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Draft 12/15/17

Comparative Medical Practices, Ethics and Law

PUBP 767 DL1

Spring 2018

Bonnie Stabile, Ph.D.

Research Assistant Professor

Schar School of Policy and Government

George Mason University

"Health is a state of complete physical, mental, and social well-being and not merely the

absence of disease or infirmity." Preamble to the Constitution of the World Health

Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on

22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2,

p. 100) and entered into force on 7 April 1948.

Course Information

Meets: Internet Campus

Office Hours: Tuesdays 6:00 – 7:00 pm, Room FH 652, or by appointment in person or

via Skype or phone

Contact: Email bstabile@gmu.edu, or office phone 703 993-8566

Course Description

This class will examine some of the most prominent and enduring ethical issues raised in

medical and public health practice in nations around the world. It will take a comparative

look at those issues through the application of various ethical frameworks, and an

examination of various legal and policy solutions derived to deal with them. The classic

principles of biomedical ethics as outlined by Beauchamp and Childress – respect for

autonomy, nonmaleficence, beneficence and justice – will help to guide our inquiry, as

will consideration of several major schools of thought in political philosophy, including

utilitarianism, libertarianism and communitarianism.

Learning Outcomes

A familiarity with some important bioethical, ethical and philosophical

frameworks pertinent to medical policy issues.

An ability to approach common bioethical dilemmas in medical policy from a

variety of philosophical viewpoints.

An ability to write effective analyses applying bioethics to medical policy issues.

An ability to give effective oral presentations regarding bioethics and medical

policy.

An appreciation of a multiplicity of ethical and legal viewpoints and policy

solutions regarding some current medical issues in the global community.

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Course Requirements/Evaluation

Participation: Weekly posts and dialogue 30%

2 Policy Briefs (7 pages each) 50%

Final Presentation – voice over power point 20%

See Appendices for descriptions of Participation requirements, and Policy Brief and

Presentation guidelines.

A grade of A or A- indicates sustained excellence and outstanding performance on all

aspects of the course. The grades of B and B+ denote mastery of the material and

very good performance on all aspects of the course. The grade of B- is given for marginal

quality work that is not quite up to graduate level standards. The grade of C denotes work

that may be adequate for undergraduate performance, but is not acceptable at the graduate

level. The grade of F denotes the failure to perform adequately on course assignments.

All written work is expected to be of the highest quality, representing both grammatically

correct and carefully considered analysis. Elements of central importance to sound

analysis include adequate depth, breadth, relevance and clarity of the concepts

considered.

Assignments must be submitted on time to receive full credit.

Finally, all students are required to use their GMU email accounts or have GMU

emails forwarded to their regular email accounts, as this will be the primary means of

correspondence with students regarding the class. Even if you do not regularly use your

GMU e-mail account, be sure to open it and place a forwarding address to the account

that you regularly use so that you can get GMU and class announcements.

Required Readings

The required book is available in the George Mason University bookstore:

Beauchamp, Tom L. and James F. Childress. 2012. Principles of Biomedical Ethics 7th

Edition. Oxford: Oxford University Press.

Other readings will be available online at the indicated web address, or via e-journals

through the George Mason University library website at library.gmu.edu

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Academic Integrity

Faculty in the Schar School have zero tolerance for academic dishonesty and will strictly

enforce Mason’s honor code.

The Schar School Statement on Plagiarism, the University Honor Code, and some

valuable Resources on Graduate Research and Writing are available at

http://schar.gmu.edu/current-students/masters-advising/masters-101/topic-5-graduate-

research-and-writing/

Citation Rule of Thumb

You are responsible for knowing how to properly cite referenced material. To be on the

safe side, if you use more than three consecutive words of another author or speaker, put

them in quotation marks and cite them. If you are citing five lines or more from

another’s work, those lines should be single-spaced and indented. Plagiarism will

automatically result in a grade of “F” for the assignment.

