This exercise works with a group of case studies and helps the students focus in on one aspect of an issue. Each case study varies only with respect to this one aspect, which progressively may become more significant in determining what one thinks about the cases. It allows students to ‘silence’ other considerations which may be distracting and focus on one feature in order to assess its significance. This exercise can be made more demanding by varying two features (although probably no more than two otherwise things become muddled again).
What is it in a nut-shell?
More than one case studies, similar apart from one feature which changes in significance from one case to the next, testing the students’ tolerance, how far are you willing to go?
Two feature variation: escalation of harm and difference in the justification for the trial.
A nutritional scientist proposes to carry out a study measuring salad eating habits in the general public. She will ask members of the public to fill in a questionnaire on their eating habits in general over a period of time and from this material she will gather information on salad consumption. Her consent form will explain that she is carrying out research on eating habits, but will not mention that she is only interested in salad consumption as she is worried that revealing this fact will distort the results, i.e. if people know that she is measuring salad eating habits, and given assumptions about healthy eating and the benefits of eating salad, her subjects will either change their eating habits or inaccurately report their eating habits for the duration of the trial.
This is a real case. It was turned down by the Research Ethics committee on the grounds that it deceived the subjects as to the true nature of the trial.
A sociologist specialising in issues affecting elderly people wants to carry out a study on how poverty affects choices amongst the elderly. In her consent procedure she tells subjects that she is examining how lifestyles, rather than poverty, affect the elderly, as she does not want to insult and upset her subjects by implying that they are poor, however she is only interested in those subjects affected by poverty.
This is a real case. There is no information as to whether this research had been put before a Research Ethics committee.
A social psychologist wants to find out whether people are likely to behave immorally if told to do by someone in authority. Revealing the aims of the trial to the subjects will invalidate the results as people will modify their behaviour accordingly, so he tells subjects that they will be involved in an experiment to see how pain affects knowledge acquisition. The experiment reveals that large numbers of people (up to 60% in some variations) are willing to kill (as far as they know this is a real experiment and not a set up) others at the command of someone in authority, which contradicts predictions by subjects that they would never behave immorally under such circumstances (when asked in advance 100% of subjects thought they would do the right thing). Subjects are debriefed as to the true nature of the experiment after it is complete and they are offered counselling to deal with what they have learnt about themselves from this experiment (i.e. that they are capable of killing someone merely because they were told to do so).
This is a summary of the Milgram experiment. This experiment was carried out in the 1970s but it is highly unlikely that a similar experiment would gain ethics approval nowadays.
These cases are designed to be used together as they bring out the following distinctions:
- the first one seems to be a case where minor, negligible or even no harm is caused to subjects through deception necessary for the scientific validity of the trial, i.e. the truth would invalidate the trial
- the second one seems to be a case where deception is necessary to avoid harm to the subjects and the deception itself is not concerned with anything important therefore likely to be deemed harmless (or causing minor or negligible harm)
- the third one seems to be a case where deception is necessary for the scientific validity of the study, but substantial harm is caused to the subject because of the deception.
They can help students think about the following questions:
- Is deception always harmful? If yes, or in cases where it is harmful, why is it harmful? Can there be different levels of harm caused by deception?
- If deception is harmful, can this harm be overridden by considerations requiring the researcher to avoid other greater harms, such as harm to the subject?
- Can deception be justified by its aims? That is, is deception more or less acceptable if it is required to ensure the scientific validity of the trial, or if it is carried out for the subject’s benefit? How is the answer to this question affected by how much harm you think deception causes in itself?
- Can we ever justify harm to the subject through deception in the interests of science? Is your answer affected by the degree and severity of harm? Is your answer affected by the scientific value of the study?
Mainly one feature variation in the escalation of harm, but other features enter into the later cases, e.g. variations on competence issue, potential for harming others.
Adam is a well informed adult who decides to have his belly button pierced. Most belly button piercings get infected with minor repercussions and there is a very small risk of contracting a more significant infection from the procedure. Would you tolerate this behavior in your society? Why?
