Teaching and Learning > DISCOURSE

Analysis of Contextualised Healthcare Ethics Scenarios (ACHES)

Author: N. Athanassoulis, J.C. Jackson, and C. Megone

Journal Title: Discourse

ISSN:

ISSN-L: 1741-4164

Volume: 4

Number: 1

Start page: 83

End page: 111

Return to vol. 4 no. 1 index page

Introduction

This paper presents a report on an ETHICS project conducted at the University of Leeds2. The aim of this project was to examine the use of case studies couched in a philosophical framework and to explore and develop resources to provide useful philosophical underpinning for case analysis. For the purposes of the study we used case studies on Pre-implantation Genetic Diagnosis; active and passive euthanasia; and incompetent patients and best interests. In the paper we begin by presenting the context in which these case studies were used, noting first the growth in the use of case studies in teaching philosophy, and second the location of the particular projects examined within the medical curriculum and Leeds. We then outline the methodology employed in carrying out the project before turning to an analytical description of each author’s experiences in using his/her chosen cases. Specific comments attach to some of the case studies, but in the final section of the paper we present some more general reflections on the use of case studies in teaching ethics3.

Context: Case Studies and Philosophy

The teaching of philosophy has evolved. Philosophy has always been a subject taught through direct interaction with students, encouraging them to engage with the ideas, construct their own arguments and defend their positions. However, whereas previously small group teaching was mainly accomplished through tutorials, made up of two or three students discussing long essays, which they had written for this purpose, nowadays most departments have had to accommodate significantly larger numbers of undergraduates. As a result, tutorials are now largely reserved for final year undergraduates or postgraduate students, while for the most part undergraduates are taught in groups made up of twelve students or more. Such group sizes require a different method of teaching, one that ensures that each student has the opportunity to contribute to the discussion. At the same time, tutors have to ensure that discussions are meaningful, i.e. that relevant points are raised, that misconceptions or inconsistencies are challenged, that appropriate reference is made to significant philosophical ideas, that all students understand what is being discussed, etc. One of the methods used in order to stimulate discussion and provide focus for such a large group discussion is that of case studies.

Not only are case studies useful in managing large group teaching in undergraduate philosophy, but they also have a significant role to play in teaching philosophy to non-philosophy students. Over the last few years, a number of professional organisations have recognised that philosophical training (and often ethics in particular) should be a crucial part in their educational curricula. So, for example, medical students, nurses, students in biomedical sciences, genetics, computing, business studies, etc. are required to take courses in philosophy. Case studies are extremely useful for such students as they are a direct way of illustrating the relevance of philosophical theories and concepts to their practical, applied concerns.

With case studies playing an ever-increasing role in teaching, this project was set up to elucidate the role of philosophy in using case studies. Case study work can potentially prove frustrating and unproductive. The concern is that the case study may well succeed in stimulating discussion, but, in a sense, it may succeed too well. The case study may well provoke contributions, but these may lack focus, coherence or relevance and as a result the discussion may become disjointed, confusing and ill-defined.

Context: The Ethics Theme within the Medical Curriculum at the University of Leeds

The General Medical Council’s document “Tomorrow’s Doctors” which makes recommendations on undergraduate medical education, lists ethics as one of the requirements of a comprehensive medical degree. In response, the University of Leeds Medical School in co-operation with the School of Philosophy have set up the Ethics Theme (ET). As a theme, the ET contributes to a variety of courses over the first three years of undergraduate teaching and makes up 7% of the medical degree. The Theme uses a variety of teaching methods, but its overall objectives are to integrate fully philosophical teaching within the clinical curriculum and, over time, help students develop their ability to recognise, reason about, understand and, possibly even resolve, ethical issues. In its early years, the ET relies on lectures, which introduce philosophical arguments and theories, followed by small group work, which allows students to engage with the ideas and attempt to structure their own views. Later on, as students become more proficient and gain other general skills, such as IT, research, and presentation skills, the Theme allows for greater flexibility and student choice. In later years, students are expected to take an active role in guiding their own work, framing their own questions and through self-directed learning finding answers to those questions. Whereas in the early years it is the role of the tutor to stimulate and clarify, in later years the tutor acts more as a research supervisor, guiding and helping out when needed.

The ET covers a variety of topics, some, such as autonomy, confidentiality, justice, resource allocation, etc., are taught to all students, whereas others, which tend to be more specific, are chosen based on individual student preferences. Examples of the latter include “Organ allocation within the Leeds Trust”, “Three philosophers on abortion”, and “Patient lifestyle and entitlement to treatment”. The ET is fully assessed within the courses in which it takes place, using a variety of methods, such as long essays, group presentations, process, and short reports. The Theme receives feedback from both students and external examiners.

