Seminar in Biomedical Ethics-Fall 2012
The concept of a patient’s best interests plays a major role in bioethics. Those who support paternalistic behavior in at least some cases justify their support in those cases at least in part by reference to what is in the patient’s best interests. Surrogate decision makers for previously competent adults are supposed to make decisions based on what is in the patient’s best interests if they do not know what the patient would have decided. Surrogate decision makers for children and never competent adults are supposed to make decisions just based upon the interests of the children or the never competent adults. We sometimes justify breaching confidentiality because doing so would serve the patient’s best interests. Many more examples can be given of the use of this concept in bioethics. While much used, the concept is not necessarily well understood philosophically. Developing such an understanding and applying it to issues in bioethics is the objective of this course. The closest philosophical literature which can help us in developing such an understanding is the philosophical literature on the well-being of individual people, so it is to that literature which we will turn.
The first eight sessions of the course are devoted to three major theories of a person’s well-being, the hedonistic theory, the preference satisfaction theory, and the objective good theory. For each session, the syllabus contains a brief clinical scenario which illustrates the question or position we will be discussing. It then lists several readings available on the internet. Students will be expected to hand in two papers (8-10 pages each, one due by the end of September and the other due by the end of October) in which they discuss two of the scenarios in light of some of these theories. The second half of the course will consider more general issues, cutting across the three major theories about well-being. Students will be expected to hand in by the end of exam period a 20 page paper in which they present and defend an original view about one of these issues (or some approved other general issue). Your grade in the course will be determined by your grades on the first two papers (20% each) and by your grade on the final paper (60%)
I am in my office a lot. Feel free to drop in, except on Wednesday morning. If I can’t see you when you come, we will set a definite alternative time.
THREE MAJOR THEORIES
August 22- Hedonistic Theories
Mr Z is a severely demented gentleman in his late 80s. He is otherwise in good health and seems to take pleasure in eating, in watching TV (although it is unlikely that he knows what he is watching) and in staring at pictures of his grandchildren (although the pictures are often pictures of someone else’s grandchildren). Nobody knows what he would have said when competent about whether he would want to be allowed to die in this condition, although he had told his doctors that he feared the advanced stages of Alzheimer’s disease. His doctors therefore want to let him die from the infections he occasionally develops. His children are not sure because they believe that it is in his best interests to continue to live in this relatively pleasant state.
Feldman, “The Good Life: A Defense of Attitudinal Hedonism” http://people.umass.edu/ffeldman/TGL.pdf (2002)
Crisp,“HedonismReconsidered” http://www.tc.umn.edu/~ston0235/3311/crisp.pdf (2006)
August 29- Are Pleasures Always Worthwhile?: A Challenge to Hedonism
Ms Y is a woman in her mid 30s who has been referred for psychiatric counseling. She is a dominatrix who has engaged in sadomasochistic behavior for many years. All of her partners are adults who have freely consented to the mutual behavior in question. The referral arose out of an incident in which one of her submissives suffered unexpected and extensive harm. She was referred for psychiatric counseling as part of a plea deal. Ms Y sees no point to the psychiatric counseling, claiming that (a) she would be more careful in the future about her “punishments,” (b) these activities give pleasure to all those involved, and (c) the activities do not interfere with her and her partners otherwise quite productive and successful lives. So, she says, it is in her best interest (and in theirs) to continue in these activities.
Brock, “Can Pleasure be Bad for You” http://www.jstor.org/stable/pdfplus/3561719.pdf (1983)
Nussbaum, “Who is the Happy Warrior?” http://mfs.uchicago.edu/institutes/happiness/prereadings/nussbaum_happy_warrior.pdf (20
September 5- Desire Satisfaction Theories
Mr X is a 77 year old gentleman with metastatic prostate cancer. The standard treatment, which extends life from 30-36 months, is castration. This can be accomplished by a bilateral orchiectomy or by chemical castration involving total androgen blockade (TAB). Both are associated with decreased libido, impotence, hot flushes, anemia, hair loss, osteoporosis, fatigue, and psychological problems. Recent evidence suggests a modest increase of survival with TAB over bilateral orchiectomy. Mr X has a strong preference for increasing his life expectancy and that leads him to prefer TAB. But he also has a strong preference for maximizing his quality of life, and this leads him to prefer orchiectomy which is simpler and does not involve regular medical treatments (going to clinic reminds him that he is dying). He and his physicians find it hard to talk meaningfully about comparing the strengths of these preferences, so they are totally confused about what is in his best interest.
