Life and Death: Medical Ethics — Ethics 8 (C1)

ETHICS · LESSON 8

Life and Death: Medical Ethics

C1 (B2–C2) · 90 minutes

Where do you stand?

Task Write P, N or D for each act. Don't explain yet.

P = permissible · N = not permissible · D = it depends

1. At her family's request, a doctor does not tell an elderly patient that her cancer is incurable.

2. A hospital gives its last intensive-care bed to the patient most likely to survive, not the one who arrived first.

3. A competent adult refuses a treatment that would save his life, and his doctors respect the refusal.

4. A doctor prescribes drugs that a terminally ill patient, at her own request, may take to end her life.

5. A man sells one of his kidneys to a stranger through a legal, state-regulated scheme.

6. A doctor gives a patient a sugar pill without telling him, because she believes it will help.

READING

Four principles, and their critics

In 1979 the philosopher Tom Beauchamp and the theologian James Childress published Principles of Biomedical Ethics, now in its eighth edition (2019). Its framework, often called principlism, became the shared language of clinical ethics in many countries. It names four principles. Respect for autonomy: respect the informed, voluntary choices of people able to make them; informed consent is its everyday form. Beneficence: act for the patient's good, weighing benefits

against risks. Non-maleficence: do not cause harm without good reason, the old maxim "first, do no harm". Justice: share benefits, burdens and scarce resources fairly.

The principles are prima facie, a term the authors take from W. D. Ross: each one binds unless it conflicts with a weightier one, and none wins automatically. Hard cases are settled by specification, making a principle precise for the context, and balancing, judging which weighs more here.

READING · CONTINUED

Four principles, and their critics

The authors claim the principles come from a common morality shared by all morally serious people, so that people who hold rival theories can still agree on them.

Critics have pressed on exactly that point. In 1990 K. Danner Clouser and Bernard Gert argued that the principles work like chapter headings: reminders of what to consider, with no unified theory to settle conflicts between them. Defenders of casuistry, notably Albert Jonsen and Stephen Toulmin,

argued that good judgement grows from cases and precedents, not from principles applied from above. Others question the claim to universality. Where Confucian family ethics is strong, serious medical decisions are often made by the family together, and critics say an individualist reading of autonomy misdescribes how many patients wish to decide. Defenders reply that a patient can autonomously choose to let her family decide.

The four principles

Respect for autonomy

Beneficence

Non-maleficence

Justice

Act for the patient's good, weighing benefits against risks.

Do not cause harm without good reason, the old maxim "first, do no harm".

Share benefits, burdens and scarce resources fairly.

Respect the informed, voluntary choices of people able to make them; informed consent is its everyday form.

Specify, then balance

READING

Who gets the ventilator?

Justice stops being abstract when there are more patients than machines. In 2015 the New York State Task Force on Life and the Law published guidelines for allocating ventilators in a severe flu pandemic. Patients would be prioritised by the SOFA score (Sequential Organ Failure Assessment), which measures how far the body's organs are failing. Priority would go to those most likely to survive with a ventilator. Patients would be reassessed after 48 and 120 hours, and a ventilator could be reallocated from a patient who was not improving.

In March 2020, as COVID-19 spread, Ezekiel Emanuel and colleagues set out six recommendations in the New England Journal of Medicine. The leading value was to maximise benefits: save the most lives, and

the most years of life after treatment. Front-line health workers should get priority, not because they are worth more, but because keeping them working saves others. Among patients with similar prognoses, a lottery is fairer than first come, first served.

Critics warned that "likely benefit" can quietly disadvantage disabled people. In England, the rapid COVID-19 guideline on critical care from NICE (the National Institute for Health and Care Excellence) used the Clinical Frailty Scale. After disability groups objected and a legal challenge was threatened, NICE amended it on 25 March 2020: the scale should not be used for younger people, people with stable long-term disabilities, learning disabilities or autism.

Ethics committee

Task Groups of 3 or 4. Take the case your teacher gives you on the slide "The three cases", and one role each. In 14 minutes, agree a recommendation the whole committee can sign.

Chair

Patient advocate

Keep time, make sure every role is heard, and write the committee's recommendation in one or two sentences.