For this project we concentrated on the latter years of the Theme. In the third year, medical students undertake a Student Selected Component (SSC) course entirely on ethics. This is a compulsory course, in that all students have to take it and pass it in order to progress. However, it is designed to allow for student choice and for the expression of individual preferences. Students are offered over 70 projects each year, ranging from theoretical philosophical topics, to applied ethical questions closely linked to clinical practice. Tutors are drawn both from academic philosophy and from medical colleagues with an interest and qualifications in ethics. The students work in small groups of 4-5, meeting with their tutor three to five times over one semester (about a three-month period). They are allocated four hours per week study time to work towards an individual essay (of 3,000 words), and a group presentation. Thus although the students pursuing these SSCs will have undertaken preliminary work in ethics as described above, this is their first opportunity to undertake sustained examination of an ethical issue that might arise in medical practice.

The overall mark for these SSC courses is made up of a process mark for each student, the individual essay mark and a peer assessed mark for the group presentation. The emphasis is very much on student choice, not only in the selection of particular topics, but also in how the project shapes over the weeks and how they wish to develop their research and the content of the assessed work. Resources are provided to support the students’ self-directed learning. The Ethics Theme has a web site with suggestions for further readings, useful sites, etc. and we make use of Leeds’ virtual learning environment to post information on how to read and write philosophy, short introductions to the main philosophical arguments and theories, and guides on how to structure research.

Methodology

For our project, the Analysis of Contextualised Healthcare Ethics Scenarios (ACHES), each of the writers selected a theme and two cases around which to shape our students’ learning. We liaised with the ETHICS Project Coordinator to select the cases and we met to discuss how we might draw on philosophical and other sources to facilitate their use in teaching. Over the early months of the project we each developed in outline a sketch-plan of how we would present the material for study, indicating what readings we would direct students to. We also sought guidance on our project from three external assessors each of whom was experienced in this kind of teaching. We put to them the following questions:

1) If you were teaching on these topics, how helpful would you find our notes/plans?
2) What would you add/scrap?
3) Are there questions we should raise that we have overlooked?
4) Are there any important philosophical issues raised by these issues that we have not covered?
5) Are there better angles for shaping how students work on these topics?
6) What resources would you use to guide the discussion of these issues? Can you suggest other readings —e.g. on the web?

In the next stage of the project, we forwarded to our externals the final plans for our teaching. Towards the end of the session in which the teaching occurred, we held a symposium that was attended by our students, external assessors and by other colleagues at Leeds who are involved in this form of teaching.

At the symposium, which was the culminating stage of the project, we reported on our experience of using case studies within a philosophical framework. In addition, the students who had been at the receiving end of this teaching gave feedback, as did each of the external assessors. This was followed by general discussion which ranged over all aspects of the study including: the aims of this type of teaching, the particular value of case studies in pursuing those aims, the extent to which philosophical skills were involved in the teaching and the problem of finding suitable readings.

The Case Studies

I. Case studies on Pre-implantation Genetic Diagnosis

This part of the project examined the use of case studies in looking at some of the ethical issues that may arise around the technique of Pre-Implantation Genetic Diagnosis.

1. The Cases

A. The Hashmi Case: The Hashmi case involved a couple with a four-year old child with Beta-Thalassaemia. They wanted to conceive a second child by IVF, and desired that the embryos produced should be given pre-implantation genetic diagnosis (PGD) both for that disease itself and for the compatibility of the future child as a bone-marrow donor for the existing sick child. The parents requested that only an embryo satisfying both these conditions be implanted.

B. The Whitakers case: This was a quite similar case. However the Whitakers wanted their IVF-conceived embryos to be subject to pre-implantation genetic diagnosis (PGD) simply to determine the compatibility of the future child as a donor for an existing child and not because that future child him/herself was likely to suffer any serious congenital disease. Key issues
Both cases involve issues concerning screening for therapeutic and non-therapeutic purposes; best interests; the interests/rights/value of embryos; consent and non-competents, in particular parental consent for children.

What follows will first outline the intended approach to using these case studies for the purposes of examining ethical issues in PGD. The second section describes what actually happened.

2. How it was intended to go

Stage 1
The students taking the SSC are asked to make contact with their tutor to arrange a first meeting. In preparation for this meeting the students will be asked to:

a) find out all they can about the two cases, the clinical facts, patient arguments, court rulings and HFEA directives; and perhaps identify any other cases they think raise similar ethical issues. One possible source here will be the HFEA website.
b) “brainstorm” about the cases, each writing up to two pages in note-form in which s/he identifies as many ethical questions as s/he can that s/he deems to be raised by the cases;
c) try to organise the questions they raise into provisional ethical themes to address in examining the cases.

In the first meeting itself, we will aim to clarify the medical aspects of the case. We will examine the ethical questions the students deem to be raised by the case and try to distinguish ethical issues from others, for example from legal, medical, or psychological issues. We will try to identify some main ethical themes and will select one of these to work on for the next session. The “brainstorming” activity already mentioned will drive the themes that follow. However likely themes will include those such as best interests, referred to above. In each case the students will also be asked to consider how, if at all, those themes bear on the cases presented.

Stage 2
The students will be asked to consider the issue of best interests and its application here. Some possible readings on best interests are:

Discussion will consider whether, in either case, the use of PGD or the treatment of the embryo is consistent with the requirement to act in a child’s best interests.