Brenda is a well informed adult who would like to undergo a series of major cosmetic surgery operations. She has the funds to pay for them herself. Like with any operation she is at risk from the anesthetic and possible post-operative complications. She plans to have a number of operations and will be in considerable pain during her recovery. Would you tolerate this behavior in your society? Why?
Cyril is a sadist and along with his boyfriend Dennis, a consenting adult, they practice sado-masochistic sexual acts which involve serious (although not permanent) harm. Cyril and Dennis are happy with their arrangement. Would you tolerate this behavior in your society? Why?
Ewan is a habitual heavy drinker. Every evening he drives home from the pub. Sometimes he looses control of his vehicle and swerves all over the road and occasionally over the pavement. Ewan drives in a well populated residential area. Would you tolerate this behavior in your society? Why?
Faye is a building contractor who is working on the façade of a large building in your high street. Faye has provided scaffolding for her workers but no way of safely getting rubble to the ground level. She encourages her workers to throw rubble from the higher floors down to skips on the pavement at ground floor level. Would you tolerate this behavior in your society? Why?
Ghipe takes her twelve year old daughter Hanna to be circumcised. This is a very common practice in her native Nigeria and involves the removal of external parts of the genitalia and stitching of the vaginal opening. Would you tolerate this behavior in your society? Why?
The initial case is probably easy to tolerate, whereas later cases are clearly intolerable or more controversial.
Adam is engaging in an activity which has a slight risk of small physical harm for reasons of vanity (risks of major infections can be prevented with reasonable precautions). Note that Adam is a well informed adult. Students are likely to allow this unproblematically. Note the precedent we now have: competent adults may expose themselves to risk of minor harm.
Brenda is engaging in an activity which will result in more serious harm than Adam and greater risk of other harm. Again she is a well informed adult (someone may bring up here the idea that Brenda may be mentally ill and suffering from body image disorders, but resist the temptation to classify her as incompetent. For the purposes of this exercise she knows what she is doing and is capable of making this choice). Brenda puts the pressure on whether students are willing to allow adults to inflict more serious harm on themselves. How far are they willing to take this? Would they allow a competent adult to commit suicide (the ultimate harm)?
Cyril and Dennis are again competent, consenting adults, causing each other quite serious harm for sexual pleasure. Does the level of harm here lead students to change their minds about the permissibility of such actions? Or is it perhaps that two people are involved? Adam and Brenda only harm themselves, but Cyril and Dennis harm each other. However, both Cyril and Dennis agree to this (consent), are we happy to allow consenting adults to harm each other (we will return to this in Session 4)? Or perhaps we are concerned with the reasons for the harm. Adam and Brenda risked or suffered harm in the interests of personal vanity, Cyril and Dennis seek sexual gratification, is it acceptable for consenting adults to cause each other harm for sexual pleasure?
Ewan is the first person to risk/cause harm to others who are not consenting. At least Dennis agreed to be harmed by Cyril and knew what he was getting into. Ewan’s drunk driving is risking the lives of innocent others. Does that make a difference here?
Faye is also risking harm to innocent others, any bit of rubble could hit a passer-by. In addition she is a professional builder and should know better. Her case is a case of negligence, failing to take due care and attention when she should have known better (any builder, if not any reasonable human being, could predict that sooner or later someone would get hurt from such sloppy building practices).
Ghipe and Hanna are a difficult case. Hanna is under age and therefore not able to consent for herself. Her mother can consent on her behalf for medical procedures, but we expect Ghipe to act in Hanna’s best interests. According to Ghipe’s religious and cultural beliefs it is in Hanna’s best interests to have this done, but many of us from Western cultures would disagree. (More on this in the exercise on Female Genital Circumcision).
Variation on harm to consenting individuals, although third case will raise issues of competence. This exercise also has elements of The Value of Misdirection, as it takes a while for the students to see the point of what you are trying to do (the students will come to see the point before the ‘doctor’ volunteer so they become accomplices in the misdirection).
