Course Syllabus

Medical Ethics, Section B

Faculty

Elise Schiøler Cand. phil., MA (philosophy, University of Copenhagen). External lecturer in medical ethics and -theory of science, and philosophy of health technologies, University of Copenhagen, 2007-. External lecturer in theory of science, scientific method and argumentation analysis at The Defense College, 2012-. With DIS since 2011.

Course Description

The course is divided into three major sections:

1. Ethical theory and clinical values and principles
2. Clinical ethics: Concrete issues of clinical ethics
3. Research ethics: Concrete issues of ethics in clinical research.
   
   

Introduction

Medical science and biotechnology in the 20th century have created a multitude of dilemmas for the healthcare provider in a hospital setting: issues of justice and healthcare access, of confidentiality, informed consent, reproductive technologies, end-of-life issues, etc. Difficult choices, evaluations, and decisions involving values, norms, principles, and priorities are pressing. The perplexity of many healthcare providers, patients, and relatives in complex ethical situations show the need for systematic, ethical reflection.

Ethics is the philosophical study of morality. It addresses questions such as, “How should I act?,” ”How do I decide whether one way I could act is morally better than another valid way?,” and “Is there a right and wrong?” In addressing the many contemporary issues of decisions and responsibilities facing health care providers, the course will use ethical theories, principles and reasoning as a foundation for the critical analysis of clinical situations. 

This course focuses on medical ethics that concerns the identification, analysis, and resolution of ethical questions and problems arising in planning for the care of patients. But for medical practice to live up to the required values and principles it must rest on a foundation of medical research, where basic clinical standards for prognosis etc. cannot prevail. Therefore we will also take a brief look on the ethics of clinical research.

Expected Learning Outcomes

The primary objective of this course is to provide students with the intellectual tools requisite for examining fundamental questions in medical ethics and in particular clinical ethics. It is designed to help the student acquire the skills of conceptual analysis and identification of presuppositions. Philosophical inquiry teaches the student to read, write, discuss critically, and appreciate diverse points of view. The course is a critical search for understanding through argumentation.

The course aims to discover connections between ethical conceptions, ethical approaches to medical cases, and apply knowledge of ethics to concrete cases in biomedicine.

More specific objectives include the clarification of central concepts and distinctions developed in the literature of moral philosophy and medical ethics and applications of those concepts and distinctions to concrete cases in medical practice.

In short, the course will:

• Sensitize the student to value issues in medical practice
• Develop their ability to reason ethically and frame dilemmas
• Enforce their ability to work critically with moral statements
• Ability to conduct an ethical debate
• Enhance their ability to communicate difficult material
• Teach good comparative, argumentative and problem-solving skills

Required Readings

1. Singer, Peter; Kuhse, Helga: What is bioethics? A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199

2. Singer, Peter; Kuhse, Helga: Introduction. Bioethics: An Anthology Blackwell Publishing Ltd., 2006 ISBN: 9781405129480

3. Beauchamp, Tom L., ”The Principle of Beneficence in Applied Ethics" section 1-6.4,
   http://plato.stanford.edu/entries/principle-beneficence/

4. Beauchamp, Tom L.; Walters, Leroy: The Hippocratic Oath. Contemporary Issues in Bioethics Wadsworth Publishing Company, 1994 ISBN: 0534584411

5. Lægeforeningen; Schiøler, Elise: Lægeløftet/The Danish Oath. Lægeforeningen Url:http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/R%C3%A5dgivning% 20og%20regler/ETIK/LAEGELOEFTET

6. Gillon, Raanan: Confidentiality. A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199

7. Det Etiske Råd; Schiøler, Elise: Et spil om liv og død (A Game of Life And Death). Det Etiske Råd/Danish Ethics Council. Url: http://etiskraad.dk/upload/publikationer/oevrige-udgivelser/spil-om-liv-og- doed/index.htm

8. Beauchamp, Tom L.; Childress, James F.: Justice. Principles of Biomedical Ethics Oxford University Press, 2013. ISBN: 9780199924585