Stage 3
The students will be asked to consider the status or value of the embryo and its relevance here. Some possible readings are:

Discussion will consider both the question in itself and how it bears on these cases.

Stage 4
The students will be asked to consider non-competence, and the issue of consent and its relevance here. Possible readings are:

At each of stages 2, 3, and 4, students will be expected to produce in advance a piece of written work of about 1500 words, and discussion will focus on the issues raised by these pieces.

Stage 5

Students will be asked to come with a draft of a group presentation focused around the two cases mentioned, drawing together themes developed in stages 1-4. They will also be asked to come with draft essay plans for their individual essays on the topic.

3. What actually happened

Stage 1
For the first meeting the group had been asked to try to find out in advance all they could about the medical and ethical aspects of the two cases, and the HFEA website had been mentioned as a possible source of information. Regrettably the meeting itself, at which they reported and discussed their findings, was interrupted by a fire alarm, which was somewhat disruptive! Nonetheless the group had identified several issues.

a) Best interests. They distinguished the two cases with respect to this issue. In the Hashmi case the parents were screening for the sake of the child’s best interests and for the sake of the other child’s interests. However in the Whitaker case the screening might be seen as only undertaken for the sake of the other child’s interests.
b) The moral status or value of the embryo.
c) The issue of consent. The parents might be seen as consenting on behalf of a non-competent entity.

Finally, the group wanted to know (d) how important the science involved in the procedure was, and what to say about that.

Stage 2
In preparation for the second meeting the group did not write essays, but they did make further inquiries into all the four areas mentioned above. With respect to (d), they had uncovered more detail on the diseases involved and the actual procedures undertaken in PGD. They had not made much progress on the issue of consent (c) in these cases. On topic (b) they had established some preliminary ideas. They had uncovered that the HFEA currently takes 14-days as the cut-off point in embryo development and why this is supposed to be significant. They had come across the notion of personhood, in various guises, and its supposed relevance to the debate. Finally they noted conception as another possible cut-off point at which an entity of value comes into existence. They had made limited progress on (a), the concept of best interests, and its relevance here.

In addition to this they raised the new issue of screening for the purposes of sex and discussed how this might relate to the two principal cases under consideration. They conceived this latter procedure as screening for a social reason, and suggested this might involve slippery slopes. The tutor tried to steer the group away from pursuing this further case at length, being worried that they would end up with too much material to cover.

At the end of this meeting the group agreed on a division of labour. Some wanted to pursue the question of the value of the embryo, some wanted to explore the concept of best interests and its application here, and some wanted to examine the cases under both lights. One group was given some readings on the status or value of the embryo and the concept of personhood as outlined above, but further readings by Tooley, Singer, Harris, Hursthouse and Ford (‘When did I begin?’) were added. For the other students Feinberg and Dworkin on interests were mentioned. However the tutor faced the difficulty of identifying reading material in this area that was appropriate both to give them some philosophical depth, and yet to allow them to apply the ideas discussed to their cases.

Stage 3
For the third meeting some long essays were produced. Several of the group gave good descriptions of what PGD involves from a scientific point of view. The discussion in the tutorial was mainly on the status of embryo. The students had made impressive progress wrestling with some difficult articles on personhood theories and potentiality arguments. Those working on best interests had noted that the cases raised the question of respecting the preferences/interests of parents and also respecting those of the live sibling. In the tutorial they also discussed whether embryos have interests, and whether it is better to be alive with disease, or whether the agent is sometimes better off dead.

Stage 4
For the fourth tutorial meeting there was further examination of the written work produced by the students. This time the focus was on best interests. Some discussion considered the repercussions of the view that embryos have no interests. If this were so, what would it mean to respect such entities? And why have constraints on PGD at all in this case? The interests of parents and the interests of the second child involved in these cases were also raised. Some time was given to outlining the nature of a philosophy essay, and to running through the barebones of the group presentation. So the group never returned to the question of consent in these cases.

II. Case studies on incompetent patients and ‘best interests’

This part of the project examined the use of case studies in look at ethical issues concerning parental proxy-decision making regarding surgery on children:

1. The Cases

A. The case of Tyrell Dueck: Tyrrell was a thirteen year old with leukaemia. Doctors had urged the necessity of amputation of one leg to prevent the spread of disease. The parents and the child did not wish this surgery to be performed and the doctors sought a court order to override parental refusal. While the court decision was pending Tyrell’s parents were debarred from visiting him for fear he might be abducted. Tyrell was assessed by a psychiatrist and deemed to be of normal intelligence but immature in that he said that he could not conceive of ever disobeying his father. The court ruled in favour of the doctors but meanwhile the disease had progressed to such a point that the doctors decided the surgery would not arrest its spread. The parents were then allowed to take their son to Mexico as they had wanted to all along—for alternative therapy. He died some months later.

