The Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979) identified the basic principles of respect for persons, which means identifying individuals as autonomous decision makers and protecting persons with compromised capacity; beneficence, meaning minimizing harms and maximizing benefits; and justice, indicating a fairness in the distribution of the benefits and burdens of research. In its primary application, the Belmont Report forms the modern basis of informed consent (Czubaruk, 2019). The actual term informed consent dates to a judge’s ruling in a 1957 court case relating to a surgeon who had not been forthcoming concerning the hazards of a surgical procedure that left the plaintiff paralyzed. In the 1957 US case of Salgo v. Leyland, Justice Bray wrote “a physician violates his duty to his patient and his subjects himself to liability if he withholds any facts which are necessary to form the basis of an intelligent consent by the patient to the proposed treatment…” (Simpson and Innes, 2020). The following historical events also significantly influenced the evolution of biomedical ethics in the 20th century (Jonsen, 2000): ● Discovery of DNA (1953) : This discovery was the beginning of the understanding of genetics and the inception of genetic engineering, whose many aspects have incited fierce ethical debate. ● Oral contraceptives (1960) : Greater understanding of the hormonal factors associated with female reproduction led to the development of oral contraceptives (“the pill”) and subsequent debate over their moral permissibility. ● Chronic hemodialysis and the Seattle Dialysis Selection Committee (1960) : The success of hemodialysis as a medical treatment for acute and chronic kidney failure was a double- edged sword; the treatment could save lives, but resources were extremely limited. A committee was formed in Seattle, where the technology was first available, with the mandate to select patients for treatment based on specific criteria. Committee members debated the decision of who would live and who would die, and why (Butler, Mehrotra, Tonelli, & Lam, 2016). ● Harvard definition of brain death (1968) : As artificial life support became available, the debate over the definition of irreversible coma began (Wijdicks, 2018). ● Roe v. Wade (1973) : This landmark decision by the U.S. Supreme Court ruled that the right to privacy guaranteed under the U.S. Constitution extends to a woman’s decision to have an abortion. This moral debate continues. ● Karen Ann Quinlan (1976) : The case of Karen Ann Quinlan spurred the debate over the definition of “persistent vegetative state,” and when it should be permissible to remove someone from artificial life support. On March 31, 1976, the Supreme Court ruled in a 7 to 0 decision that Karen Ann Quinlan should be removed from life support because she could not reasonably be expected to recover (Nursinganswers.net, 2020). This case prompted the creation of ethics committees in many hospitals (CDC, n.d.). ● Baby Louise Brown (1978) : The world’s first “test tube baby” was born to parents who could not conceive naturally. Some people accused physicians of playing God. Some Early ethical theories Before the 1979 release of the Belmont Report, which introduced principle-based ethics in health care, three schools of thought primarily guided the process of ethical decision making. These three approaches are important to understand because they have deep roots in history and society, and they governed ethical decision making in health care prior to the latter part of the 20th century. However, the diversity of these theories did not offer a standard upon which medical or dental practitioners could rely.
people greeted the news with excitement and joy while others expressed fear and hostility (Saunders, 2018). ● Baby Doe (1982) : A child born with Down’s syndrome had a serious but correctible birth defect that the parents decided, on the advice of their obstetrician, not to have repaired. The baby died after a few days (Kett, 2020). The baby’s birth and death caused people to explore the moral and ethical dilemmas of “special care nurseries” for handicapped and premature infants. ● Artificial heart (1982) : A retired dentist named Barney Clark was the first artificial heart recipient to survive the procedure. He lived 112 days. This procedure sparked fierce debate over the allocation of healthcare resources for one person. ● AIDS epidemic (1983) : Although the acquired immunodeficiency syndrome (AIDS) was already prevalent in some areas of the country, it was officially labeled an epidemic in the United States on April 11, 1983. The epidemic brought up several ethical issues, including that of patient confidentiality (Hlongwa, 2016). The rights of the patient need to be balanced against the welfare of potential sex or needle-sharing partners (HIV.gov, 2017). ● Patient Self-Determination Act (1990) : The parents of Nancy Beth Cruzan, a patient in a vegetative state, requested that the hospital discontinue artificial nutrition and hydration keeping her alive. Their request was denied. This case drove Congress to enact the Patient Self-Determination Act (Teoli, 2021). The advent of advance directives, right-to-die, and end-of-life decision making continues to present ethical dilemmas, as was evident in the case of Terry Schiavo in 2005. ● Terri Schiavo case (2005) : In 1990, complications of an eating disorder caused Terri Schiavo to suffer a cardiac arrest that led to catastrophic brain damage. At her parents’ insistence, she was kept alive through artificial hydration and a feeding tube for the next 15 years. Her husband insisted that all but the most basic brain function had ceased and that Terri Schiavo should be allowed to die. In the midst of legal wrangling, her feeding tube was removed and reinserted on several occasions. When the parents’ final appeal was denied, and the feeding tube was not reinserted, Terri Schiavo died (Approved Scholars, 2017). The Oregon Death with Dignity Act of 1997 (Oregon Health Authority, n.d., 2018) has been developed for situations such as the Terri Schiavo case. To read about these events in more detail, please see the Resources section of this course. The 20th century was a pivotal time in the evolution of medical ethics. As technology became more sophisticated and consumers of health care more knowledgeable, healthcare practitioners had no choice but to look more closely at ethical practices that surrounded patient care and research involving human subjects. Dentistry was no exception. The ethical challenges in health care have not ceased; rather, they have only increased in number and variety as society has become more dependent on technology and as medical advances have continued to grow exponentially. Utilitarian ethics Attributed to the 19th century English philosopher John Stuart Mill, utilitarian ethics suggests that the moral value of any action – that is, whether the action is right or wrong – depends on what consequences will ensue once the person makes the decision. Mill believed that the right action should always be the one that maximizes benefit for the most people and causes the least amount of evil. This theory holds that the consequences of actions should be beneficial and avoid harm (Prassad, et.al., 2019).
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