Heathwood, “Desire Satisfaction and Hedonism” http://spot.colorado.edu/~heathwoo/DSH.pdf (2006)
Arneson, “Desire Formation and Human Good” http://philosophyfaculty.ucsd.edu/faculty/rarneson/desireformationandgood2004.pdf (2006)
September 12- Dorsey Desire Satisfaction Paper
September 19- Corrected Desire Satisfaction Theories
Mr W is a 43 year old gentleman who has derived most of his satisfaction in life from engaging in strenuous physical activities, even if this has been difficult due to his worsening physical problems. Unfortunately, he is a diabetic who has not been careful about his diet, medicines, etc. The poor blood flow in his legs has finally resulted in complications requiring a bilateral amputation which he refuses because he believes that his life will have no meaning if he cannot satisfy his desire to engage in these strenuous activities. His physicians say to him that it is in his interest to undergo the surgery because there are many other good things in life, and that people can, given more information and experience, thoughtfully develop new preferences that given new meaning to their life. He has his doubts, saying I don’t care about those things.
Rosati, “Persons, Perspectives, and Full Information Accounts of the Good”
http://www.jstor.org/stable/2382347 (1996)
Noggle, “Integrity the Self and Desire Based Accounts of the Good”
http://www.jstor.org/stable/4320987 (1999)
September 26- NO CLASS
October 3- Adaptive Preferences and Desire Satisfaction Theory
Ms V is a 19 year old woman who led an active athletic as well social life, in addition to being a good student. Unfortunately, she had a diving accident which resulted in her becoming a high quad. As the weeks went by, and she came to better understand what this would mean to her life, she increasingly desired to die and requested help from her physicians to end her life. They counseled her about how other quadriplegics had found meaning in their lives, however limited their physical abilities, but she insisted that all of this was phony, that they were just trying to make the best of a miserable situation, and that she wanted no part of that farce.
Bruckner, “In Defense of Adaptive Preferences”
http://www.springerlink.com/content/kgg72l53h5m523r3/fulltext.pdf?MUD=MP (2009)
Dorsey, Preferences, Welfare and the Status-Quo Bias” http://people.ku.edu/~ddorsey/statusquo.pdf (2010)
October 10- Satisfaction of Different Desires at Different Times in Life
Ms U is a 29 year old successful currency trader, who works very long hours, but is also a competitive runner. She has thought a lot about her future and does not see children as being part of that future; they don’t fit with her intensive work load and her extensive training. She is active sexually, and is careful about contraception, but is concerned about contraceptive failures (especially because she is opposed to abortions). She approaches her OB-GYN with a request to be sterilized surgically. The OB-GYN suggests to Ms U that she needs to be more concerned about the possibility that her life plans may change, and urges her to consider long term contraceptive measures; doing so would be more protective of Ms U’s long term best interests. Ms U says that the person resulting from such a change would not be her, so she is unconcerned
Brink, “Prudence and Authenticity” http://philosophyfaculty.ucsd.edu/faculty/dbrink/pdf%20articles/prudence%20and%20authenticity.pdf (2003)
Huckfeldt “Prudence, Commitments and Intertemporal Conflicts”
http://onlinelibrary.wiley.com/doi/10.1111/j.1755-2567.2010.01084.x/pdf (2011)
October 17- Objective Goods
Mr T is a man in his early 70s dying from lung cancer, although he may live for weeks (perhaps even for a few months).Unfortunately, he has developed metastatic lesions which are causing him great pain. Having been only partially successful in their best efforts to control his pain, his physicians have sedated him and plan to keep him in that sedated state until he dies. They believe that this is in his best interests. They did this without consulting him because they thought that his pain and his pain medications impaired his competency to make such a complex decision. Some of his friends who have been visiting regularly think that the doctors were wrong. They believe that he would be better off conscious (with the pain relieved as best as possible with regular pain meds) because that would enable him to interact to some degree with these friends, something of considerable value which is being lost because he is sedated.