B. The case of Re B 1987: B was a seventeen year old with a mental age of five to six years. She was epileptic. It was alleged that she could not be made to understand the causal connections between intercourse, pregnancy and birth. She had the sexual inclinations of a normal seventeen year old. If she were given oral contraceptives there was estimated to be a 40% chance of her keeping to a daily regimen. There would be serious side effects. She was also obese and had irregular periods so that if she became pregnant this might not be discovered early. B’s mother, advised by the social worker, gynaecologist and doctor, applied for her sterilisation to be authorised to avoid the risk of pregnancy.

Key issues
Both cases raise issues concerning children’s competence to be involved in decisions; the notion of ‘interests’: how these are related to wishes and welfare; the notions of best interests and best health interests; the role of parents in assessing best interests and parental rights in deciding for their children.

What follows describes the tutor’s experience of using these cases by describing the first meeting with the students and then presenting: 1) a copy of the handout that the tutor prepared for the students who opted for this study; together with 2) a summary of subsequent reflections on how it might be improved.

First meeting
At the first meeting with the students the tutor presented the students with a handout and explained that their group project was to be based on one or both of the cases above along with mention of any other cases raising similar issues that they might want to include. For their individual essays, though, they were encouraged to select any cases within the realm of incompetence. Thus, some might have preferred to discuss incompetence in the context of palliative care or in relation to participating in clinical research. It was pointed out that cases in these different areas might raise slightly different ethical issues and students were advised to consult the tutor when fixing on their particular essay topic both for reading suggestions and for flagging up of the relevant issues.

At this first meeting the group discussed the two cases in outline seeking opinions a) as to the ethical issues needing study in this case; b) their own initial views on how adequately the cases were resolved.

1. The Study Plan (Handout given to the students who undertook this SSC)

Before next (second) meeting
Find out what you can about the two cases—especially regarding the clinical factors (in case of Tyrell, alternative treatments, prospects for recovery; in case of Re B, alternative precautions; health implications of proposed measure).

Also, find out what you can of what was said by the parents, the doctors concerned and by the courts in these cases. You should also see if you can find other recent cases raising similar issues, by way of comparison. If you do, you might decide to make use of these in your essay submission.

Second meeting
We will seek an overview of the issues that these cases raise (see above) and the points of comparison between the two cases. At this meeting we will make a start in distinguishing how clinical, legal and ethical considerations might bear on decisions on these cases. The focus at this meeting will be mainly on the clinical aspects.

Before third meeting
Explore the legal aspects of these cases—and seek some other cases for comparison (e.g. young anorexics refusing treatment). You should meet and discuss your readings and decide what questions to raise at our third meeting. Two aspects deserve special attention:

1) assessing competence in children: how competent must they be to have a say? What is ‘Gillick competence’? Was Tyrell ‘Gillick competent’? Why/Why not?;
2) parental rights to make choices for their children. Why do they have such rights? When are they justifiably overridden? If parents and doctors disagree: who should decide and why? Can you find other cases where parental rights have been an issue? How were they decided? Do you agree with how they were decided? Why/why not?

Readings

Third meeting
The focus of this meeting will be mainly on the legal aspects of the cases. Come prepared to discuss the legal position regarding parents’ proxy role and the assessing of children’s competence. Attention will be paid in this seminar to the distinction between what is ethically required and what is legally required. Different measures of competency will be reviewed—their bearing on our cases. We will also discuss the trend away from medical paternalism vis a vis children (Children Act 1989). What lies behind this trend? Is it a sign of moral progress?

Some advice will be given about planning for group presentations and about choice of individual essay topics.

Before fourth meeting
You should reflect on some of the underlying ethical concepts and on their bearing on these cases: especially the notion of ‘interests’: taking note of the distinction between what is in one’s interests and what one is interested in; the related notions of welfare, happiness and one’s good. Consider the connections between health and happiness; and between one’s health interests and one’s good or one’s welfare.

Prepare your own draft essay plan: one page outline + readings that will be used; bring these to the fourth meeting to hand in for comment.

Readings
For readings on best interests, welfare and happiness: look up encyclopaedia entries under headings: interests, needs, happiness, welfare. The philosophy encyclopaedias are housed at A0.19 in the Brotherton, philosophy shelves. Look in Becker and Becker’s Encycl. Of Ethics, the Routledge Encycl. of Philosophy and, on ‘Welfare Policies’, in Chadwick’s Encycl. of Applied Ethics. Come prepared to discuss the readings. We will hope to draw from discussion of these some pointers for clarifying and resolving our cases.

Fourth meeting
The focus of this meeting will be on the ethical issues in these cases, drawing so far as possible on philosophical readings to address these. At this meeting we will discuss whether ‘best interests’ is the appropriate ethical standard for proxy decision-making and whether when deciding on treatments the child’s best interests may sometimes be balanced against other familial concerns (as with living sibling donation). We will also consider what weight if any should attach to the child’s wishes if these are deemed by others to run contrary to the child’s welfare. Attention in this seminar will be paid to the extent to which assessment of best interests requires medical expertise. We will also draw on some philosophical analyses of human good and happiness.

