How might you
apply ethical philosophies and principles that summarize what you perceive to
be the top five ethical issues challenging health care delivery today?
HEALTH CARE ETHICS
PRINCIPLES AND PROBLEMS
Thomas M. Garrett
Harold W. Baillie
John F. McGeehan
Rosellen M. Garrett
University of Scranton
Prentice Hall
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ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.Library of Congress Cataloging-in-Publication Data
Health care ethics : principles and problems/Thomas M. Garrett . . . [et al.].—5th ed.
p. cm.
Earlier ed. entered under: Garrett, Thomas M.
Includes bibliographical references and index.
ISBN-13: 978-0-13-218790-9
ISBN-10: 0-13-218790-6
1. Medical ethics. 2. Medical ethics—Case studies. I. Garrett, Thomas M., 1924-
II. Garrett, Thomas M., 1924- Health care ethics 4th ed.
R724.G35 2010
174.2—dc22
2009008663
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10 9 8 7 6 5 4 3 2 1
ISBN 10: 0-13-218790-6
ISBN 13: 978-0-13-218790-9
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.CONTENTS
Preface to the Fifth Edition vii
Preface ix
Principles of Health Care Ethics
Chapter 1 Ethics, Professional Ethics, and
Health Care Ethics 1
Emotions and the Ethical Life 3
Human Nature and Ethics 3
Theories of Ethics 4
Key Issues 10
Applied Ethics 17
The Professions and Professional Ethics 18
The Health Care Professions 23
Summary 29
Chapter 2 Principles of Autonomy and
Informed Consent 31
General Formulation 31
Patient Autonomy: Informed
Consent 32
Paternalism: Weak and Strong 41
The Consent of Children, Adolescents,
and Incompetent Patients 45
Exceptions in Emergencies 47
The Right to Refuse Treatment 51
Problem Areas 52
Summary 53 • Cases for Analysis 53
Chapter 3 Principles of Beneficence and
Nonmaleficence 58
Introduction 58
Specifications of Beneficence 60
Specifications of Nonmaleficence 62
The Patient’s Obligation 67
The Health Care Provider’s Obligation 68
The Surrogate’s Obligation 71
Summary 78 • Cases for Analysis 79
iii
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.Chapter 4 The Ethics of Distribution 82
Introduction 82
The Goals of Health Care 82
Theories and Their Limits 90
Microallocation: Individual and
Institutional Rationing 96
Summary 103 • Cases for Analysis 104
Chapter 5 Principles of Confidentiality
and Truthfulness 109
Introduction 109
Truthfulness 110
Confidentiality 115
Summary 128 • Cases for Analysis 128
Problems of Health Care Ethics
Chapter 6 Professional Standards and
Institutional Ethics 133
Introduction 133
Judging Quality 134
Institutional Ethics 136
Ethics Committees 141
The Obligation to Police 143
Competition and Institutional Ethics 153
Summary 157 • Cases for Analysis 158
Chapter 7 Ethical Problems of Death
and Dying 163
Introduction 163
Ethics of the Patient 163
Health Care Providers and the Ethics of
Suicide Prevention 168
Health Care Providers and the Ethics of the
Death of a Patient 170
Physician Initiatives 176
Cooperation with Active Suicide
and Euthanasia 178
Surrogates and the Termination
of Treatment 182
Summary 189 • Cases for Analysis 190
iv Contents
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.Chapter 8 Abortion and Maternal Fetal Conflict 194
Introduction 194
Does the Fetus Have Rights? U.S. Law 195
The Definition and Types of Abortion 197
The Moral Status of the Fetus 198
Moral Status: Summary 201
The Autonomy of the Pregnant Woman 202
The Ethics of Abortion as a Social Phenomenon 209
Abortion and the Health Care Provider 211
Maternal Fetal Conflict 215
Summary 219 • Cases for Analysis 219
Chapter 9 New Methods of Reproduction 224
Introduction 224
Artificial Insemination and the General
Problems of Assisted Reproduction 225
In Vitro Fertilization 227
Surrogate Mothers 231
The Charge of Artificiality 235
The Ethics of the Health Care Provider 237
A Question of Distributive Justice 239
Summary 240 • Cases for Analysis 240
Chapter 10 The Ethics of Transplants 245
Introduction 245
The Ethics of Organ Donation from the
Patient’s Perspective 246
Basic Questions Regarding the Idea of Transplants 249
The Ethics of Cadaver Organ Donation 252
Increasing the Supply of Organs: Ethical Problems 254
The Ethics of the Health Care Team 256
The Health Care Provider’s Ethics of Distribution 259
The Society’s Ethics of Distribution 263
Summary 267 • Cases for Analysis 267
Chapter 11 The Ethics of Testing and Screening 271
Introduction 271
Testing 272
Ethical Problems of Mass Screening 281
Summary 288 • Cases for Analysis 289
Contents v
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.Chapter 12 The Ethics of Biomedical Research 292
Introduction 292
The Ethics of the Researcher 293
The Ethics of the User of Research Results 305
Fetal Research 309
Genetic Therapy 313
Cloning 317
Summary 319 • Cases for Analysis 319
References 325
Index 340
vi Contents
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.PREFACE TO THE FIFTH EDITION
Medical Ethics was not a course offered in my college, or in most colleges,
in the early 1970s. Throughout my four years of medical school and three
years of residency in the University of Pennsylvania health system, I cannot
recall time devoted to lectures on ethics. I am sure that mentoring in those
years has formed much of the professional I am now, but it was the opinion
of those whom I respected that guided much of what I did. That time was
filled with the promise of cure, early discovery, and amazing technical advances. The medical world was one of excitement and optimism. We kept
patients on ventilators and tube feedings believing that we could save them
if we had a little more time. Medicine was our life. We talked about cases
constantly, and even social events inevitably led to sharing tales of medical
discovery and challenge. I entered into private practice in 1980 to participate in a newly developed primary care residency program so that I could
share what I had learned and instill in others the love for medicine that had
been given to me.