Speak for what the patient wants and values, as far as anyone knows it. Ask what the patient would say if they were in the room.

Clinician

Ethicist

Set out the medical facts, the options and their risks. Say clearly what medicine cannot know.

Name what each of the four principles asks in this case, and which two conflict most sharply. Then run the case through the four lenses.

The three cases · four steps

Task Work through the four steps in order, and write down the answer to each.

1. For each principle (autonomy, beneficence, non-maleficence, justice), say in one line what it asks here.

2. Name the two principles in sharpest conflict.

3. Judge the case through the four lenses: what will happen, what rule applies, what a good person would do, and who you are to this patient.

4. Write your recommendation, and one fact that would change it.

The three cases

Task Work through the four steps in order, and write down the answer to each.

Case 1: The diagnosis the family wants kept quiet

Case 2: The patient who wants to go home

Case 3: One bed, two patients

Mrs Mei Zhou, 74, has a serious cancer that has spread. Treatment could slow it but not cure it. Her son and daughter ask the team not to tell her: in their family, they say, the children carry bad news so that a parent can keep hope. Mrs Zhou speaks to the doctors through her daughter, who interprets. She has not asked directly what is wrong.

Mr Tomasz Nowak, 83, lives alone and is recovering from a broken hip after a fall. He has mild memory problems, but he understands that he could fall again, and he insists on going home. The physiotherapist rates the risk as high. His daughter, who lives abroad, wants him moved to a care home and says he would hate it at first but be safer.

Riverside General has one intensive-care bed left during a severe flu season. Ms Ana Ferreira, 34, a nurse at the hospital, has severe pneumonia and a good chance of recovery with intensive care. Mr Kwame Mensah, 68, a retired teacher, has the same pneumonia and heart disease; he arrived two hours earlier, and his chance is lower but real. A hospital 90 minutes away may have a bed, but the journey carries risk for either patient.

The three cases · four lenses

Consequences

Duty

Character

Relationships

What will happen?

What rule applies?

What would a good person do?

Who am I to them?

Your committee's case

Judge the case through the four lenses: what will happen, what rule applies, what a good person would do, and who you are to this patient.

READING

The right to die: both sides

Three practices are often confused. Withdrawing or refusing treatment, such as stopping a ventilator at a patient's request, is lawful in most countries. In euthanasia, a doctor or nurse gives a lethal drug at the patient's request. In assisted suicide, often called assisted dying or medical aid in dying, a doctor provides the drug and the patient takes it.

Supporters start from autonomy: a competent adult's life is their own, including its last chapter.

They appeal to beneficence: some suffering cannot be relieved, even with excellent palliative care. The line between refusing a ventilator and requesting a drug, they argue, is thin, and a regulated, reported practice is safer than a hidden one. They point to Oregon's official data: in 2024, the concerns most often recorded for people who died under its law were losing autonomy (89%) and being less able to enjoy life (88%), not pain, which was cited by 34%.

READING · CONTINUED

The right to die: both sides

Opponents begin from the value of life itself, a conviction held in both religious and secular forms. They warn that people who are old, disabled, poor or lonely may come to feel a duty to die: in the same Oregon data, 42% cited being a burden on family or carers. Many disability-rights groups oppose legalisation. Critics also point to expansion: Belgium extended its law to minors in 2014, and Canada dropped its requirement that death be "reasonably foreseeable" in 2021.

Supporters answer that these were open democratic decisions, not a slide. Others argue that the doctor's role as healer, and patients' trust, are at stake, and that prognoses can be wrong: 6% of those who died under Oregon's law in 2024 had outlived the six-month prognosis that qualified them.

Laws compared

Assisted-dying rules in six jurisdictions, as of October 2026

Jurisdiction and date

Who qualifies

Key safeguards

Adults, and minors from 12 (ages 12 to 15 need parental consent). Suffering must be unbearable with no prospect of improvement; it may be psychiatric, and terminal illness is not required.

Netherlands

in force 2002

A voluntary, well-considered request; no reasonable alternative; an independent second doctor; every case reviewed afterwards by a regional committee.

