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The beginning of this rampage through biomedical ethics no amount of paper will ever be able to cover this vast subject will start off with 3 thought experiments. Thought experiment 1: You are the conductor of a train and your train's brakes have broken causing there to be no way to stop the train any time soon. Looking ahead, you see 4 workers standing on the tracks with their backs turned to you and there is no way of alerting them. At the same time, you also see that you can change tracks before you reach these 5 workers, but a single worker is standing on the track to which you can switch. What do you do? Thought experiment 2: You are a world-renowned surgeon who people from far and wide come to, but you still make your services available to the needy. One day, a homeless man with no family, job or interest in improving himself comes in for a checkup and you see that he has healthy lungs, liver, and pancreas. That same day, you received four patients; one needing a pancreas one a liver, and two needing a lung. They will die by midnight if they do not get any transplants. What do you do? Thought experiment 3: You are a biomedical engineer who has started his own blooming business selling housing furniture. At the height of your business, you think of a medical device that could save lives. To create this device though, there will still have to be a lot of research and funding meaning that you would have to sacrifice your business for something that may never turn out. What do you do? These are just three ethical situations that biomedical engineers will face. In light of that, in order for a biomedical engineer to be ready to enter the work field, he or she must be able to handle difficult ethical situations.
In beginning the journey of biomedical ethics for engineering, first seeing what biomedical engineer is helps one understand the fast need for ethics in this field. Biomedical engineering is defined as "The application of engineering techniques to the understanding of biological systems and to the development of therapeutic technologies and devices. Kidney dialysis, pacemakers, synthetic skin, artificial joints, and prostheses are some products of biomedical engineering" ("biomedical engineering," The American Heritage Science Dictionary). That list that was given is by all mean completely inclusive of all the things biomedical engineering does.
Medicine by design: The Practice and Promise of Biomedical Engineering by Fen Montaigne lays down the foundation for what biomedical engineering is and the hope it provides for the future. This book begins with the story of Jay Joice, a West Point graduate and former army officer, who after running one day, had his heart beating at more than 200 times per minute for more than 6 hours in a condition called tachycardia. Now, through the work of biomedical engineering, Jay Joice lives a more normal life because of the implantation of a pacemaker in his heart. This book then heads into all the different areas that biomedical engineering affects. This includes all of these areas: the artificial heart, heart-lung machines, stents, pacemakers, defibrillators, heart pumps (LVAD), functional electrical stimulation (allows severe spinal cord injury patients to restore certain functions like breathing), deep brain stimulation, robotic surgical systems, prosthesis, micro-electrical-mechanical systems (small chips as implantable replacements for diseases organs), bone rebuilding, imaging, tissue engineering, stem cells, artificial organs, cells implanting, and the genome projects. Even this extensive list does not cover everything.
Fen Montaigne ends his books with a look into "The Road Ahead." He says, "But just half a century ago, numerous problems faced by medicine and engineering also appeared to pose nearly insurmountable difficulties. Those worlds have been substantially conquered. Now, biomedical engineers are focusing their attention on an entirely different universe (nanotechnology, genes, and stem cells)" (221). Montaigne is ending his book with a challenge to all those reading it to conquer these new areas of medicine in order that more lives will be saved.
While it is good to help others and to be "devoted to developing and using engineering and technology to advance human health and well-being" as is the vision of the Biomedical Engineering Society, this devotion must be checked with ethics to see whether your helping is right or wrong. Should one try to solve the universe in bioengineering that they cannot see in nanotechnology, genes, and stem cells or are there just limitations to what one should do? How can one respond to all the different situations that are thrown at them? These are some of the question that will be answered in the rest of this journey through biomedical engineering.
Let us start this journey by laying the foundations of ethics. Dictionary.com defines ethics to be "a complex of moral precepts held or rules of conduct followed by an individual." This lays down the idea that what is right for someone is wrong for another, but Dictionary.com also defines ethics as "the body of moral principles or values governing or distinctive of a particular culture or group." That means that ethics are not completely subjective to the individual, but the group plays a role in deciding what is right and wrong. In particular though, ethics is functions between clearly right and clearly wrong. For example, although painful, the therapy was worthwhile. This example falls in between clearly right and clearly wrong.