9. Elwyn, G., et al.: Shared Decision Making: A Model for Clinical Practice, J Gen Intern Med 27(10): 1361-7, 2012

10. Beauchamp, Tom L.; Childress, James F.: Respect for Autonomy. Principles of Biomedical Ethics Oxford University Press, 2009. ISBN: 9780195335705

11. Rendtorff, Jacob: Definition of the Basic Principles in Bioethics. Basic Ethical Principles in Bioethics and Biolaw Centre for Ethics and Law, 2000. ISBN: 8492352531

12. Zaner, Richard: Integrity and Vulnerability in Clinical Medicine. Bioethics and Biolaw, vol. II: Four Ethical Principles Rhodos, 2000. ISBN: 9788772458144

13. Higgs, Roger: Truth-telling. A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199 Beauchamp, Tom L.; Childress, James F.: Types of Ethical Theory. Principles of Biomedical Ethics Oxford University Press, 1994

14. Noddings, Nel: The Language of Care Ethics, Knowledge Quest, v40 n5 p52-56 May-Jun 2012

15. Rachels, James: Ethical theory and bioethics. A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199

16. Hare, R.M.: A Utilitarian approach. A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199

17. Crigger, Bette-Jane: AIDS and a Duty to Protect. Cases in Bioethics St. Martin's Press, 1998 ISBN: 0312067465

18. Rachels, James; Rachels, Stuart: What Is Morality? The Elements of Moral Philosophy Random House, 1986. ISBN: 9780078038242

19. Beauchamp, Tom L.; Childress, James F.: Confidentiality. Principles of Biomedical Ethics Oxford University Press, 2013. ISBN: 9780199924585

20. Rachels, James: Are There Absolute Moral Rules? & Kant and Respect for Persons in The Elements of Moral Philosophy Random House, 1986. ISBN: 9780078038242

21. Crigger, Bette-Jane: Can the Fetus Be an Organ Farm? Cases in Bioethics St. Martin's Press, 1998 ISBN: 0312067465

22. Foot, Philippa: The Problem of Abortion and the Doctrine of the Double Effect. Virtues and Vices: and other essays in moral philosophy, No. 5, 1967 Oxford Review. ISSN: None

23. Ridley, Aaron: Reproductive Rights and Abortion.Beginning Bioethics. Bedford Books of St. Martin's Press, 1998 ISBN: 0312132913

24. Devettere, Raymond J.: Euthanasia and Physician Assisted Suicide. Practical Decision Making in Health Care Ethics: Cases and Concepts Georgetown University Press, 2009. ISBN: 9781589012516

25. Kuhse, Helga: Why Killing is Not Always Worse - and Sometimes Better - Than Letting Die. Bioethics: An Anthology Blackwell Publishing Ltd., 2006 ISBN: 9781405129480

26. Callahan, Daniel: When Self-Determination Runs Amok. Bioethics: An Anthology Blackwell Publishing Ltd., 2006 ISBN: 9781405129480

27. Nagel, Thomas: In whose interest? Assisted Death: A Study in Ethics and Law Oxford University Press, 2003. ISBN: 9780199607983

28. Devettere, Raymond J.: Infants and Children. Practical Decision Making in Health Care Ethics: Cases and Concepts Georgetown University Press, 2009. ISBN: 9781589012516

29. Miller, Geoffrey: Personhood Extreme Prematurity Cambridge University Press, 2007 ISBN: 9780521862219

30. Miller, Geoffrey: Quality of Life and Best Interests. Extreme Prematurity Cambridge University Press, 2007 ISBN: 9780521862219

31. Miller, Geoffrey: Futility. Extreme Prematurity Cambridge University Press, 2007 ISBN: 9780521862219

32. Vederhus, B.J., Markestad, T., Eide, G.E. et al. Health related quality of life after extremely preterm birth: a matched controlled cohort study. Health Qual Life Outcomes 8, 53 (2010). https://doi.org/10.1186/1477-7525-8-53

33. Crawford, Doreen A.: Circumcision: a consideration of some of the controversy. Journal of Child care, Vol 6(4) 259-270, 1367-4935(200212)6:4, 2002