At this meeting we will discuss plans for the group presentation: what will be its focus? What materials you will need/use? How each of you will contribute? You will hand in your one page draft for essay (see above) at this meeting.

Before fifth meeting
You should meet as a group at least twice. At first meeting: agree on overall shape of group presentation; how each member will contribute to it and what each needs to do to prepare their bit. At second meeting: report findings and rehearse presentation; discuss what gaps need filling.

Fifth meeting
The aim of this meeting is to advise on work to be assessed: group presentations and individual essays. You will report on your progress with the group presentation and be advised on content and style of presentation.

Supervisor will return individual essay plans.

2. Specific Reflections on how this teaching material (the Study Plan) might be improved

Structure of the study plan
The division into clinical, legal and then ethical aspects seemed to work well for the students. It allowed them to begin from where they felt most secure and confident in gathering relevant information and bringing it to bear on the cases. Of course, the division between legal and ethical is not a sharp one and it would not have been sensible to try and force it. The focus in the legal analysis needed to include some discussion of how we should distinguish legal from ethical aspects? Ideally, the discussion of legal aspects of the cases should bring home the need for further probing of the ethical aspects that the law does not address or leaves fuzzy. If the law seems not always consistent, ethics begins to seem more attractive. Why, for example, does the law say that children can consent but cannot refuse?

The Content of the Study Plan
Here experience suggested some significant changes. One should not choose to focus on these same two cases for comparison again. Patients who are incompetent fall into a number distinct categories and it would make better sense to select cases of patients who fall within the same category. Thus, there are:

1) patients who were competent but will be no more;
2) patients who fluctuate sometimes being competent and sometimes not;
3) patients who will be but are not so yet;
4) patients who never were and never will be.

The above study plan straddled the Dueck case (category 3) and the Re B 1987 case (category 4). In fact the students found other category 3 type cases that were better for comparison with Dueck. They sensibly chose to concentrate on these. But they were free to take up (and did) other cases raising some different issues in their individual essays.

Since ‘best interests’ was a central notion for this study, the tutor was concerned to find readings that would help the students to analyse this notion in a relevant way. The students did not find the encyclopaedia references as helpful as had been hoped. In part this was because they were expecting that the notion would lend itself to easy definition. But ethics is not like that. Definitions, if appropriate at all, come in at the end of our enquiries not at the outset.

On the other hand some other sources, though, could be provided to students another time. One is an extract from Joel Feinberg’s Harm to Others, Oxford, 1984, in which he distinguishes one’s interests as ‘all things one has a stake in’. He goes on to distinguish preference-interests (what one is interested in) from welfare-interests (what is in one’s interests). This latter distinction is of central importance for patient-treatment decisions. Patients generally can be expected to be better informed than their doctors concerning the former sort of interests; not so, concerning the latter. But of course, the former sort of interests can have a bearing on the latter, and doctors need to be mindful of this.

Another aspect of ‘best interests’ that could usefully be emphasised in teaching on this topic is how best interests relate to the injunction to ‘Do no harm!’ It is important not to assume that this injunction means the same as ‘Always act in the patients’ best (welfare) interests!’. Even if doctors should stand by the strict ‘Do no harm!’ are there not some cases where they may be justified in choosing sub-optimally for their incompetent patients (for patients who are not able to consent). Mightn’t doctors be justified in choosing first a sub-optimal but adequate drug for a patient as an economy? (The sub-optimal drug might be incompatible with alcohol but otherwise equally effective and safe.) If this is defensible in regard to competent patients, is it not likewise so in regard to incompetent patients?

An interesting aspect of the Dueck case was how the law sided with medical opinion against the parents’ opinion. The doctors were better placed to judge their treatment to be a better bet for the boy than the Mexican alternative. But did they factor in the benefits of faith, prayer and trust in God, that obviously lay behind the parents’ choice? How could the doctors factor these considerations in? Were the religious concerns of the parents irrelevant to their child’s best interests? Does the law in discounting parental proxy decisions based on such religious considerations treat religion as a life-style choice (for adults only)?

Final thought
Under the heading ‘best interests and incompetent patients’ the tutor selected only one sort of incompetence, concerning older children. It would be equally useful and instructive to explore other areas—for example, concerning elderly frail patients with fluctuating or fading competence. It is important, though, to guard against superficiality and to select cases for comparison that illustrate one particular type of incompetence.

III Case studies on active and passive euthanasia

This part of the project examined the use of case studies to explore ethical issues concerning euthanasia.

The Cases

Miss B: Miss B, a 43 year old woman paralysed from the neck down as the result of a blood clot lodged in the spinal cord, appealed to the Courts to allow her breathing machine to be switched off against the wishes of her doctors. She had only a 1% chance of recovery from paralysis and wanted to die. Miss B was mentally competent, and did not wish to switch off the machine herself as she thought this would look like suicide and would affect her relatives. The Courts ruled in favour of Miss B, who died shortly after her ventilator was switched off.