Arneson, “Human Flourishing versus Desire Satisfaction
http://philosophyfaculty.ucsd.edu/faculty/rarneson/flour4.pdf (1999)
Adams, “Well-Being and Excellence” http://philosophyfaculty.ucsd.edu/faculty/rarneson/Courses/ADAMSwellbeing.pdf
October 24 Simon Keller’s New Approach (session led by Prof Keller)
Keller, “Wefare and the Achievement of Goals”
http://www.springerlink.com/content/r7646807877q5283/fulltext.pdf?MUD=MP (2004)
Keller, “Welfare as Success” http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0068.2009.00723.x/pdf (20
October 31- Objective Goods and Perfectionism (Gwen will join us)
There is increasing concern that chemotherapy regimens may have a long term negative impact on various forms of cognitive functioning. Much more research is needed before firm conclusions can be drawn. Of particular interest is the issue of whether some regimens are more toxic for cognitive functioning than others. One nightmare scenario is that some regimens which cause a modest incremental improvement in survival over others might be the most toxic. Some have concluded that if this is so, then the information should be presented to the patients who could then decide which treatment they prefer. Others have concluded that this is too subjective an approach, and that it is in the best interest of patients to withdraw such toxic drugs from the market unless the improvement in survival is sufficiently great.
Haybron, “Well-Being and Virtue” http://www.jesp.org/PDF/WellBeingandvirtue.pdf (2007)
Dorsey, “Three Arguments for Perfectionism” http://people.ku.edu/~ddorsey/perfectionism.pdf (2011)
GENERAL ISSUES
November 7- Internalism about the Good for a Person
Rosati, “Internalism and the Good for a Person” http://www.jstor.org/stable/2382061 (1996)
Sarch, “Internalism about a Person’s Good” http://www.springerlink.com/content/l35l22657w071363/fulltext.pdf (2011)
November 14- The Good Life as a Whole
Kahneman, “Experienced Utility and Objective Happiness: A Moment-Based Approach” http://www.cepr.org/meets/wkcn/3/3503/Papers/kahneman.pdf (2000)
Raibley, “Welfare Over Time and the Case for Holism” http://www.tandfonline.com/doi/pdf/10.1080/05568641.2012.699174 (2012)
November 21- Self-Interest and Self- Sacrifice
Overvold, “Self-Interest and the Concept of Self-Sacrifice
http://www.jstor.org/stable/40231134 (1980)
Heathwood, “Preferentism and Self-Sacrifice”
http://spot.colorado.edu/~heathwoo/PSS.pdf (2011)
November 28- Well-Being and Death
McMahan,”Death and the Value of Life”
http://www.jstor.org/stable/2380928 (1998)
Bradley, “The Worst Time to Die”
http://www.jstor.org/stable/10.1086/524878 (2008)
The first eight sessions of the course are devoted to three major theories of a person’s well-being, the hedonistic theory, the preference satisfaction theory, and the objective good theory. For each session, the syllabus contains a brief clinical scenario which illustrates the question or position we will be discussing. It then lists several readings available on the internet. Students will be expected to hand in two papers (8-10 pages each, one due by the end of September and the other due by the end of October) in which they discuss two of the scenarios in light of some of these theories. The second half of the course will consider more general issues, cutting across the three major theories about well-being. Students will be expected to hand in by the end of exam period a 20 page paper in which they present and defend an original view about one of these issues (or some approved other general issue). Your grade in the course will be determined by your grades on the first two papers (20% each) and by your grade on the final paper (60%)
I am in my office a lot. Feel free to drop in, except on Wednesday morning. If I can’t see you when you come, we will set a definite alternative time.
THREE MAJOR THEORIES
August 22- Hedonistic Theories
Mr Z is a severely demented gentleman in his late 80s. He is otherwise in good health and seems to take pleasure in eating, in watching TV (although it is unlikely that he knows what he is watching) and in staring at pictures of his grandchildren (although the pictures are often pictures of someone else’s grandchildren). Nobody knows what he would have said when competent about whether he would want to be allowed to die in this condition, although he had told his doctors that he feared the advanced stages of Alzheimer’s disease. His doctors therefore want to let him die from the infections he occasionally develops. His children are not sure because they believe that it is in his best interests to continue to live in this relatively pleasant state.