34. Mazor, J.: The child's interests and the case for the permissiblity of male circumcision. J Med Ethics 2013;39:421-428

35. Davis, Dena S.: Ancient rites and new laws: how should we regulate religious circumcision of minors? J Med Ethics 2013;39:456-458

36. Thorup, J., et al.: Complication rate after circumcision in a paediatric surgical setting should not be neglected. Dan Med J, 2013;60(8):A4681

37. Fisher, Alec: Decision-making: options, consequences, values and risks. In Critical Thinking. An Introduction. Cambridge UP, 2011

38. Devettere, Raymond J.: Transplantation. Practical Decision Making in Health Care Ethics: Cases and Concepts Georgetown University Press, 2009. ISBN: 9781589012516

39. Kass, Nancy: Ebola, Ethics, and Public Health: What's Next? Annals of Internal Medicine, 161, 10, 16 November 2014, 2014 American College of Physicians. ISSN: 00034819

40. Griffiths, PD: Ebola and Ethics Reviews in Medical Virology, 24/6/November 2014, 2014 Wiley Online Library. ISSN: 10991654

41. Singer, Peter: Famine, Affluence, and Morality. Philosophy & Public Affairs, Vol. 1, No. 3, 1972. Wiley-Blackwell ISSN: NONE

42. Chadwick, Ruth: Gene therapy. A Companion to Bioethics Blackwell Publishing Ltd., 1998 ISBN: 9780631230199

43. McConnell, Terrance: Genetic Enhancement, Human Nature, and Rights. The Journal of Medicine & Philosophy, Vol. 35, No. 4, 2010 Oxford Journals. ISSN: 03605310

44. Doudna, Jennifer A., & Sternberg, Samuel H.: Should we use gene editing to produce disease-free babies? Ideas.ted.com, Aug 22, 2017

45. Barnes, Elizabeth: Valuing Disability, Causing Disability. Ethics 125 (October 2014): 88-113.

46. Ereshefsky, Marc: Defining 'health' and 'disease'. Studies in History and Philosophy of Biological Sciences 40 (2009) 221-227

47. Kovács, Jósef: xconcept of health and disease. Medicine, Health Care and Philosophy 1: 31-39, 1998

48. Sandel, Michael J.: The Case Against Perfection. The Atlantic, April 2004

49. Offit, Paul A.: America's Master Race in Pandora's Lab. Seven Stories of Science Gone Wrong, National Geografic, Washington D.C., 2017

50. NIH (2019): Help Me Understand Genetics. Precision Medicine. http://ghr.nlm.nih.gov

51. Topol, Eric: Deep Discovery. In Deep Medicine, Basic Books, New York 2019

52. Wendler, David, "The Ethics of Clinical Research", The Stanford Encyclopedia of Philosophy (Winter 2017 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2017/entries/clinical-research/>. Section 1-4

53. Levine, Robert J.: The Distinction between Research and Treatment. Ethics and Regulation of Clinical Research Baltimore, 1986. ISBN: 9780300042887

54. Krasse, Bo: The Vipeholm Dental Caries Study: Recollections and Reflections 50 Years Later. Journal of Dental Research, Vol. 80, No. 9, 2001. American Dental Association. ISSN: 00220345

55. World Medical Association: Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. World Medical Association Clinical Review & Education. Url: http://www.wma.net/en/20activities/10ethics/10helsinki/DoH-Oct2013-JAMA.pdf

56. Møller, K.; Rossel, P. J. H.; Berg, R. M. G.: An ethical analysis of proxy and waiver of consent in critical care research. Acta Anaesthesiologica Scandinavica, Vol. 57, No. 5, 2013 Blackwell Publishing Ltd. ISSN: 00015172

57. Kendall, J. M.: Designing a research project: randomised controlled trials and their principles. Emergency Medicine Journal, Vol. 40 No. 2, 2003. BMJ Publishing Group Ltd. ISSN: 14720213

Guest Lectures
Katrine Kirk, MBA & Ph.D., partner at “Par 3 Consultants”. Par 3 specializes in how to create patient centered organizations in the health care sector.