Diane Pretty: Diane Pretty, 43 years old, terminally ill with motor neuron disease, went to the European Court of Human Rights to seek assurances that her husband would not be prosecuted for helping her to die, an act which she was physically incapable of carrying out herself. Diane lost her case in Court and died shortly after. What follows presents the tutor’s original thoughts on how this case study should be taught, together with reflections following the teaching.

Before the first meeting
The students were asked to find out as much as they could about the two cases. In particular, the tutor wanted them to find out about the clinical diagnosis of the two patients, prospects for recovery, possible treatments, effectiveness of palliative care, etc. This was important firstly because she wanted them to become familiar with the clinical context of the two cases, but also because, as will become clear below, the clinical details of the cases impacted on the ethical questions. Also, she asked them to identify as many of the arguments used by the patients themselves, their solicitors, the doctors, and the Courts. This was intended to give them a first glimpse of the types of problems which were raised by these two patient requests and the kinds of arguments which were used either in favour of, or against, granting them.

First meeting
Half of the first meeting was spent looking at the facts of the case. The students had worked hard to get these details together and it was good to give them the opportunity to contribute right from the start. This made the students feel more confident and confirmed, right from the start, the course’s objective, i.e. that the students should shape the research. The clinical details were discussed in depth, as many of them were relevant to the ethical issues. For example, clinical details about the two women’s states of mind were of relevance to categorising these two requests as voluntary requests. Immediately this gave the project some focus, as it was agreed to set aside other cases of euthanasia, such as the non-voluntary. Furthermore, facts about Miss B’s life expectancy and the amount of pain she was suffering compared to Diane Pretty’s situation, raised questions about how one should determine quality of life and when life is not worth living. Palliative care, and what can be done to make the end of life as bearable as possible were also discussed, which led to questions about the nature of death, and whether death is always a bad thing.

Significantly, the tutorial also spent a long time looking at the nature of the patient’s request. Questions such as the following were raised: What exactly is the patient asking for? Who will carry out the request? What will be the consequences of the request? What are the intentions of the person carrying out the request? Is the patient physically able to carry out the request herself? If yes, should she be allowed to do so and why is she not choosing to do so? This was a preliminary discussion for drawing out what would turn out to be the main difference between the two cases, namely the difference between passive and active euthanasia.

In retrospect, one aspect of these cases was not touched upon, but should have been. This was the legal and medical definition of passive euthanasia, and the classification of Miss B’s request as a request for withdrawal of treatment rather than passive euthanasia. Although the tutor aimed to avoid letting her personal philosophical views influence her students unduly, this was one case where her own judgement, that the distinction between the withdrawal of treatment and passive euthanasia, at least in this case, is mistaken, did influence her teaching. It would have been better to ask the students to look into this possible distinction and to find out about professional guidelines, whether they are philosophically plausible or not.

This discussion was intended to be fairly general and aimed at raising questions rather than answering them. The objective was to open up possible avenues for further research, rather than to try to give answers to really complex questions. A variety of different questions raised by the cases were looked at, as an incentive for the students to read further on the topics which interested them. The second half of the seminar was spent looking at the question of consistency. All the students who took this course, arrived with pre-conceived ideas on euthanasia. At this stage the tutor did not want to so much challenge their ideas, as to ask them to consider whether those ideas were internally consistent. This was done by asking the following question about the topics below: “Is the following practice (morally) acceptable?”

Practice Answer  
Suicide yes no
Assisted suicide yes no
Active euthanasia yes no
Passive euthanasia yes no

The question was understood rather broadly, asking whether it was morally acceptable for an agent to carry out this practice, stand by or even to encourage others or to participate in the practice. One aim of the exercise was to help students challenge their own beliefs in terms of internal consistency. For example, a student who thought suicide was unacceptable because human life was always sacred, might be expected to answer “no” all the way down the column.

Another aim was to make specific points about the nature of the practices. The first three practices are ordered in terms of the involvement of another person in bringing about the death. Suicide can be carried out independently of others (it may require that they refrain from preventing it, but it requires no assistance). By contrast assisted suicide requires some assistance and active euthanasia requires that something be done to the person killed. Passive euthanasia was set to one side with respect to this question, anticipating the debate over the role of the doctor who carries it out, i.e. the issues of act/omissions and intentions. At the same time, trying to give answers to the questions imposed some order on the students’ own thoughts. For example, two thoughts emerged during the discussion of suicide. Some students thought that we should not interfere with competent adults who decide to end their own lives for plausible reasons, such as terminal illness and severe pain. At this point the tutor made the connection with previous teaching they had had on Mill’s conception of autonomy. However, some students thought that it was wrong to attempt suicide as it went against our duty to our own selves to prolong our lives. Here the tutor introduced Kant’s account of autonomy and encouraged students who were interested in these views to read further.

Before the second meeting
The tutor suggested the following readings, which were given to students at the end of the first seminar, and reflected the topics raised there, as well as expanding on related issues:

Second meeting
The aim of this meeting was to introduce a wide variety of different considerations as related to what the students had read, deal with any misunderstandings arising from the readings, and provide as wide a field of research for the students to choose from as possible.

