1. WHAT IS BIO-, MEDICAL- CLINICAL- ETHICS? Steve Miles, MD

2. Ethics = Morals  1350  Greek to Latin to English  Ethos  A body of moral precepts  1350  Latin  Mores  Rules or principles of right conduct Ethics Morals

3. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Values  Rules (deontology)  Virtues (character, relationships)  Utilities (ends)  Principles (priorities)  Justice  Casuistry (comparison with settled cases) Is Ought (should, priority, duty, responsibility,)

4. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Rules (deontology) Whose rules? How rigid? How applicable?  E.g., Doctors and torture Is Ought (should, priority, duty, responsibility,)

5. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Virtues (character, relationships) Who defines right relationship?  E.g., Duty to treat contagious infections Is Ought (should, priority, duty, responsibility,)

6. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Utilities (ends)  Greatest good for greatest number, most bang for the buck?  What is the frame of reference?  E.g., Triage Is Ought (should, priority, duty, responsibility,)

7. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Principles (respect for autonomy, beneficence, maleficence, justice)  Who says there are four?  Do these solve problems or rationalize not thinking deeply about them?  Does deinstitutionalizing persons with combat veterans with PTSD really respecting autonomy or rationalizing neglect? Is Ought (should, priority, duty, responsibility,)

8. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Justice  Fairness (all comparable cases get treated the same)  Compensatory (most disadvantage get treated more to equalize opportunities)  Retributive (distribute as compensation for past injustice)  E.g., Negligence lawsuits or outreach to poor neighborhoods Is Ought (should, priority, duty, responsibility,)

9. Is (descriptive) Ought (normative)  Facts  Givens  Changeables  Bad luck  Casuistry (comparison with settled cases)  Are the comparisons apt?  E.g., how is voluntary euthanasia similar to or different from Nazi medicine or like the right to refuse treatment? How do differences and similarities affect the analysis? Is Ought (should, priority, duty, responsibility,)

10. Clinical- Medical - Bio- Ethics Values Biosciences, Medical Care, Clinical Care Biosciences, Medical Care, Clinical Care

11. Bioethics Values Biosciences Ecosphere Animals Plants Biosciences Ecosphere Animals Plants

12. Medical - Ethics Values Medical System Training Professionalism Conduct of Research Funding Health Policy Medical System Training Professionalism Conduct of Research Funding Health Policy

13. Clinical Ethics Values Clinician or Researcher-Patient Relationship Consent Confidentiality Coercion Disclosure Clinician or Researcher-Patient Relationship Consent Confidentiality Coercion Disclosure

14. Distinctions are thought provoking illusions Bioethics Clinical Ethics Medical Ethics Values

15. What is it? TR is a 28-year-old woman with AIDS renal failure on dialysis. She lives with her husband, young daughter and mother. She worked as a salesperson. Recently, TR became noncompliant with treatment. At times she stopped taking antiretroviral medications and drugs related to renal disease. A month ago, she stopped dialysis for 10-days. She was found at home nearly-comatose. She was intubated and dialyzed and recovered quickly. TR said she didn't like going for dialysis. She denied that she wanted to die, saying she wanted to live for her daughter. A psychiatrist said she was competent, depressed but not incapacitated by her depression. She was discharged and agreed to continue dialysis. One month later, her mother reported that TR had stopped going to dialysis for 10-days.

16. What is it? The mother of a 13-year-old California girl who is brain dead after complications from a tonsillectomy says her daughter is "still asleep" in an interview 10 weeks after moving her daughter from the Oakland hospital, the mother said, "I do not use the word 'brain-death' towards my daughter.” Doctors said that after finding the girl brain dead, they could no longer treat her under California state law. "Once death is pronounced and is validated by multiple physicians and well-established tests, as outlined in the law, and a reasonable period has been provided to the family, the hospital no longer preserves artificial respiration and circulation," hospital officials said in a statement.

17. What is it? Dear Legislators, I propose adding three words to statute below that I have put in CAPITAL LETTERS and UNDERLINED. It has no costs and will save lives. 144.344 EMERGENCY TREATMENT. Medical, dental, mental and other health services may be rendered to minors of any age without the consent of a parent or legal guardian when, in the professional's judgment, the risk to the minor's life or health is of such a nature that treatment should be given without delay and the requirement of consent would result in delay or denial of treatment. 144.3441 HEPATITIS B VACCINATION. A minor may give consent for a hepatitis B OR HUMAN PAPILLOMAVIRUS vaccination. The consent of no other person is required.

18. What is it?  A Nevada inmate denied cataract surgery because he had one functioning eye has won a ruling in the 9th U.S. Circuit Court of Appeals.  Inmate John Colwell was denied surgery recommended by his doctors because of the agency’s “one eye policy” that denies treatment if an inmate can function in prison with one eye.  The court, in a 2-1 decision, said blindness in one eye caused by a cataract is a serious medical condition.  “We also hold that the blanket, categorical denial of medically indicated surgery solely on the basis of an administrative policy that ‘one eye is good enough for prison inmates’ is the paradigm of deliberate indifference,” the court majority said.

19. What is it?  SOUTH ROYALTON –– Vermont Law School has partnered with the Center for Food Safety’s BEE Protective Campaign, making it the first higher-education campus in the country to earn official neonicotinoid pesticide-free designation.  “Over the past few decades, there has been a significant loss of pollinators, including honey bees, native bees, birds, bats, and butterflies, from the environment.”

20. What is it?  Swiss see rise in 'suicide tourism’  172 "suicide tourists" travelled to Switzerland in 2012, double the 2009 number, to die with medical assistance.  Most were from Germany and the UK.  The reasons most often cited were neurological conditions like paralysis, motor neurone disease, Parkinson's and multiple sclerosis.  The ages ranged from 23 to 97, with an average of 69.

21. What is it?  August 27, 2014 -- Pennsylvania agreed to expand Medicaid under the Affordable Care Act, joining 26 states and the District of Columbia.  Federal regulators accepted a modified proposal from Gov. Tom Corbett (R) that will offer an estimated 500,000 low-income individuals subsidies to purchase private insurance.

22. What is this?  Q. Do you recall any differences from Mr. West’s execution from the prior four executions?  MD. Mr. West’s execution was the first that we gave the chemicals through a peripheral IV.  Q. Why did that happen?  MD. The director felt that there was increased scrutiny on the protocol and that if possible, we should use a peripheral IV as the primary.  Q. What was your response?  MD. I said that we would make that attempt for him.  Q. In your professional opinion, did you want to use the peripheral line as the line through which the drugs should be administered?  MD: No.

23. Steve Miles, MD Professor of Medicine Maas Family Foundation Chair in Bioethics University of Minnesota Slides available miles001@umn.edu Questions?