Reality came slow and hard. Physicians soon came to realize that we
did not have all the answers. Patients began to assert their desire not to be
kept alive artificially when hope was really not in sight. The cost of medicine was skyrocketing, and for the first time a provider had to enter that
into the equation of treatment. The magic of the doctor-patient relationship
that can only be learned over time and experience was now added to the
fulfillment of medicine. My patients became another family. I shared in
their lives, celebrated times of successful treatment, and experienced those
moments of sorrow that reality brings. I love being a physician.
Youth and a respectable education can create a dangerous self-confidence.
It was at this time in my life when I met and became a friend of a patient,
Dr. Hal Baillie. To those who preach that physicians should not treat friends,
I would like to say that treating all patients as you would a friend can make
your life full, and I suspect would result in a return in the trust that patients
once had in us and a support for health care in general. Hal mentioned to
me that he and Drs. Tom and Rosellen Garrett, all professors at the University of Scranton (and all patients at the time) were writing a textbook on
medical ethics.
Friends can and should be honest with each other. Hal and I were
friends. We had a long, honest discussion. I made it clear that I thought it
was ridiculous for philosophers to think they could write about medical
ethics without knowing what it is like to care for patients in various situations. Hal made it clear to me that he thought I was naïve to think I knew
about ethics just because I had a medical degree. We were young, confident,
and steadfast, and the result was that the friendship came to an end and we
did not speak for a long time.
vii
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.Before the first edition of Health Care Ethics went to the publisher, I was
asked to read it. That was a day that affected the rest of my career. Hal was
right: I did not know how powerful a sound basis in ethics as applied to
medicine could be. We spoke again, much to his dismay, and have been best
friends since that day over 20 years ago. I have had the pleasure of offering
comments, cases, and suggestions, and we have worked together on ethics
committees and lectures.
When he asked if I would be willing to coauthor the fifth edition of
Health Care Ethics, I was surprised by my sudden affirmative reply and the
excitement surrounding the opportunity. Over my 30 years as a physician, I
have realized that by combining experience, moral values, respect, and a
constant desire to learn, the hours and challenges of health care become
more gift than burden. I thank my family for making sure that I am more
than a doctor, my patients for their friendship and all they have taught me,
the profession of medicine for not becoming a job, and for the opportunity to
apply practical wisdom in all aspects of my life though the foundation provided by Dr. Baillie (and yes, we are still friends after this book).
John F. McGeehan, M.D.
viii Preface to the Fifth Edition
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.PREFACE
The 20 years this book has been in print have seen many changes in health
care ethics and similar changes in the lives of the authors. Tom Garrett has
passed away, and Rosellen Garrett has retired. When Prentice Hall asked
that I do another edition, my own circumstances had changed considerably
as well. Clearly, it was necessary that I add another author if I was to ever
complete a revision. I am deeply appreciative of the enthusiasm and perspective John McGeehan has brought to the task. He is right; we remain
friends. But as important (at least for the book) is that we remain caught up
in the debate about the nature of health care and health care ethics.
Health care ethics has evolved considerably in the last few decades,
and it continues to do so. That evolution creates a dilemma for the revision
of a textbook. The original conception was to direct this work at an educated
audience, who were not necessarily (or perhaps not yet) professionals but
wanted a solid, comprehensive introduction to the subject. Tom, Rosellen,
and I had in mind college juniors as we wrote. In writing this edition, John
and I have kept that same audience in mind. Although professional health
care ethicists have somewhat moved on from the basic concerns of establishing the foundation for informed consent or the right to refuse treatment, the
new student starts much where students of health care have always started.
Thus, John and I decided that there would be limits on how dramatic the alterations of the original book would be. Much has been updated, but much
has remained fundamentally the same. Discussion of principles has been enlarged, but remain basically the same. The later chapters on problems have
received a fair amount of revision and updating.
We would like to thank Nancy Kotary for copyediting that caught
errors 20 years old as well as in our more recent contributions. We would
also like to thank our wives for tolerating our often meandering collaboration, and Tom and Rosellen Garrett for getting the whole enterprise started
those many years ago.
Harold W. Baillie
ix
ISBN 0-558-64008-7
Health Care Ethics: Principles and Problems, Fifth Edition, by Thomas M. Garrett, Harold W. Baillie, John F. McGeehan, and Rosellen M. Garrett. Published by Prentice Hall.
Copyright © 2010 by Pearson Education, Inc.
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