Feldman, “The Good Life: A Defense of Attitudinal Hedonism” http://people.umass.edu/ffeldman/TGL.pdf (2002)
Crisp,“HedonismReconsidered” http://www.tc.umn.edu/~ston0235/3311/crisp.pdf (2006)
August 29- Are Pleasures Always Worthwhile?: A Challenge to Hedonism
Ms Y is a woman in her mid 30s who has been referred for psychiatric counseling. She is a dominatrix who has engaged in sadomasochistic behavior for many years. All of her partners are adults who have freely consented to the mutual behavior in question. The referral arose out of an incident in which one of her submissives suffered unexpected and extensive harm. She was referred for psychiatric counseling as part of a plea deal. Ms Y sees no point to the psychiatric counseling, claiming that (a) she would be more careful in the future about her “punishments,” (b) these activities give pleasure to all those involved, and (c) the activities do not interfere with her and her partners otherwise quite productive and successful lives. So, she says, it is in her best interest (and in theirs) to continue in these activities.
Brock, “Can Pleasure be Bad for You” http://www.jstor.org/stable/pdfplus/3561719.pdf (1983)
Nussbaum, “Who is the Happy Warrior?” http://mfs.uchicago.edu/institutes/happiness/prereadings/nussbaum_happy_warrior.pdf (20
September 5- Desire Satisfaction Theories
Mr X is a 77 year old gentleman with metastatic prostate cancer. The standard treatment, which extends life from 30-36 months, is castration. This can be accomplished by a bilateral orchiectomy or by chemical castration involving total androgen blockade (TAB). Both are associated with decreased libido, impotence, hot flushes, anemia, hair loss, osteoporosis, fatigue, and psychological problems. Recent evidence suggests a modest increase of survival with TAB over bilateral orchiectomy. Mr X has a strong preference for increasing his life expectancy and that leads him to prefer TAB. But he also has a strong preference for maximizing his quality of life, and this leads him to prefer orchiectomy which is simpler and does not involve regular medical treatments (going to clinic reminds him that he is dying). He and his physicians find it hard to talk meaningfully about comparing the strengths of these preferences, so they are totally confused about what is in his best interest.
Heathwood, “Desire Satisfaction and Hedonism” http://spot.colorado.edu/~heathwoo/DSH.pdf (2006)
Arneson, “Desire Formation and Human Good” http://philosophyfaculty.ucsd.edu/faculty/rarneson/desireformationandgood2004.pdf (2006)
September 12- Dorsey Desire Satisfaction Paper
September 19- Corrected Desire Satisfaction Theories
Mr W is a 43 year old gentleman who has derived most of his satisfaction in life from engaging in strenuous physical activities, even if this has been difficult due to his worsening physical problems. Unfortunately, he is a diabetic who has not been careful about his diet, medicines, etc. The poor blood flow in his legs has finally resulted in complications requiring a bilateral amputation which he refuses because he believes that his life will have no meaning if he cannot satisfy his desire to engage in these strenuous activities. His physicians say to him that it is in his interest to undergo the surgery because there are many other good things in life, and that people can, given more information and experience, thoughtfully develop new preferences that given new meaning to their life. He has his doubts, saying I don’t care about those things.
Rosati, “Persons, Perspectives, and Full Information Accounts of the Good”
http://www.jstor.org/stable/2382347 (1996)
Noggle, “Integrity the Self and Desire Based Accounts of the Good”
http://www.jstor.org/stable/4320987 (1999)
September 26- NO CLASS
October 3- Adaptive Preferences and Desire Satisfaction Theory
Ms V is a 19 year old woman who led an active athletic as well social life, in addition to being a good student. Unfortunately, she had a diving accident which resulted in her becoming a high quad. As the weeks went by, and she came to better understand what this would mean to her life, she increasingly desired to die and requested help from her physicians to end her life. They counseled her about how other quadriplegics had found meaning in their lives, however limited their physical abilities, but she insisted that all of this was phony, that they were just trying to make the best of a miserable situation, and that she wanted no part of that farce.