Plagiarism is using another’s words or ideas and representing them as your own. In this

age of clicking, cutting and pasting, it is easier than ever to plagiarize (and to detect

plagiarism), but it is as important as ever to respect the rights of owners and originators in

the marketplace of ideas. The use of quotation marks and meticulous, proper citation will

help you to avoid going astray.

Students with Special Needs

If you are a student with a disability and you need academic accommodations, please see

me and contact the Disability Resource Center (DRC) at 993-2474. All academic

accommodations must be arranged through the DRC.

Weekly Readings and Assignments

Session 1 (Week of January 22): Course Introduction and Overview

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Moral Norms,” Chapter 1, and

“Moral Theories,” Chapter 9 in Principles of Biomedical Ethics 7th Edition. Oxford:

Oxford University Press.

Session 2 (Week of January 29): Mental Health and Autonomy

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The principle of self-governance runs deep in moral thought and law, whether it refers to

the liberty of groups or individuals. At times, medical conditions affecting mental health

may cause us to consider instances in which personal autonomy might be constrained

through policy. Such constraints raise important issues of implementation, and how we

might safeguard both public and individual wellbeing, and the principle of autonomy

itself.

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Respect for Autonomy,” Chapter 3

in Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

Laakkonen, Marja-Liisa. 2009. “Ethical Care in Dementia.” British Medical Journal

339:b3993. doi: 10.1136/bmj.b3993.

For further study:

Richardson, Genevra. 2007. “Balancing Autonomy and Risk: A Failure of Nerve in

England and Wales? International Journal of Law and Psychiatry 30: 71-80.

Roper, Cath E and Edan, Vrinda. 2011. “Autonomy in Jeopardy: Contrasting

Participatory Health Models with Patient Decision Making Under Mental Health Law.”

Journal of Participatory Medicine. September 12, 3:e42. Available at

http://www.jopm.org/evidence/case-studies/2011/09/12/autonomy-in-jeopardy-

contrasting-participatory-health-models-with-patient-decision-making-under-mental-

health-law/

Session 3 (Week of February 5): Helping Someone Die: Assisted Suicide,

Euthanasia and the Principle of Nonmaleficence

Does Assisted Suicide constitute a violation of the principle of nonmaleficence – the

Hippocratic Oath’s admonition to do no harm? Or does it constitute an act of

compassion and afford autonomous individuals an opportunity to die with dignity? Few

nations have legalized assisted suicide. What is the ethical basis of this outcome and

what are the implications in medical practice?

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Nonmaleficence,” Chapter 4 in

Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

Yang, Y. Tony. 2016. “Why Physicians Should Oppose Assisted Suicide,” JAMA 315 3:

247-248. Available at http://jamanetwork.com/journals/jama/fullarticle/2482333

“The Fight for the Right to Die.” 2009. CBC News |Canada. February 9. Available at

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http://www.cbc.ca/news/canada/story/2009/02/09/f-assisted-suicide.html.

For further study:

Drum, Kevin. 2016. “My Life to Leave: Assisted Suicide, My Family and Me,” Mother

Jones January and February

Lagay, Faith. 2003. “Physician Assisted Suicide: The Law and Professional Ethics.”

Virtual Mentor (American Medical Association Journal of Ethics) January 5 (1).

Available at http://virtualmentor.ama-assn.org/2003/01/pfor1-0301.html.

Lewis, Penney. 2009. “Euthanasia in Belgium Five Years After Legislation.” European

Journal of Health Law 16: 125-138.

Session 4 (Week of February 12): Obesity and Paternalism: Beneficence or

Bureaucracy?

Should the government have a role in planning our meals? If children, or adults for that

matter, are fat, is personal moral failure or systemic environmental change to blame?

What policy responses have different nations in the international community devised in

response to the burgeoning problem of obesity, and what is the ethical basis of such

policies?