That is where a study of biomedical ethics enters in order for one to be able to handle those difficult decisions that all biomedical engineers will be faced with. Daniel A. Vallero wrote a test book called Biomedical Ethics for Engineers: Ethics and Decision Making in Biomedical and Biosystem Engineering and this text was used extensively for creating a handle on difficult biomedical engineering ethical decisions. In order to learn about biomedical ethics, Daniel A. Vallero presents two ways: exploring cases to find examples and to treat biomedical ethics as a series of design problems (4). Both of these approaches have their advantages and disadvantages. Case analysis is great because one can study something that really happened, but it fails in numerous ways. Case analysis can by over simplified and they fail to help one put things into practice because even when the facts are right in front of us in the real life, one often does not see them, making case analysis useless (5). For example, one cannot learn how to drive from simply learning the rules, but they must go out and drive.
On the other hand, treating ethics as a series of design problems allows for the engineer to be placed within the problem itself. This method allows one to build solutions rather than trying to find right and wrong elements. Treating ethics as a series of design problems allows an engineer to take a comprehensive viewpoint; to see the whole picture (14-15). One instance of this would by stem cell research. If looked at from case analysis, one might see an already wasted embryo as something to be at least used for good. They would only be looking for right and wrong elements of using useless embryos for research. On the other hand, if one were to jump in and design the solution, they would see the whole picture; the whole life cycle. Using the design ethical approach, one would have to look at the ethical treatment of embryos that have gone on before one got to the point of wasted embryos.
Philosopher Caroline Whitbeck further advocated the idea of design-based ethics. She shows that ethics is very similar to an engineering problem (12). First, there is not a right answer, but a variety of correct solutions. At the same time though, some solutions have advantages of other ones (13). In the end, as Caroline Whitbeck puts it, "A proposed solution must do all the following: achieve the desired performance or end, conform to given specifications or desired criteria, and be consistent with background constraints" (13). This definition can be used for both ethics and design, or more appropriately to this paper, design ethics.
Whitbeck uses an example of stealing drugs in order to survive as why this design approach is better (16). She shows that when only looking for right and wrong element, it is difficult to come to a proper solution. This solution would depend on ones values. One might say that the person can work more or borrow some money to pay for the drugs while others would say that life is more valuable than thievery. Just looking at the case like that pigeon holes one into a limited number of solution. Instead, one must design their own solution, looking for other possibilities and different solutions (16).
Both case analysis and designing solutions are tools in which to make ethical decisions, but they are not enough. A more analytical approach must also be taken. To do this, one should use a code of ethics. The fundamental canons of the National Society of Professional Engineers (NSPE) are as follows:
Engineers, in the fulfillment of their professional duties, shall:
1. Hold paramount the safety, health, and welfare of the public.
2. Perform services only in areas of their competence.
3. Issue public statements only in an objective and truthful manner.
4. Act for each employer or client as faithful agents or trustees.
5. Avoid deceptive acts.
6. Conduct themselves honorably, responsibly, ethically, and lawfully so as to enhance the honor, reputation, and usefulness of the profession. (357)
This code of ethics is something to which an engineer can base his or her decision off of.
A decision matrix, which engineers use for a variety of situations, is a tool that can be used in coordination with this code of ethics. It is illustrated in figure 1.1 below.
Act for eachâ€¦
Avoid deceptive acts
Figure 1.1 (Kosky et al.)
This decision matrix works by writing all the different options to an ethical dilemma across the top. One then compares each option to each cannon and ranks how well that option upholds the engineering cannon. Once all the options are compared to the cannons, one must total up how each option compared to each cannon. The option with the highest total is inevitably the best choice using this method.
This might seem abstract, but a simple example should clear up the air.