In this seminar the tutor asked the students to make a list of the topics they had read and talk a bit about them. As the readings were divided between the students, their task was to introduce the ideas they had read about to the rest of the group. The following ideas were raised in no particular order, but the tutor initiated discussion on them in such a way as to link them together as much as possible:

All these points were developed from and related back to issues raised by the two cases, for example, Miss B’s reluctance to commit suicide, and Miss B’s doctors’ refusal to take part in a course of action which did not conform with the goals of medicine, Diane Pretty’s request for her husband to assist her to die, and the fact that both women were mentally competent and able to make decisions about their own best interests.

The tutor’s role during this seminar was purposefully minimal. The group of students were particularly hard-working and bright. They had read quite a bit on the topic and had gotten together to discuss the issues before they met with the tutor. As a result they had quite a lot to say and felt comfortable talking to each other. Despite the divergence in opinion between the students on what can be a sensitive subject, they got on together very well as a group and found it easy to respect each other’s opinions while challenging them.

Before the third meeting
At the end of the second meeting the students were asked to read, take notes on, and prepare questions on:

This collection of readings was set in order to get to the heart of the distinction between active and passive euthanasia and to raise all the main questions about the doctrine of double effect, acts and omissions, and intentions and consequences.

Third meeting
This meeting concentrated on the major difference between the two cases, namely that Miss B’s request was deemed an acceptable request for withdrawal of treatment/care (according to the Courts), whereas Diane Pretty’s request was deemed (by the Courts) an unacceptable request for active euthanasia. The tutor was expecting this to be a particularly difficult seminar, however the students surprised her by having read well beyond her expectations and coming to the seminar with particularly sophisticated ideas (as indicated below).

The discussion began by looking at James Rachels’ example of Smith and Jones, which discusses the moral evaluation of agents and the role intentions play in such evaluations. The discussion first involved listing the different components of an action, such as the intentions or motives, the act (as in what is done or omitted), and the consequences. They then talked about how we should evaluate a variety of acts, such as non-culpable accidents, negligence, intentionally harmful acts, unintentionally good acts, etc. At this point the students brought up the differences between the ways in which different normative theories evaluate actions, noting how consequentialists focus on results in order to do this, whereas deontologists emphasise intentions. This insight was then linked to the disagreement between Rachels, Nesbitt and Kuhse, which the students had read about.

The group then went on to draw up another table bringing earlier distinctions made with respect to euthanasia together with the recent thoughts expressed on actions:

Practice Intention? How is it carried out? Consequences
Suicide certainty of death directly is death a harm?
Assisted Suicide unclear limited action not under the doctor’s control
Active Euthanasia killing act Certain death
Passive Euthanasia letting die omission foreseen but uncertain death

The discussion of the intentions of the person carrying out these practices allowed the group to talk about the distinction between killing and letting die and the doctrine of double effect. The discussion of the act itself, gave rise to the acts/omissions distinction, whereas consequences were relevant to the certainty of the outcome and related to whether the outcome was intended. Different students gave different answers to these questions. For example, some students felt that we are not as responsible for deaths which result from omissions as for deaths which result from actions. This type of disagreement between the students was particularly welcome, as the aim at this stage was not to impose a uniform solution to these philosophical debates, but to give the students a framework within which they could understand their ideas, and how those ideas related to the views of others and to different topics, as well as to what kinds of objections they were vulnerable to.

Euthanasia can often be a very confusing topic because of the large number of related questions which are often confused with each other. The aim of this session was to create a “mental map” of how different arguments are related and how they work together or against each other.

Before the fourth meeting
At the end of this meeting the tutor reminded the students of the assessment requirements for the course and the need to start focusing their group work towards the presentation. She also encouraged them to think through an individual essay plan for the next meeting.

Fourth meeting
The aim of this meeting was to go over the preparations for the assessed work. The students gave a brief outline of the group presentation, both in terms of its structure and presentation skills and in terms of its content. They were also given an opportunity for a trial run of the presentation, after which the tutor gave them detailed comments on content and style. The presentation focused on two questions: “Is euthanasia morally acceptable?” and “Is there a difference between passive and active euthanasia?” Both were discussed in the form of a debate, with a chair summarizing the arguments and applying them to the cases of Miss B and Dianne Pretty. This group’s presentation was judged by a cohort of their peers and other course supervisors to be one of the best four from the year.

The tutor also spent some time with each student, on an individual basis, discussing their essay plans. Interestingly each student had different ideas about what he/she wanted to work on. One student argued against active euthanasia because of the role of the doctor in bringing about death, but for passive euthanasia on the basis of the doctrine of double effect and the classification of passive euthanasia as withdrawal of treatment. Another student argued in favour of active euthanasia based on quality of life issues and the claim that death is not always a harm, and went on to argue further that active euthanasia was preferable to passive euthanasia because of its more immediate and guaranteed results.

Some reflections on our experiences
We conclude this report with some general comments on the use of case studies in a philosophical context that arose from reflecting on our experiences with the three projects above.