Bruckner, “In Defense of Adaptive Preferences”
http://www.springerlink.com/content/kgg72l53h5m523r3/fulltext.pdf?MUD=MP (2009)
Dorsey, Preferences, Welfare and the Status-Quo Bias” http://people.ku.edu/~ddorsey/statusquo.pdf (2010)
October 10- Satisfaction of Different Desires at Different Times in Life
Ms U is a 29 year old successful currency trader, who works very long hours, but is also a competitive runner. She has thought a lot about her future and does not see children as being part of that future; they don’t fit with her intensive work load and her extensive training. She is active sexually, and is careful about contraception, but is concerned about contraceptive failures (especially because she is opposed to abortions). She approaches her OB-GYN with a request to be sterilized surgically. The OB-GYN suggests to Ms U that she needs to be more concerned about the possibility that her life plans may change, and urges her to consider long term contraceptive measures; doing so would be more protective of Ms U’s long term best interests. Ms U says that the person resulting from such a change would not be her, so she is unconcerned
Brink, “Prudence and Authenticity” http://philosophyfaculty.ucsd.edu/faculty/dbrink/pdf%20articles/prudence%20and%20authenticity.pdf (2003)
Huckfeldt “Prudence, Commitments and Intertemporal Conflicts”
http://onlinelibrary.wiley.com/doi/10.1111/j.1755-2567.2010.01084.x/pdf (2011)
October 17- Objective Goods
Mr T is a man in his early 70s dying from lung cancer, although he may live for weeks (perhaps even for a few months).Unfortunately, he has developed metastatic lesions which are causing him great pain. Having been only partially successful in their best efforts to control his pain, his physicians have sedated him and plan to keep him in that sedated state until he dies. They believe that this is in his best interests. They did this without consulting him because they thought that his pain and his pain medications impaired his competency to make such a complex decision. Some of his friends who have been visiting regularly think that the doctors were wrong. They believe that he would be better off conscious (with the pain relieved as best as possible with regular pain meds) because that would enable him to interact to some degree with these friends, something of considerable value which is being lost because he is sedated.
Arneson, “Human Flourishing versus Desire Satisfaction
http://philosophyfaculty.ucsd.edu/faculty/rarneson/flour4.pdf (1999)
Adams, “Well-Being and Excellence” http://philosophyfaculty.ucsd.edu/faculty/rarneson/Courses/ADAMSwellbeing.pdf
October 24 Simon Keller’s New Approach (session led by Prof Keller)
Keller, “Wefare and the Achievement of Goals”
http://www.springerlink.com/content/r7646807877q5283/fulltext.pdf?MUD=MP (2004)
Keller, “Welfare as Success” http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0068.2009.00723.x/pdf (20
October 31- Objective Goods and Perfectionism (Gwen will join us)
There is increasing concern that chemotherapy regimens may have a long term negative impact on various forms of cognitive functioning. Much more research is needed before firm conclusions can be drawn. Of particular interest is the issue of whether some regimens are more toxic for cognitive functioning than others. One nightmare scenario is that some regimens which cause a modest incremental improvement in survival over others might be the most toxic. Some have concluded that if this is so, then the information should be presented to the patients who could then decide which treatment they prefer. Others have concluded that this is too subjective an approach, and that it is in the best interest of patients to withdraw such toxic drugs from the market unless the improvement in survival is sufficiently great.
Haybron, “Well-Being and Virtue” http://www.jesp.org/PDF/WellBeingandvirtue.pdf (2007)
Dorsey, “Three Arguments for Perfectionism” http://people.ku.edu/~ddorsey/perfectionism.pdf (2011)
GENERAL ISSUES
November 7- Internalism about the Good for a Person
Rosati, “Internalism and the Good for a Person” http://www.jstor.org/stable/2382061 (1996)
Sarch, “Internalism about a Person’s Good” http://www.springerlink.com/content/l35l22657w071363/fulltext.pdf (2011)
November 14- The Good Life as a Whole
Kahneman, “Experienced Utility and Objective Happiness: A Moment-Based Approach” http://www.cepr.org/meets/wkcn/3/3503/Papers/kahneman.pdf (2000)
Raibley, “Welfare Over Time and the Case for Holism” http://www.tandfonline.com/doi/pdf/10.1080/05568641.2012.699174 (2012)
November 21- Self-Interest and Self- Sacrifice
Overvold, “Self-Interest and the Concept of Self-Sacrifice
http://www.jstor.org/stable/40231134 (1980)
Heathwood, “Preferentism and Self-Sacrifice”
http://spot.colorado.edu/~heathwoo/PSS.pdf (2011)
November 28- Well-Being and Death
McMahan,”Death and the Value of Life”
http://www.jstor.org/stable/2380928 (1998)
Bradley, “The Worst Time to Die”
http://www.jstor.org/stable/10.1086/524878 (2008)