Saturday, April 25, 2009

Medical Ethics

[from John] Joel’s previous topic on medical ethics raises the broader question of medical ethics in its many forms. I would like to explore one or two points at this time.

Is it ethical for the nation or the state, to control the following medical practices if the individual wishes to participate? I’m discussing ethics not the law. I believe that these are personal choices and that the state has no ethical authority to interfere.

a. Use of drugs that are legal in other nations but not here. Drugs that are legally available in other countries may help an individual when drugs currently available in the US are not as effective.
b. Use of experimental drugs. Experimental drugs undergoing human blind test may help an individual, should it not be his choice?
c. Medical use of marijuana. The same argument as above.
d. Personal use of drugs now illegal.

In the last case ( d ) and as a second point the state will claim that it has an obligation to protect its citizens against the abuse of certain habit forming drugs is this a valid ethical position or a sophism? I don’t have the figures nor do I have the energy to pursue them however, intuition leads me to the conclusion that there is little valid evidence supporting their position. How does the state, ethically justify legalizing tobacco and alcohol, yet banning other drugs?

Does the zero tolerance policy make rational or ethical sense? Today we have locked up thousands for minor drug offensives. The illegal drug trade thrives as it did when alcohol was banned. What are we accomplishing?

In the early 1900s, we amended the constitution banning alcohol. It did not significantly reduce the use of alcohol rather it resulted in an active trade in contraband alcohol. The amendment was reversed after a few years. The illegal trade disappeared. Now that it is legal, does the use of alcohol present a serious problem for the nation? No.

Drugs are easily available today, in large quantities, if we are to believe the media, yet we are not swimming in drug addicts. Does anyone know the population of true drug addicts? How does that population compare to the population which uses the cancer causing drug tobacco or those using the legal drug alcohol? I would venture to say that the population of true drug addicts is small. The major harm to the nation is to the individuals incarcerated for minor drug offenses and the cost of fignting an ineffective war on drugs which in turn encourages a dangerous trade in illegal drugs.

Do irrational, illogical standards of medical morality and ethics guide our national policies rather than rationality and justice? I vote yes!


joel said...

Joh said: Is it ethical for the nation or the state, to control the following medical practices if the individual wishes to participate? I’m discussing ethics not the law. I believe that these are personal choices and that the state has no ethical authority to interfere.
a. Use of drugs that are legal in other nations but not here. Drugs that are legally available in other countries may help an individual when drugs currently available in the US are not as effective.
b. Use of experimental drugs. Experimental drugs undergoing human blind test may help an individual, should it not be his choice?
c. Medical use of marijuana. The same argument as above.
d. Personal use of drugs now illegal.

Hi John,

Thanks for the thought provoking post. I'm not sure at what level we can say an entity can have ethics or morals. Obviously government can have laws but the ethical principles of those who voted in the law may be different. Beyond "we hold these truths to be self evident......" I don't know if we as a country have ever defined any ethics. Perhaps, also "We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense,[1] promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity," provides us with some ethical principles. Otherwise, I don't think our government has any ethics, as I say, because each member votes for or against a law for different reasons. That leaves us with whether or not it's within the medical code of ethics to do the various things you've pointed out above.

I think the case of thalidomide is instructive with respect to your (a) above. While Europeans were using this drug effectively, we were withholding it, because our approval system was stricter. As a consequence, we had vastly fewer cases of mis-developed babies. It's true that our doctors by obeying the law were not using every possible method to help their patients and were therefore unethical. Do you do what is lawful or what is ethical. Which trumps? With respect -Joel

JohnS said...

Joel, you never make these things easy. You bring up an interesting point, can any entity other than a human be ethical or have ethical standards? Do humans have an innate sense of morality or ethics? I find the following phrases when looking up the words ethics, ethical, morality and moral in my Encarta dictionary.

a. A system of moral principles governing the appropriate conduct for a person or group.
b. Consistent with agreed principles of correct moral conduct.
c. The rightness or wrongness of something as judged by accepted moral standards.
d. Relating to issues of right and wrong and to how individual people should behave.
e. Based on what somebody's conscience suggests is right or wrong, rather than on what rules or the law says should be done.
f. Regarded in terms of what is known to be right or just, as opposed to what is officially or outwardly declared right or just.