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Beneficence,” Chapter 5 in

Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

Holm, Soren. 2008. “Parental Responsibility and Obesity in Children.” Public Health

Ethics 1: 21-29.

National Council of State Legislatures. 2013. “Childhood Obesity – 2013 Update on

Legislative Policy Options.” Available at http://www.ncsl.org/research/health/childhood-

obesity-legislation-2013.aspx

For further study:

Branca, Franceso, Haik Nikogosian and Tim Lobstein, Editors. 2007. The Challenge of

Obesity in the WHO European Region and the Strategies for Response. World Health

Organization. Available at

http://www.euro.who.int/__data/assets/pdf_file/0010/74746/E90711.pdf.

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Crombie, Iain K., Linda Irvine, Lawrence Elliott and Hilary Wallace. 2005. “Public

Health Policy to Tackle Obesity: An International Perspective.” Commissioned and

funded by NHS Health Scotland. Available at

http://www.healthscotland.com/uploads/documents/obesity_full_report.pdf.

Session 5 (Week of February 19): Justice and Access to Health Care

First Policy Brief Due

Does justice require broad access to healthcare? Is there a minimum standard of care to

which everyone has a right? How do different ethical and legal constructs contend with

these questions?

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Justice,” Chapter 6 in Principles of

Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

Daniels, Norman. 2011. "Justice and Access to Health Care", The Stanford Encyclopedia

of Philosophy (Spring Edition), Edward N. Zalta (ed.). Available at

http://plato.stanford.edu/archives/spr2011/entries/justice-healthcareaccess.

Session 6 (Week of February 26): Moral Character and Health Care Provision:

From Conscientious Refusal to Exceptional Heroism

Certain attributes of “Moral Character” as described by Beauchamp and Childress can

help us consider the complexities of health care policy and provision. The “five focal

virtues for health professionals” include “compassion, discernment, trustworthiness,

integrity and conscientiousness.” While this latter virtue can at times lead to a refusal of

care, what the authors describe as exceptional heroism leads some to offer care in

extraordinary circumstances, such as the treatment of Ebola patients, which places

providers at considerable personal risk.

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Moral Character,” Chapter 2 in

Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

McGill, Natalie. 2014. “Health workers put themselves at risk for Ebola while saving

lives: Shortage of staff, supplies a concern” The Nations Health. October (44) 8: 1-16

For further study:

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Shaw, Jacquelyn and Jocelyn Downie. 2014. “Welcome to the Wild, Wild North:

Conscientious Objection Policies Governing Canada's Medical, Nursing, Pharmacy, and

Dental Professions.” Bioethics: Special Issue: Let Conscience Be Their Guide?

Conscientious Refusals in Health Care. January (28) 1: 33-46.

Session 7 (Week of March 5): Moral Status and Reproductive Technology

How might we apply the concept of moral status, as defined by Beauchamp and

Childress, to sort through contentious policies relating to embryos where personhood,

abortion, infertility treatment and contraception are concerned?

Beauchamp, Tom L. and James F. Childress. 2012. “Moral Status,” Chapter 3 in

Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University Press.

Farsides, Bobbie and Rosamund Scott. 2012. “No Small Matter for Some: Practitioner’s

Views on the Moral Status and Treatment of Human Embryos.” Medical Law Review

Winter (20) 1: 90-107.

Week of March 12: No Class - GMU Spring Break!

Session 8 (Week of March 19): Don’t Mess with Mother Nature? CRISPR and

Genetic Modification

Required:

Caplan, Arthur L., Brenden Parent, Michael Shen and Carolyn Plunkett. 2015. “No

Time to Waste: The Ethical Challenges Created by CRISPR.” EMBO Reports 16 (11):

1421-1426.