Example: You own a large corporation and a recent economic downturn requires you to eliminate all dividends to your company stockholders. This is a highly confidential decision because it will negatively affect your stock prices. Several of your wealthy neighbors own a considerable amount of your company stock. At a recent picnic in your backyard one of them asks if she should sell some of your company's stock, considering how bad the stock market is doing in general. If you say "no," she could lose a considerable amount of money. What do you do? (kosky et. al 343)
Act for eachâ€¦
Avoid deceptive acts
As one can see from that the decision matrix, the best option would be to be political and not answer the question at all because it follows the NSPE canons the best. One thing to add to this discussion of decision matrixes and code of ethics are that there are other codes of ethics that one can follow including the Biomedical Engineering Society Code of Ethics.
Another analytical way to solve ethical problems is to use a step by step method. Michael Davis, of the Illinois Institute of Technology, argues that engineers need "a systematic means of probing ethical questions, not a toolbox with one or more theories" (Vallero 338). He adds that engineers need, "one easy to use method for guiding discussions, focusing on reasons, and forcing judgments" (339). Below is Michael Davis's seven-step guide for ethical decision making:
1. State your concerns.
2. Check facts.
3. Identify relevant factors.
4. Develop list of options.
5. Test the options-Harm test, Publicity test, Defensibility test, reversibility test, colleague test, professional test, organization test.
6. Select the best option based on steps 1-5.
7. Review (339)
This is just one more tool that can be used to simplify the ethical decision process into a more analytic process.
While a code of ethics, a decision matrix, and a step by step method for making ethical decisions are good, they are not perfect. There are limitations to them. For instance, the NSPE cannons fail to reference who the "public" is that safety must be help paramount for (147). One case in which this flaw could be misused is in the use of a dangerous chemical. An American company could see Americans as the public and not see a problem with uses this dangerous chemical in other areas. Another problem is that the ethical decision make becomes too analytical. Humans are not just machines. If one solution in a decision matrix ends up with the best value, one should not simply take that at face value. There must be more thought given to the situation. Lastly, these analytical processes can limit one from truly designing a solution. One must never forget to look at the whole picture.
With a general platform laid as to how to make an ethical decision, going into specific cases is the next step. The first question that will be asked is whether research using human pluripotent stem cells is ethical. In answering this question, some people turn to the "greatest good" argument. This argument does not hold water because choosing to sacrifice someone at the expense of another does not hold paramount the welfare of the public. Another argument that one might make for this research is that they are not human, but that is exactly what was done to slaves and what the Nazis did. People classify things a certain way in order for their ideas to sound better (56). When one comes into this situation and designs their own solution, they start to see that stem cells from amniotic fluid or placenta are the correct ethical choices. It offers more promise without the ethical dilemma.
The next question is how to go about organ transplantation. This question was asked because many people do not even realize it is a problem. How does one handle organs with the different views out there in the world? What can be done in procedures to help people who are uneasy with the current system of transplants? These questions bring up the point that an engineer must be aware of all the different opinions out there so that they can handle all the different ethical questions thrown his or her way (60).
Human research and animal testing also provide one with more insights to ethics. Human research calls for three ideas: respect for persons, beneficence, and justice (61) and there also must be a respect for animals as well. Beyond these requirements, the ethics of these situations often get fussy, unless one takes a step back. The first thing that must be done is finding new technologies for research. These new technologies must be focused on reduction, refinement, and replacement; the reduction of animals used; the refinement of stress and discomfort to the animals; the replacement of animals with other methods such as modeling (67). The next reality that must be faced is that the ends do not justify the means. One case of this is justifying animal research solely based on possible benefits to the human race (64). The last thing that must be applied to these situations is a lack of objectification. Too often, one is able to do unethical things by objectifying things. One calls it euthanasia instead of killing. One says remains rather than dead pet's body (63). One must be faced with the truth before they do anything.