1. What were our aims in using case studies for the teaching of philosophy? We all agreed that we wanted the students to begin to think in some philosophical depth about an ethical issue, to practice philosophical methods and to appreciate their bearing on practice.

2. And how did the case studies help in these aims? Case studies facilitate this development in various ways. In the case studies the students could begin from where they felt most secure and confident in gathering relevant information and bringing it to bear on the cases. They could also express their initial pre-conceived views as a basis for further examination. As tutors we can then help them examine these ideas. They can be challenged for internal consistency. They can be asked ‘why?’ questions which probe those ideas for justification. And they can develop the skill of identifying the issues on which beliefs and justification matter in the cases in question. In sum the cases provide a focus on which they can work towards clarifying the issues and the arguments. Thus a topic such as euthanasia can often be very confusing, but starting from cases they can work towards a ‘mental map’ which lays out how different arguments are related and how they work together or against each other.

Student respondents reported that this was the first time in the medical course that they had engaged in a sustained (3 month long) piece of thinking on a single topic in this way. However this was also seen as a beneficial and enjoyable aspect of the module, and they recognized the way in which their ethical thought had developed through that process.

A related point is that at first sight these case studies present themselves to the students as examples of an attractive high-profile topic, but the groups soon found that they were entering deep philosophical waters. For example they needed to think quite deeply on the value of embryos, and on interests, who can have them, where they lie.

3. Choice of cases
This last point has a bearing on a tutor’s choice of cases. As noted above, in one of the projects in our sample we felt, on reflection, that more closely related cases would have been a better choice. This is because the cases chosen need to serve as a focus for discussion. If, whilst related, the case content is too diverse (in the example above, too diverse in the kinds of incompetent agents considered) then the cases serve to spread the students’ investigations rather than focus them. We felt that tutors using case studies for philosophical teaching need to bear in mind the goal of depth rather than superficiality.

4. Relations between cases and ethical themes
The chosen cases exemplify issues raised within a theme, incompetent patients and best interests, for example. However we all allowed the students to develop their own responses to the cases, and this in a range of ways. Some considered other cases pertinent to the theme. Others focused their examination on just some of the central issues raised by the cases. And naturally, despite working in groups, they would often defend quite different judgements on the cases. The case study method is clearly amenable to such student led development.

Having said that, in the first project above, for example, the tutor found that that the group were raising new issues such as sex selection, slippery slopes, and eugenics (which PGD might raise), beyond those specifically raised by the cases. Addressing these in addition to those of the status of the embryo, best interests, and consent would have been too much, so tutors may need to encourage students to focus their investigations. Also in this case, because of the group work, students had to bear in mind the need for some degree of coherence in their group presentation.

Two of us allowed the students to identify key issues themselves at the outset. The third gave the students their plan for five meetings (as presented above), which included an identification of key points. There is something to be said for both these approaches. The one encourages the skill of recognizing ethical issues in context, whilst the other allows the students to move straight on to the examination of their own beliefs.

5. Model answers

Allowing students to develop their ideas in the ways mentioned above militates against the notion of producing model answers for any case study based work, (though of course the essays will need to have the standard virtues of clear well-structure development of an argument). As noted, students wanted to develop different lines of argument, to focus on different issues within the cases, or sometimes to bring in other cases which raised similar but different issues. All of this was fine from our point of view.

6. Group work

We all found that there were several benefits to including group work in the use of these cases. Given the wealth and complexity of themes to pursue, the students could divide their labours, for example sharing out readings and reporting to each other on them. It also gave them an insight into team-working, where professionals with different perspectives need to learn to listen to those perspectives and reason about them. (In the feedback session one of the students also argued that group assessments also accurately mirrored real-life team work where one might sometimes be faced with needing to achieve goals even though colleagues were not pulling their weight.) In addition group working encourages dialectical engagement which is a crucial pedagogical tool for the development of an individual’s own ideas.

7. Transferable skills

Case studies used in these ways enable medical students (in this case) to develop transferable skills not always honed by other aspects of their studies. They encourage learning to read critically, and to develop a systematic and extended line of argument, to mention but two.

8. Who can teach this kind of thing? (Role of experts?)

We have made a case for using case studies in a philosophical way. This involves tutoring techniques which professional philosophy encourages (dialectical) but need not be confined to such professionals, so long as the aims of this kind of use, and the means to achieve them, are recognised by the tutors involved.

9. What kind of level of outcome?

There was some disagreement about the quality of outcome to be expected from students engaged in such projects. This was partly because some of the attainments by students at Leeds have been outstanding. But given that this was the first time these students had been asked to produce an extended piece of philosophical work the consensus at the colloquium expect the students to reach the attainment levels of a first year philosophy student (but adapted to an inter-disciplinary exercise).

Return to vol. 4 no. 1 index page

This page was originally on the website of The Subject Centre for Philosophical and Religious Studies. It was transfered here following the closure of the Subject Centre at the end of 2011.

 

-
The British Association for the Study of Religions
The Religious Studies Project