Examining these phrase leads one to the conclusion that there is no such thing as universal ethics, morality or ethical standards. Rather ethics are an artifact of one’s social group or local environment. In examining this point social group and local environment must be considered broadly, they can include nations, The United States, larger groups such as the Western World or religious groups such as Methodists or Catholic or Christians. Within these groups or environs, one can find ethical splintering. Some Christian religions accept abortion some do not; some accept gay marriages others do not. In the case of nations, ethics are established by law; nations establish minimal ethnic standards through the law. An individual’s ethical standards may be more extensive but cannot be less.

In the case of thalidomide and my ethical code, a preference for personal responsibility, it was unethical initially to restrict its use on the premise that a drug must undergo more stringent testing than other developed nations lest we find problems in the future, however this is my personal position. I have no argument with a nation, the U. S. in this case, establishing the ethical standard of through testing before releasing the drug for public use. Although I disagree, in my mind it runs counter to my personal ethical standard of personal responsibility; yet, I would not violate the national standard by illegally obtaining the drug.

Returning to the ill-defined definitions above and the concept of personal liberty implied in our constitution and my personal ethic of personal responsibility I believe that I should be able to use any of the situations in my blog as long as they do no serious harm to others. I use the term serious because some may nitpick that there is always the possibility for harm in any action. With that said I will continue to comply with the national ethic.

Ira Glickstein said...

Thanks John for your topic.

Ethics are commonly accepted practices that are in the long-term, enlightened self-interest of societal survival and reproduction.

Different conditions demand different ethical practices in disparate contemporary societies and over the course of time.

For example, open immigration was ethical when the US west was being won, but now, with the whole US settled, more restrictive immigration is ethical. Ethical systems established in contemporary Islamic societies, such as status of women, would not be most ethical for western societies and (sometimes) vice-versa.

So, to consider John's questions:

a. (Drugs Legal Elsewhere) I disagree with John. As Joel points out regarding thalidomide (prescribed to ease the nausea of early pregnancy but turned out to deform the baby's extremities), ethics do not require that drugs legal in Europe be automatically be allowed in the US. It turned out the ethical thing was to follow our process for drug approval. Husbands who thought they were doing their wives a favor by bringing thalidomide home from business trips to Europe ended up damaging their children.

Therefore, it is ethical for the US government to ban drugs legal in other countries, including advanced countries such as those in Europe, unless and until the US approval process plays out.

b. (Experimental Drugs) I agree with John. Experimental drugs undergoing human testing in the US should be made available to all US doctors on condition that the status of the drug be fully disclosed to the patient with a waver.

Therefore if it is ethical to give experimental drugs to some in the US, it should be ethical for anyone whose doctor provides full disclosure of the status and risks of the drug.

c. (Marijuana) I agree with John. At long last, I have come to the conclusion it is ethical for the US to legalize marijuana and sell it to adults at licensed places, much like alcohol. If I could ban all mind-bending drugs I would, but the ban has not worked. The culture of contemporary US society include reasonable use of alcohol and now, of marijuana (though I have never used it and do not plan to.)

Therefore, marijuana should be legalized on a similar basis as alcohol.

d. (Illegal Drugs) I disagree with John. Illegal drugs (other than marijuana) are still under control for most sectors of the US. Crack and other hard drugs are so mind-boggling that users lose their ability to protect themselves from it, so they are no longer competent moral agents when they seek to buy a refill. The illegal status of marijuana has provided customers and funded criminal hard drug organizations. Legal marijuana will cut off that link and I think make it easier to find and prosecute hard drug dealers.

Therefore, it is ethical for hard drugs to continue to be illegal in the US.

Ira Glickstein

JohnS said...