One day surprise your students: walk in and say today we will do something different and I will need four volunteers. Re-assure them that the volunteers will not be asked to do anything upsetting or embarrassing. Three volunteers will be mock patients, one will be a mock doctor. The mock doctor has to walk out of the room while you brief the patients, he will then walk in to find three patient making three different requests of him. He can ask questions but in the end he has to tell the patient whether he is willing to grant the request.
The first patient will ask for (extensive) cosmetic surgery, the second for a sex change operation and the third for a healthy limb amputation. The patients have to be briefed to appear rational, well informed about the procedure they are asking for and its implication, firm in their demands that the doctor help them out and financially independent and not relying on the NHS. This fields all sorts of irrelevant worries (irrelevant for the purposes of this exercise!) and allows the students to focus on the main question: “Should clinicians honor patient requests even when these are not medically required and reflect personal values which may be considered eccentric”. Encourage students to present the third patient as mentally competent, this puts further pressure on whether they are willing to respect autonomous choices even when the choice seems silly, eccentric or down-right peculiar.
In this exercise there is escalation in the level of harm the doctor is being requested to cause and, along with this, there is the thought that perhaps how we evaluate harm is related to whether we are sympathetic to the reasons for which the harm is being risked (or accepted). For example, students have been known to say during this exercise that harm from cosmetic surgery is not ‘really harm’ as everyone wants to look good, whereas who would want to lose a healthy limb?
Our Obligations to the Developing World
Case 1: Christina is the production manager of a large sports goods company with an international distribution network. She is exploring the possibility of moving the production lines for her goods from the company’s base in the Western world to a developing country. The benefits would include significantly lower production costs, which would mean greater profits for the company, but also reduced prices for consumers. Benefits for the company in terms of increased profits would translate into general benefits for the developed country where the company originates, but also for the developing country where the production will take place. Unemployment is high in the developing country and more jobs would mean access to health care, education and a massive increase in living standards. In fact rumors of the possible move have circulated in the developing country and Christina has already received representations from different regions exhorting the advantages of moving production to their particular area. The developing country Christina is considering, which is the one that presents the best financial deal, uses child labor, has an authoritarian government with a record of human rights abuses and bans trades unions. Should Christina go ahead with the move?
Case 2: A large US based multinational corporation owns and runs an agricultural pesticide plant in India. Low demand for pesticides have made the plant economically unviable, and in an effort to turn things round the management have imposed a large number of redundancies especially in the production and maintenance areas of the plant. The plant has now beenshut down for a major overhaul and with all safety devises out of commission and no safety trained personnel present, an accident occurs which releases a toxic gas into the atmosphere. As a result 3,000 people die, many more are injured and thousands more are expected to suffer and die from related conditions in the future. However, the multinational owner corporation has at no time behaved illegally. Due to financial pressures, local inspectors had approved procedures at the plant and there is no judicial redress for the victims in India, while the US courts have no jurisdiction over what happens in another country. Has the corporation done anything morally wrong in operating the plant?
Inspired from the real life Bhopal case, discussed in detail at:
Case 3: Nuclear power is making a come back, heralded as the new, greener source of energy (in January 2008 the UK government announced plans for new nuclear power stations). However, concerns about the difficulty and cost of disposing of nuclear waste remain. Luckily a developing country has recently approached the UK with what sounds like a good deal: for a modest price (modest for the UK but quite considerable for the developing country given the state of its economy), they will assume responsibility for our nuclear waste which will be transported to their country and stored at their cost. Should the government accept this offer?
The first case creates a tension between economic considerations and the idea that economic progress leads to progress in democracy and human rights versus current exploitation and human rights abuses. The second one escalates the tension as now we have economic considerations versus risk of harm and actual substantial harm to human beings. The third escalates the tension further as we now have risk of even greater and more pervasive harm to huge numbers of human beings. Through-out the three case studies there is an issue of global justice with the developed country accruing the benefits, while the developing country has access to the benefits but only by accepting the risks.
Exercise adapted from the "Introduction to Ethical Thinking Resource", IDEA CETL, University of Leeds.