Kahn, Jennifer. 2015. “The Crispr Quandry: A New Gene Editing Tool Might Create an

Ethical Morass – Or it Might Make Revising Nature Seem Natural.” The New Times,

November 9. Available at http://www.nytimes.com/2015/11/15/magazine/the-crispr-

quandary.html?_r=0

Session 9 (Week of March 26): Palliative Care and Hospice: The Quality of Death

Second Policy Brief Due

Modern medicine, which proffers many miraculous interventions, can nonetheless offer

no antidote to death. What does it mean to die well? How is our experience of death

influenced by varying medical practices, ethics and law?

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Economist Intelligence Unit. 2010. “The Quality of Death: Ranking End of Life Care

Across the World.” The Economist. A report commissioned by the Lien Foundation.

Available at http://graphics.eiu.com/upload/QOD_main_final_edition_Jul12_toprint.pdf

Gawande, Atul. 2010. “What Should Medicine Do When it Can’t Save Your Life?” The

New Yorker. August 2.

Smith, Richard. 2014. “Dying of Cancer is the Best Death.” The British Medical

Journal, December 31. Available at http://blogs.bmj.com/bmj/2014/12/31/richard-smith-

dying-of-cancer-is-the-best-death/

Stabile, Bonnie and Aubrey Grant. 2016. “How Do We Die?” Politics and the Life

Sciences 35 2: 69-74.

For further study:

Al-Shahri, Mohammad. 2002. “The Future of Palliative Care in the Islamic World.”

Western Journal of Medicine 176 (1): 60-61.

Stanley, John M. 2003. “What the People Would Want if they Knew More About It: A

Case for the Social Marketing of Hospice Care.” Hastings Center Report Special

Supplement 33 (2): S22-S23.

Session 10 (Week of April 2): Ethical Codes and Practical Challenges in Clinical

Trials

Despite the principles established in such foundational sources as the Nuremburg Code,

the Declaration of Helsinki, and the Belmont Report, it seems that ethical dilemmas in the

conduct of research are routinely raised. In particular, we’ll consider the conduct of

clinical trials in routine and urgent circumstances.

Required:

Belmont Report. Available at http://ohsr.od.nih.gov/guidelines/belmont.html.

Nuremberg Code. Available at http://ohsr.od.nih.gov/guidelines/nuremberg.html

Presidential Commission for the Study of Bioethical Issues. 2011. Research Across

Borders. Executive Summary and selected sections. Available at

http://bioethics.gov/cms/sites/default/files/PCSBI-IRP_Research-Across-Borders.pdf

World Medical Association. 1964. Declaration of Helsinki – Ethical Principles for

Medical Research Using Human Subjects. Available at

http://www.wma.net/en/30publications/10policies/b3/.

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For further study:

Ehni, Hans-Jorg and Weising, Urban. 2012. “Testing Drugs Together with Those Who

Need Them.” World Medical & Health Policy 4 (1).

Allen, Nathan G., Jennifer S. Blumenthal-Barby and Laurence B. McCullough. 2015.

“Placing and Evaluating Unproven Interventions Within a Clinical Ethical Taxonomy of

Treatments for Ebola Virus Disease.” The American Journal of Bioethics 15 (4): 50-53.

Session 11 (Week of April 9): Electronic Medical Records and Privacy

Technological advances in managing information may well improve the quality of

medical care, but they also raise concerns of potential threats to patient privacy. What

varying ethical and legal frameworks inform the proliferation of the use of electronic

medical records around the world?

Required:

Beauchamp, Tom L. and James F. Childress. 2012. “Professional-Patient Relationships,”

Chapter 8 in Principles of Biomedical Ethics 7th Edition. Oxford: Oxford University

Press.

Kopola, Beverly and Mitchell, Mary Ellen. 2011. “Use of Digital Health Records Raises

Ethics Concerns.” JONA’s Healthcare Law, Ethics and Regulation 13 (3): 84-89.

Session 12 (Week of April 16): Not Enough to Go Around: Triage and Rationing in

Pandemics, Mass Casualty Incidents and Routine Medical Care

Required:

Goodman, John C. 2015. “What Everyone Should Know About Rationing by Waiting.”