Adults with constant, unbearable physical or psychological suffering from a serious, incurable condition; terminal illness not required. Minors of any age with "capacity of discernment", if terminally ill and suffering physically.

Belgium

2002, minors 2014

A second doctor; if death is not expected soon, a third doctor and a one-month wait; parental consent for minors; review afterwards by a federal commission.

Switzerland

Criminal Code, in force 1942

The law only punishes assisting suicide "for selfish motives", so non-profit organisations offer it, and one, Dignitas, accepts foreigners. Euthanasia remains illegal.

The person must take the drug themselves; doctors' guidelines (2022) require decision-making capacity, unbearable suffering from illness or impairment, and two conversations at least two weeks apart.

Laws compared

Assisted-dying rules in six jurisdictions, as of October 2026

Jurisdiction and date

Who qualifies

Key safeguards

Oregon, USA

1997

Adults with a terminal illness expected to cause death within six months, able to make their own health decisions; since 2023, non-residents too.

Two spoken requests at least 15 days apart (waived if death is expected sooner) and a witnessed written request; two doctors; a psychological assessment if judgement may be impaired; the patient must take the drug themselves.

Adults eligible for Canadian public health care with a serious, incurable illness, disease or disability, an advanced state of irreversible decline, and intolerable suffering. Since 2021, death need not be reasonably foreseeable. Mental illness as the only condition is excluded until at least 17 March 2027.

Canada

2016, widened 2021

Two independent assessors; a witnessed written request; if death is not foreseeable, a 90-day assessment period. In 2024, 5.1% of deaths in Canada were assisted.

Laws compared

Assisted-dying rules in six jurisdictions, as of October 2026

Jurisdiction and date

Who qualifies

Key safeguards

People with a serious, incurable illness or injury causing intense physical or mental suffering. The Constitutional Court removed the terminal-illness requirement in 2021 and decriminalised medically assisted suicide in 2022; the rules come from the Court and the health ministry, not from a law passed by Congress, where repeated bills to regulate it have failed.

Colombia

court rulings, 1997 onwards

Free, informed consent; each request reviewed by a hospital's interdisciplinary committee.

Recent changes. Uruguay's parliament passed a euthanasia law in October 2025. France's law creating a "right to assistance in dying" was promulgated in August 2026, but cannot operate until its implementing decrees appear. In England and Wales, a bill passed the House of Commons in June 2025 but ran out of time in the House of Lords; MPs rejected a new version on 11 September 2026.

Which safeguards matter most?

Task Choose three or four questions. For each, name the jurisdiction on the slide "Laws compared" whose rule comes closest to your view, and say why. You don't have to agree.

1. Should a person have to be terminally ill to qualify, or is unbearable suffering enough?

2. Should a waiting period apply to someone who has only weeks to live?

3. Should the patient have to take the drug themselves, or may a doctor give it?

4. Is capacity a better test than age for deciding whether a young person can ask?

5. Is a review after death a real safeguard, or must approval come first?

6. Is a law like these likely where you live? Would it be welcomed?

Iran's kidney market

Task Before reading, write a number from 1 to 5 for the motion below and keep it.

Motion: A legal, regulated market in kidneys, like Iran's, should be allowed where you live.

1

strongly agree

2

mostly agree

3

on the fence

4

mostly disagree

5

strongly disagree

READING

Iran's kidney market

Iran has the world's best-known legal market in kidneys. Since 1988, patients who cannot get a kidney from a relative or a deceased donor can be matched with an unrelated living donor through a non-profit patients' body, the Dialysis and Transplant Patients Association. The donor receives a fixed payment from the government, and usually a further sum from the recipient; charities help recipients who cannot pay. Foreigners may not buy kidneys from Iranian donors. In 2006 the Iranian nephrologists Ghods and Savaj reported that the waiting list for kidney transplants had been eliminated by 1999.

Critics dispute the picture. The short list partly reflected patients who were never

diagnosed or referred, as Ghods and Savaj themselves noted. The sellers are mostly poor. In two 2001 studies of Iranian sellers, the urologist Javaad Zargooshi found that most had sold for purely or mainly financial reasons, and many reported harm to their health, regret and resentment afterwards.

