Portfolio project and outcomes

Ileana Final Portfolio

Bioethics Final

This portfolio documents performance of key class and personal objectives for HU280-01: Bioethics 1103C, specifically analytical skill building, knowledge acquisition and practical application. The samples demonstrate achievement by presenting excerpts from submitted assignments, Discussion and Seminar interactions, interactions with the instructor and reflections on progress mastering central concepts, ideas and perspectives in bioethics. This work demonstrates a progression from identification, synthesis and recapitulation of selected relevant ethical systems, placing those systems in the contexts through which they arose, and applying those precepts to emerging controversies in modern life. The underlying benchmark this presentation attempts to demonstrate is that if learning is indicated by a change in behavior, then my implementation of new methods considering bioethical dilemmas and also improved critical reasoning and research methods, indicates learning over this process of course inquiry.

This process has provided a structural framework that translates directly to my work in the field as a Registered Nurse and beyond, to wider issues in medicine and other fields of personal interest or situations we all encounter in a social environment. Many of these ethical controversies in medicine generalize to wider questions of access to scarce resources, rights and obligations all individuals inherit participating in society; a formal ethical framework provides a method to implement weighing options for decision with criteria that can be compared across otherwise unique situations. The resulting structured evaluation delivers outcomes we can thus justify within the context of precedent and consistency, rather than arbitrary personal preference.

The evidence is presented in three major sections, which demonstrate a progression from identification and retrieval, through contextual situation and critical analysis, and finally into direct application. The sections "Analytical Skill Building," "Knowledge Acquisition" and "Practical Application" below contain brief narration outlining relevance of selected evidence and placing selections within the structured progression. This reflection process results in a meta-analytical consideration of each section in a consolidated approach to bioethical reasoning. The final outcome results in a method that applies in the real world to new questions that may never have arisen before, and new perspectives on fundamental questions when environmental change alters existing constraints.

Analytical Skill Building

This inquiry process has improved my critical reading, writing and thinking skills in ways that apply to future coursework and outside the classroom in professional and personal life. Many examples demonstrate this progress but the following three illustrate the rest effectively.

The first illuminating experience came through a difficult lesson I imposed on myself, when I failed to document a critical piece of evidence for my argument early in the course regarding bureaucracy and medical leave (Unit Two), and then wasted an hour searching fruitlessly until I realized a convincing argument would be supported by other examples, which I discovered in the process. This allowed me to abandon the original support but served as a difficult reminder that documenting every source may be tedious, but is more efficient than attempting to relocate a particular section of text in a growing body of complex information. I now save my research materials in a file I can simply delete after selecting ultimate source material, or reference again by searching for content if I failed to retain a more detailed citation. Saving DOIs or citations in an ongoing list if they are not embedded in the source material is worth the effort compared to searching again with no result.

A second resource I learned to access was working with a different person to proofread for syntax and language choices that slip through automated spelling and correction features. I have learned through feedback that all authors face a dilemma where they cannot identify errors they were convinced were accurate. This points to an epistemological problem where we cannot know what we don't know, so we don't recognize incorrect usage we think is correct. I have learned through this course the value of feedback and comment by other readers in addition to instructor guidance, which I have incorporated into some of the citations here, applying critical thinking to improve my own prior work. Thus this portfolio process delivers continued improvement beyond the collection and synthesis process, a real-world indicator of learning evidenced by new behavior that I will continue to apply in future study.

A third demonstrated progress measure was increasing my attention to critical reading. Much of the research I rejected tried to couch advocacy for one position or another as balanced consideration, using sophisticated techniques attempting to win issues for one side, rather than unbiased evaluation. Much of the discussion around controversial topics we considered, particularly abortion, stem cell research and low-birth-weight right to care, tried to frame argument as neutral, but critical analysis revealed assumptions that did not necessarily hold. Selecting appropriate works cited meant rejecting such biased assertions where the volume of flawed material is so vast that such examples often are the most prevalent results. Another example of this critical reading improvement is that I now accept that Wikipedia may be an appropriate research tool to locate primary research, but because the peer review is not guaranteed to academic standards, and because Wikipedia articles are secondary rather than primary research, using such articles as academic reference (Unit Ten) is a practice I will not pursue through the rest of my degree.

Knowledge Acquisition

A core purpose of any knowledge work is of course acquisition and mastery of central concepts. We identified several of the most relevant theories from ethics in general, outlined in the following citation from my response in Unit Two, derived from Parks and Wike (2010).

When asking how various ethical theories from unit one might approach this dilemma, the following applies:

With Deontological theory the therapist would not have alerted police because it is his duty to maintain therapist-patient confidentiality. In Kantian deontology this case would not be unique and would be treated like any other. It would be found rational to do nothing about the patient's threat to kill his wife and business would go on as usual.

In applying Consequentialistic theory the therapist would have acted just as he did by alerting campus police and maybe even upon hearing of their decision to let the patient go, argued against such decision and insisted the suspect be held for observation. The therapist would have been breaching patient confidentiality because he could foresee the greatest amount of overall happiness for all involved.

With Justice theory the therapist would take into account what is just and fair and emphasize the big picture. But in this case what is just and fair for the patient is not just and fair for the patient's intended victim, so under justice theory, one would have to consider both sides of the coin and arrive at a conclusion or decision.