In response to Ira’s comment, I will comment on his points a. and d. In his point a. (Drugs Legal Elsewhere) I tried to be careful, I did not intend to imply that we in the U.S. should legalize a drug here simply because it is legal in another developed nation. The point I was trying to make is I should be allowed to use the drug if I accept full responsibility. While thalidomide is a poor example, suppose that I, a male, felt that it would help me and I accept full responsibility why shouldn’t I be allowed to use it? Let’s assume that it helps my condition, would it not be ethical for our nation to allow my use?
I have a second concern, I agree that it is ethical for the U.S. to be cautious in approving a new drug, however that caution can have complications, the delay may cause deaths or unnecessary pain and suffering. Accepting full responsibility, should I not be allowed to use the drug?
It seems to me that a nation has a dual ethical standard in this and similar cases. It must protect the people of the nation (by restricting the use of drugs not reasonable proven safe) yet must allow for individual liberty and responsibility and allow my use of the drug, where no other person is involved including a fetus, if I choose and bear the responsibility.
In Ira’s comment d. (Illegal Drugs), let me make two points to start, it is ethical for the U. S. to restrict the use of drugs, illegal drugs. As a member of the U.S. community, it would not be ethical for me to use illegal drugs even if I accept responsibility. On the other hand, it is not ethical, in the U.S. guaranteeing each of us Life, Liberty and the Pursuit of Happiness, to become a nanny state forcing us to accept the pabulum the state deems acceptable. In the case of illegal drugs, are our national policies appropriate? I used the case of the U. S. banning alcohol and later legalizing it. I am applying the same logic. Is the government attempt to enforcing something the people won’t accept? If so I believe it would be unethical, however, I don’t believe this is the case. Rather, I suggest that the nation has almost become hysterical on the matter of illegal drugs and the government has reacted to that hysteria. The government may also have contributed to that hysteria. Yes, a person can become an addict from the illegal, hard drugs; he can also become an addict using the legal drugs alcohol and tobacco. Why legalize one and not the other? Yes, many of these drugs are more addictive than either tobacco or alcohol; however, I am questioning whether we are pursuing the correct course. We spend billions of dollars, put thousands in jail for minor drug offenses at tremendous expense and ruined lives in a seemingly unsuccessful attempt to stem drug trafficking. Instead, we have created a successful criminal underground railway where drugs pass easily and where murder and bribery are commonplace.
I don’t know how many people are addicted to illegal drugs just as I don’t know how many alcoholics there are; I am inclined to believe they are comparable numbers – maybe less drug addicts. If drugs were readily available, as alcohol is, would the expense to the nation both in lives destroyed and money be greater or less than our fruitless attempt to stem the drug trade? I believe a new direction is needed and my suggestion is, as we did with alcohol, let it become an individual’s responsibility.

Ira Glickstein said...

John, your original topic and your most recent comments are quite well reasoned and we agree more than we disagree.

On the matter of Drugs Legal Elsewhere (John's item a.), I would go along with personal use in the following circumstances:

1) The drug is not mind-bending and is legal in developed, westernized countries such as Canada and the UK and western Europe and Japan, and
2) The drug was legally purchased in the foreign country for personal use by the person taking it and brought back into the US by that person (and not purchased via Internet or mail-order and not for the purpose of giving or selling it to someone else).

That would allow US citizens to take day trips into Canada (or vacations to Europe or Japan if they could afford it) and see a doctor there and get the drugs and bring them back to the US for their personal use.

If giving or selling the drugs to another person was allowed, that would enable some future dangerous drug (like thalidomide) to be imported by family members or drug stores and used by people who have not seen a doctor in the foreign country or in the US.

Perhaps I would allow a US doctor to import the drug legal in developed countries for use by his or her patients in the US, with full disclosure and waiver, similar to experimental drugs undergoing human tests in the US.

On the matter of Illegal Drugs (John's item d.), if they are hard mind-bending drugs, I think we can still contain them here in the US to the communities that currently abuse them. For example, user/dealers in poor neighborhoods, Hollywood, and spoiled rich kids, etc.

The key issue for me on hard mind-boggling drugs is that the users, once addicted, are not competent moral agents. The government has a duty to protect children and the mentally infirm who cannot protect themselves.

The only reason I favor continued legal sale of alcohol to adults and would legalize marijuana on a similar basis is that the battle is lost with respect to those mind-bending drugs. I would if I could, but the toothpaste is already out of the tube.

Ira Glickstein