Forbes, November 9. Available at

http://www.forbes.com/sites/johngoodman/2015/11/09/what-everyone-should-know-

about-rationing-by-waiting/

Larr, Amos and Debra DeBruin. 2015. “Ethics Sensitivity of the Ghana National

Integrated Strategic Response Plan for Pandemic Influenza.” BMC Medical Ethics 16

(30). Available at http://www.biomedcentral.com/1472-6939/16/30/

Lerner, Brooke E. et al. 2015. “A Consensus-Based Gold Standard for the Evaluation of

Mass Casualty Triage Systems.” Prehospital Emergency Care 19 (2): 267-271.

Session 13 (Week of April 23): Student Research Voice Over Power Point

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Presentations

Session 14 (Week of April 30): Student Research Voice Over Power Point

Presentations

Course Wrap-Up

Appendix A: Participation

I. Class Participation and Professionalism

Participate meaningfully in discussion on the week’s topics. Respond to

suggested prompts on the Discussion Board Weekly, and contribute

meaningfully to the class dialogue by responding to posts of other

students, and raising issues of interest related to the course readings and

their application. Prepare by fully and actively reading the literature

assigned for each session.

II. Current Event Policy Analysis

Over the course of the semester, each student must share at least one

current event for class discussion, suggesting how the application of some

specific aspect of one of the principles or theories we are studying might

enlighten our thinking on an issue of current policy importance.

Each student will lead a brief discussion thread in which he or she will:

Identify the policy issue and its parameters

Provide a link for the article of interest

Apply a specific element of analysis from the course

readings to illuminate some facet of the policy dialogue

Consider sharing the article via Twitter. Instructor is

@bstabile1

III. Discussion Board Tips and Guidelines:

Each week, after doing the weekly readings and listening to the

lectures/voice over power points, you should respond to the prompts

posted in the Discussion Board for the week.

1. You should have one substantive post of several hundred words (equivalent to about one double-spaced page of text)

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responding to the prompts for the week. You should respond to each prompt, but may decide to give more emphasis to one or another of them, depending on your interests.

2. You should also respond briefly but meaningfully to the main posts of two or three of your classmates.

3. Posts should be articulate and grammatical, but needn’t be as formal as a regular written assignment. We want to try to capture some of the immediacy and collegiality of classroom conversation.

4. That being said, posts should involve some forethought and organization. They are meant to both demonstrate that you have read and internalized the main themes of the readings, and that you can apply them to some pertinent aspect of a policy issue of interest.

5. So, reference professional, personal or “current event” examples involving the reading concepts or policy issues at hand can serve to enrich your posts when used judiciously.

Appendix B: Policy Briefs and Presentations

Each student must write two policy briefs* of seven pages in length. Each brief

will focus on a different principle of biomedical ethics: Respect for Autonomy;

Nonmaleficence; Beneficence; or Justice, and will apply that principle as the framework

of analysis to a particular health policy of interest (the specific policy must be cited)

anywhere in the world. As part of the analysis, the brief should:

1. concisely characterize the principle at hand (referencing definitions or concepts

from the text as appropriate),

2. identify the nation and its specific policy, noting its official title, date enacted, and

any other pertinent details

3. offer a brief consideration of the treatment of the policy in the US or another

nation for comparative purposes.

Each student will create a voice over power point presentation of his or her

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favorite policy brief during one of the final two sessions of class. This presentation will

be about 15 minutes in length. The goal is to have the essence of the central ethical and

policy themes of each research project well conveyed to colleagues.

*Instructions for submission of policy briefs:

double-spaced,

12 pt font,

standard margins

submit as an email attachment

label with student last name, course number and brief number

references required (APSA style)

page count does not include references, which are required

submit to instructor at bstabile@gmu.edu by the last day of the week in

which it is due – so for the first brief, due during the week of February

19th, you actually have until midnight of February 25th to submit)