TBA

Approach to Teaching

The brief lectures will take starting point in preliminary discussions. The discussions, led by the professor, will take the form of a  dialogue between the students, facilitated by the instructor, often preceded by student discussions in smaller groups. There will be reading assignments for each class.

In a class like this, active attendance is crucial. Each student is expected to come prepared to discuss the assigned material, engage themselves in the lecture and to complete all assignments. Others cannot benefit from your input if you are not present or prepared.

Evaluation

• Preparation for and participation in class as well as online debates and sharing ideas.
• An 80-minute online midterm exam.
• One group project (oral and written). The synopsis must be handed in the day before the panel debate.
• Group presentation of case and debate themes in class, and subsequently running the group discussions and class debate.
• Final project, which can be either an analysis of a medical case of the student's own choice (8,000-16,000 characters including spaces (corresponding approximately to 4-8 pages), 1,5 spacing) or a Medical Ethics game.
  
  

Participation

Credit for participation is earned in the following ways:

Prepare for class by

1. Reading according to the syllabus, and
2. Taking the relevant quizzes on Canvas, and
3. Engaging in online discussions on Canvas before and after class. And
4. Giving reasoned responses to questions and considerations posed in class by peers or instructor. And
5. Asking questions that help clarify or extend the concepts and issues under discussion. And
6. Entering into discussions both in class and on Canvas to make a valid point or try out a thought on matter discussed, ask questions, offer a different perspective, or respond to other students' questions and comments. And
7. Contributing to an open, positive, and inquisitive dialogue in the classroom.
8. Absence must be explained to the instructor via either Canvas or elise.utke@dis.dk. When a student is seen using any electronical device for other purposes than doing research to strengthen debate, this will count as being absent from the entire session. This is also the case during field studies.

Canvas debates

Before each class (with the exceptions of #1 and 23), after having finalized the readings, students are highly encouraged to engage in discussion on Canvas. It is important that an actual discussion is going on, so before posting a point, please make sure that another student hasn't already stated the same point. Thus, engaging in discussion is first and foremost to respond to peers' thoughts.

Discussion forum 'hosts' There are 6 discussion fora, each covering 2-5 classes. Sometimes topics or questions are suggested by the instructor, most often not. For each class 2-3 students will be assigned to make sure that discussion issues are raised. Each student will bear such responsibility of 'hosting' a discussion for 2 classes. So, when you are a host in a forum for a given class you must start up a discussion relevant to the topic of that given class, and you shall do this before that class in due time for your peers to repsond to your post before class, i.e. no later than 16.00 the day before class. All posts before the class should be responses to such 'host posts', but after class all students are encouraged to start up debates.

It is of course a good idea to frame your point or question, but please keep it short; think of your discussion posts as posts on other social media. You are NOT expected to explain the assigned readings.

The discussion forum can in general be used for sharing thoughts on the particular forum's topic, raising questions, and pointing out issues for class discussion. And of course: the forum only works, if you also respond to others' posts!

These debates will both affect the content of each class and count in the participation grade. When used for the latter, emphasis is on whether the student reveal to

1. be familiar with the readings and peers' posts,
2. have own, independent thoughts on the topic, and
3. be able to perform sound and persuasive reasoning.

All students must participate in each of the 6 fora, but do not have to post for each class, and there is no due date for the posts, except by midnight after class 23. However, students are encouraged to post while the forum topic is also the topic for our classes to uphold a lively debate!

The participation grade is broken into these categories:

1. Preparation     30%

2. Attendance      25%

3. Forum posts    15%

4. Class activity   30%

Midterm exam

The midterm exam is an online test that can be taken within 80 minutes, but the students will have at least 24 hours to take the test. The test will present a case that has not been read in class, and asks questions about professional values and ethical theories taught in class, relating these to the test case.

Euthanasia Group Project 

In class #13 students will be divided into four groups, each group holding a specified perspective to a given case. These groups will prepare for a panel debate on the case - an actual euthanasia request - in class #15. The day before the panel debate each group hand in a synopsis outlining the courses of argument. This synopsis must be both submitted under 'Assignments' and uploaded in the 'Euthanasia' discussion forum.