Genetically modified organisms (GMOs) are another ethical situation that an engineer must learn from. An engineer must be careful not to decrease genetic diversity or create an organism that has no predator putting the public health and welfare at risk. Also, engineers must not strive to play God. At the same time though, GMOs could lead to more productive animals and developed treatments to deadly diseases. GMOs though, must not become a case of risks verses benefits. One must consider all the aspects beyond that. One solution that must be considered is putting labels on all GMO foods.
There are many other issues that can be covered, but the real importance is learning for certain issues so that an engineer will be ready to handle every situation that comes his or her way when they are in the field. Euthanasia is a good example of learning from an issue. Euthanasia should not be called good killing as its name applies. It should be called what it is and that is a killing of someone deemed not worthy of life nicely. Once this change of thought is made, one can better considered whether it is ethical right or not to kill someone nicely.
Another area of ethics that an engineer must consider is risk. He or she must find alternative designs for their device to make it safer while also figuring in all the possible misuses of the product of process (204). The reason for this is because an engineer is a trusted professional making him responsible for his or her device. If something goes wrong, the engineer is responsible much like the doctor working on the patient. The engineer holds responsibility.
In order for an engineer to consider all the possible missuses of a device, they can consider these six key ideas.
Devices are used in ways that were not anticipated
Devices are used in ways that were anticipated, but inadequately controlled.
Device use requires physical, perceptual, or cognitive abilities that exceed those of the user.
Device use is inconsistent with user's expectations or intuition about device operations.
The use environment effects device operation and this effect is not understood by the user.
The user's physical, perceptual, or cognitive capacities exceeds when using the device in a particular environment (233)
Holding these six ideas make it difficult for an engineer to be ethically sound, but the public trusts them to think about every situation that could occur that could cause their device to fail.
The engineer is also responsible for many other failures. Daniel A. Vallero specifically points out 5 different types: mistakes and miscalculations, extraordinary natural circumstance, critical path, negligence, and lack of imagination (236). Many of these situations, the public will not blame the engineer for failing, but that does not let the engineer of the hook. He or she is still responsible for the welfare of the public.
The first unethical failure is mistakes and miscalculations. These mistakes can be made by not correctly estimating the fatigue of an artificial material in a body or forgetting a parenthesis in a calculation. One might ask how unethical is omitting a parenthesis? In truth, it is very unethical. Engineers are professionals and as Norman Augustine said, "bad technical decisions are unethical" (236).
The second unethical failure is extraordinary natural circumstance. When building medical devices, it would be unethical if 1 out of 100 failed killing 1 out of every 100 people who used it while if a general light bulb failed at that rate, it would not matter. This gets at the point of at what point is "good," good enough. If a device was design not to fail in a six sigma production process, would that be good enough? The answer is yes. Ultimately, what must be done is that when a device is put under extraordinary circumstances, if it fails, the failure must be considered reasonable. At that point, the engineer would be acting ethically (237).
The third unethical failure is the critical path. The critical is the path it takes for something to fail. This path should be impossible, but the engineer cannot predict all of the possible failure modes. While this is true, the ethics of the failure does not depend on public opinion. The public does not decide if the engineer should have known the critical path or not. The engineer must have many contingencies plans and see many possible outcomes no matter what. To add to that, the engineer is also responsible for making sure that what he has designed has been implemented. The engineer must be part of the health and safety training that goes along with his design if necessary.
The forth unethical failure is negligence. This is the idea that if something can be done incorrectly, sooner or later it will (243).
236-244-Engineering 5 Failures 1.5 pages
How to be just and fair 261 287 1 page
Objectivity and finding truth 344-346 2 pages
Moral Courage 346-347 1 page
Steps of ethics 2 pages
Malpractice, or minimalist model
Reasonable Care, or Due Care, Model
Good works Model p36
P338 what an engineer must design for
Not just bioengineering. 1 page
Going beyond certain issues, one must determine the success and failures of one's ethical decisions. This goes hand in hand to who engineers are because engineers want to find out how well they are doing.
Go back to intro for conclusion 1.5 pages