenge to the anthropocentrism of modern ethics
b Background
i
ii
iii
iv
v
vi
			
			
			
vii
			

2

Ecological crisis first noticed in 1960s and 1970s
Report of the Club of Rome (Limits to Growth) in 1972
First United Nations environmental conference in Stockholm in 1972
Birth of environmental ethics in 1970s
1992 Rio Earth Summit Conference
2000 UN Millennium Declaration: the core of our environmental concerns has
to do with ‘the threat of living on a planet… irredeemably spoilt by humanactivities, and whose resources would no longer be sufficient’ for the needs ofall humanity, and above all, ‘the needs of our children and grandchildren’
UN Millennium Declaration: clearly indicates the object of environmental
concern: ‘current unsustainable patterns of production and consumption’

Ethical perspectives
There are different schools of environmental ethics. They differ as regards (1) the scopeof human duties towards others, (2) ethical methodologies, and (3) cultural context

a Anthropocentric environmental ethics: human centred ethics
i
ii
iii
iv

Human beings have moral duties only towards one another
Human interests prevail over the interests of other species
Ethical methodologies: utilitarianism and deontology
More related to Western culture (in which nature often has an economic value)b Non-anthropocentric environmental ethicsi

Biocentric: other living organisms have intrinsic value∆ all life forms are ‘moral patients’, i.e. subjects that are entitled to moral				 consideration∆ it is therefore an ethical imperative to respect all life forms∆ all organisms have intrinsic value∆ more related to non-western cultural traditionsii

Ecocentric: ecosystems have intrinsic value as well∆ nature as a whole is a ‘moral patient’∆ all organisms and entities in the ecosphere, as parts of the interrelated whole,				 are equal in intrinsic value∆ holistic methodologycBasic principles of environmental ethicsi

Environmental justice∆ environmental benefits and burdens should be equally distributed∆ opportunities to participate in decision-making concerning environmental				 issues should be equally provided

ii

Intergenerational justice

Every generation should leave the following generation an equal opportunity to live a
happy life, and should therefore bequeath a healthy earth (see Unit 16)

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iii Respect for nature
The prosperity of human beings depends on the prosperity of nature. Human beingsare part of nature. They have therefore the duty to conserve and protect the integrity ofthe ecosystem and its biodiversity

3

Notion of sustainability
a 2002 Johannesburg Declaration on Sustainable Development
A new ethic of conservation and stewardship should be adopted, focussing on:imeasures to curb global climate change (reduction of emissions of green			 house gases)
ii conservation and management of all types of forestsiii better use of water resources
iv intensified cooperation to reduce the number and effects of natural and			 man-made disasters
v fundamental change in the lives of the affluent
vi equitable access to resourcesb What is sustainable development?
i
			
			
			

Original definition given in report of World Commission on Environment andDevelopment (1987): sustainable development is development that meets theneeds of present generations without compromising the ability of future
generations to meet their needs.

ii

Two important qualifications:∆ the needs of the poor are central in sustainable development∆ the only constraint on sustainable development is the state of technology				 and social organization in societyiii Different views of sustainable development∆ Weak notion of sustainability

Classic view: integration of economic, socio-political and ecological spheres: threecomponents of sustainable development but interdependent and mutually reinforcing;problem is that they are often viewed as separate spheres with their own logic andvalues; often also ‘trade-offs’ between human and social development and ecologicalconcerns; economic growth and social development often have priority. This notion ofsustainability is also strongly anthropocentric; human beings and their needs are thepoint of departure; everything in nature has instrumental value, contributing to achieving human purposes.
∆ Strong notion of sustainability
In order to prevent a continuing decline of natural resources over time, a drastic change
in patterns of production and consumption is necessary; the way we are using natural
resources need to be transformed. It is necessary to emphasise the intrinsic value ofnature; nature has a value in and of itself, regardless of any benefits for humans. It istherefore more helpful to regard sustainable development as three embedded spheres;the spheres are intertwined from the outset.

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is available at:
http://www.npojip.org/contents/book/unesco-j.pdf