Group debate case presentation etc.

Each student will once during the semester, with a group of peers be responsible for

* presenting the debate case of that particular class,

* explaining various approaches to the case, and

* conducting group work and class debate.

Final Project

You can choose between option A, a case analysis, and B, designing a Medical Ethics game, as you final project.

Guideline for option A: the Final Case Analysis

The Final Case Analysis can be worked out and submitted either individually or with a peer.

For individual submissions: 8,000-16,000 characters, incl. space, excl. references and bibliography, 1,5 spacing.

For pairs: 12,000-20,000 characters, incl. space, excl. references and bibliography, 1,5 spacing.

This assignment is your opportunity to go into deeper discussion on a case or subject – of your own choice or a case or topic addressed in class –, and to cover issues that we haven't discussed in depth in class.

The term 'case' can be understood broadly, meaning that it can also be a specific kind of treatment, not necessarily a specific patient story, or it can even focus on a particular value in healthcare, or issues on adopting a particular ethical approach as a practicing healthcare professional. Or it can be a (patient/treatment) case that you have come across yourself.

So the limitations are

1. The subject discussed must be either [a] a specific clinical case (patient, health technology, or research study) discussed in class, [b] one of the professional values introduced in the course, [c] one of the ethical approaches introduced in the course, or [d] a clinical case of your own choice, whether a specific patient's story, or more general considerations on a specific kind of treatment. Such case must be a real life case.
   

2. If [a] is chosen, you must explain how your analysis adds to the discussion we had in class.

3. If [a] or [d] is chosen, you can either make a full 'what-to-do-and why'-analysis frome.g. a specific ethical approach, taking all or the most crucial professional values into account, or go into depth with a special consideration crucial to the case. If you choose the latter, it is important that you frame the importance of that consideration, i.e. explain how and why that is decisive for decision making.
   

4. If [b] or [c] is chosen, it is crucial that the value or theory is discussed through healthcare examples. Such examples do not have to be real life examples, but should be realistic or have demonstrated relevance for real practice.
   

5. If [d] is chosen, it is crucial that it is framed by use of the values and theories introduced in the course.

6. Your paper must somehow come around explaining Q1] What seems to be the problem in this case?, Q2] To whom is it a problem? Q3] What is the nature of the problem? Q4] What is the best way out of the problem?
7. You are expected to seek external sources relevant for the case on your own, and to bring relevant references for all sources involved in your analysis, using an acknowledged format.

Your work on this analysis has the following deadlines:

You can start working on this anytime after class#9 (when all values and theories have been presented in class).

I. By class#20 you must have decided upon a topic. At this point you must submit a brief outline (max. 1000 characters) sharing thoughts on your appraoch to the analysis. If requested, I'll give a brief feedback and suggestions.

II. At 16.00 the day before class#23 (our last class), you must submit a brief synopsis (max. 3000 characters) explaining a. your case, b. the problem, and c. your strategy in finding a solution to the problem, and d. possible problems you have faced and could use some feedback to overcome.

III. On Sunday, June 5, around midnight you must submit your finalized case analysis.

All steps are mandatory, but only step III is graded.

When grading, I will look for

• that the paper meets the seven criteria listed above,

• methodology and consistency in reasoning,

• familiarity with relevant readings,

• a personal contribution.

Guideline for option B: designing a Medical Ethics game

Grading 

Laptop Policy

Laptops are not allowed in class. Tablets and phones can be used for research qualifying the discussion.

DIS Contacts

Susana Dietrich, Program Director
Philippa Carey, Program Coordinator, pc@dis.dk
Jennifer Schulz, Program Assistant, jsc@dis.dk
Science & Health Program Office, Vestergade 7-37

Academic Regulations  

Please make sure to read the Academic Regulations on the DIS website. There you will find regulations on:

• Course Enrollment and Grading
• Attendance
• Coursework, Exams, and Final Grade Reports

DIS - Study Abroad in Scandinavia - www.DISabroad.org