The international consensus rejects payment. The World Health Organization's Guiding Principles (2010) say that organs "should only be donated freely, without any monetary payment or other reward of monetary value", while allowing donors' genuine costs to be reimbursed. The Declaration of Istanbul (2008, updated 2018) condemns organ trafficking and "transplant commercialism".

The kidney market debate

Task Side A argues for the motion, Side B against, whatever your own vote. 3 minutes to prepare from the cards and the slide "Iran's kidney market", 2 minutes for each side's case, 2 minutes of free exchange. Finish by saying the best point the other side made.

Side A

Side B

Argue that a legal, regulated market would save lives and respect people's freedom.

Argue that payment exploits the poor and damages the gift of donation.

The case for: lives and liberty

The case against: bodies and the poor

People on dialysis wait years, and some die waiting. Payment could raise the supply of kidneys, as Iran's supporters claim it did. We already let adults accept risk for money: paid plasma donation in some countries, paid volunteers in clinical trials. Bans do not stop sales; they push them into black markets where donors get no screening or care. A regulated market could fix the price, screen donors and fund their follow-up. And whose kidney is it?

Sellers are overwhelmingly poor, so their consent may be shaped by need rather than free choice. The rich would buy and the poor would sell, which offends justice. Putting a price on body parts treats people as stock, and critics fear it would erode unpaid donation. Iran's own sellers report harm and regret. Other routes exist: Spain, with no payment at all, has led the world in deceased donation for decades.

Vote again, and look back

Task Write a new number from 1 to 5 for the motion. Then look again at your letters for acts 1 and 4 on the slide "Where do you stand?". Would you change any of them now?

Motion: A legal, regulated market in kidneys, like Iran's, should be allowed where you live.

1

strongly agree

2

mostly agree

3

on the fence

4

mostly disagree

5

strongly disagree

1. At her family's request, a doctor does not tell an elderly patient that her cancer is incurable.

4. A doctor prescribes drugs that a terminally ill patient, at her own request, may take to end her life.

Private reflection

Task Choose one prompt and write privately. Nobody will read what you write, and sharing afterwards is optional. If today's topics feel close to home, the second prompt is a perfectly good choice.

Prompt 1

Think of a character in a film, novel or series who faced a hard medical decision. Which principle did the people around them put first? Would you have weighed it differently?

Prompt 2 (lighter)

If you sat on a hospital ethics committee, which of today's four roles would suit you best, and which would you find hardest?

Before Lesson 9

This week, find one news story about a medical decision and name the two principles in conflict.

It could be a court case, a new law, a shortage of a drug, or a hospital policy. Note whose voice was missing from the story.

Next lesson: Ethics at Work. What employees, managers and companies owe each other, and when loyalty runs out.

TEACHER'S REFERENCE · SKIP OR DELETE BEFORE CLASS

Answer key

THE THREE CASES points to listen for; there is no single right answer

• Case 1: The diagnosis the family wants kept quiet. Autonomy and the patient's right to know against beneficence as the family understands it, and a relational view of care (the Relationships lens). Strong committees notice that nobody has asked Mrs Zhou how much she wants to know or who she wants to decide; she may autonomously choose to let her family handle it. Using the daughter as interpreter is itself a problem: a professional interpreter lets the team hear Mrs Zhou directly. Several professional codes allow a patient to waive information, but not a family to waive it for her.

• Case 2: The patient who wants to go home. Autonomy against beneficence and non-maleficence. The key question is capacity for this decision: mild memory problems do not by themselves remove it, and he appears to understand the risk. If he has capacity, most frameworks would respect a risky choice; the committee can still reduce the risk (home adaptations, a care package, an alarm, a review date). The daughter's view matters, but it is not the decision.

• Case 3: One bed, two patients. Justice and beneficence. Arrival order is a weak ground on the Emanuel view; likely benefit favours Ms Ferreira; the health-worker priority in that paper is for keeping workers able to work, which may or may not apply to a nurse who will be off sick for weeks either way. Committees should notice that "likely benefit" here partly tracks age and heart disease, the kind of judgement the NICE amendment warns about, and that the safest option for both may be to use the bed for one and arrange the transfer for the other as quickly as possible.