With Virtue Ethics and Care Ethics theory the therapist would have acted just as he did in alerting campus police in trying to prevent his patient from committing a greater harm.

These were the core theories the coursework included as frames for bioethical decision making. We also acquired the broader cultural contexts these theoretical approaches evolved out of, in studying practice and perspectives contemporary with the Kantian and Utilitarian theories that underlie the more modern Ethics of Care and interpretation of Justice theory in current medical situations, although Virtue and Justice ethics are of course as old as Plato and Aristotle and underlie formal deontology and the consequentialism of Mill and Bentham. We considered American Colonial perspectives, for example, which helped contextualize these Enlightenment-era principles in Unit Three:

I learned many things I did not know by reading about the early history of Medicine in America in these series of essays. It seems like in the early colonies only the wealthy saw a physician and some people went without ever seeing one their whole lives, but as you read the article you understand why this was a custom brought from Europe; " there were no hospitals. There were no care homes. Family members helped family members. This is where the practice of nursing began, in the home. This diminutive statement speaks volumes, for it hints of the other forms of medicine practiced in the early colonies" (International Wellness Directory, 2003, para 22).

This contextual development continued throughout as we applied these fundamental theories in real medical practice as evidenced through this example from Unit Three:

After reading Unit 3 chapter readings and after doing some research on managed care reform, I concluded that the arguments for and against managed care reform are both equally strong arguments. Managed care is a new term for what many of us refer to as an HMO. In my research I learned that the first HMOs were started around 1930, and the Federal Government has promoted HMOs since the 1970s as a fee-for-service type of insurance plan. However, up until the 1980s and 1990s, HMOs had been poorly regulated and many failed at a nationwide level, which called for more stringent regulation at the local and state levels.

This type of contextualization came through knowledge acquisition specific to each issue, where I did not know the history of American managed care before, but now I do, and the context informs understanding scarce health care allocation. Other examples include the Willowbrook and Tuskeegee experiments in Unit Four, which I had heard about but only in a diffuse anecdotal sense. Now I have a more formal understanding of the justification behind human subjects review and the importance of Institutional Review Board oversight before any experiment no matter how seemingly innocuous the treatment.

Once we had identified and mastered the concepts underlying these theories, we demonstrated their application in modern ethical controversies. The result was the realization that these ethics are each a process toward obtaining answers for sophisticated modern moral problems. Applying these historic perspectives played out through selection of examples that demonstrate how these methods provide a framework and process to evaluate new ethical conundrums Kant, Bentham, Mill or Aquinas likely could not even imagine. Considering the examples just cited from Unit Three provoked discussion of autonomy, universalizeability and consistency that underlie all of the formal methods we learned to employ:

In the Willowbrook State School Study and the Tuskegee U.S. Public Health Service Study, several ethical problems arose. Every individual in our society has the right to freedom and autonomy. Autonomy is defined as "independence or freedom, as of the will or one's actions" (Collins English Dictionary, 2009). In both examples mentioned above the autonomy and freedom of the subjects were infringed upon due to the lack of informed consent, and there was a lack of protection of the rights and the welfare of the human subjects in the experiments by the entities that conducted the studies.

Then in Unit Four we expanded this formal analysis into a paradigm that would run throughout the rest of the work, and it became natural to start evaluating existing dilemmas I had encountered in my own experience and practice in these new terms from deontology, consequentialism, ethics of care and other formal frames that emerged from my research:

I am quite torn over this subject because I worked in a research clinic and saw with my own eyes what goes on with non-therapeutic studies. My argument is against human experimentation in non-therapeutic studies on the most vulnerable members of society, which include: children, mentally challenged, mentally ill, those in pain, those in total institutions, prisoners, ward patients, those in military service, students in colleges/universities and fetuses.

My argument is supported by the Kantian theory of ethics which states that "every person must be treated as an end in themselves, and not as a means only. According to this view of ethics, morality is a matter of absolute -- i.e., universal and unconditional -- duty. More importantly, Kantian Ethical Theory would prohibit the vast majority of these experiments" (Berkich, 2002, cited in Pecorino, 2002, n. pag.).

Like Utilitarianism and unlike Kantian Ethical Theory, the thought that human experimentation is important and ought to be pursued is supported on yet another ethics theory not discussed in Unit1 named Social Contract Theory. Social Contract Theory states that "morality consists in the set of rules governing behavior that rational people would accept, on the condition that others accept them as well." But like Kantian Ethical Theory and unlike Utilitarian Ethics Theory, Social Contract Theory implies that experimentation on the most vulnerable members of society is morally wrong.

Practical Application

Once we mastered the formal principles and methods of framing questions in theoretical discussion, it became almost impossible to not consider dilemmas I have found in my own practice and experience, through those lenses. One of the main underlying bioethical dilemmas is scarcity of limited medical resources, which I have seen play out in my work every day, although I never considered scarcity through a formal bioethical filter before:

As a school nurse in the public school system in a low income area I hand out a list of low cost community health clinics to parents who have no insurance quite frequently. If they qualify through proof of low income and proper documentation, then an office visit could cost them $30/visit. Some parents have told me that they could afford this, yet others have told me they cannot. Government needs to step in and regulate free enterprise systems so that the rise in cost and premiums is not overwhelming the average American citizen. Once this is done it will trickle down to the rest of the population and those clinics charging $30 a visit, could now charge $5 or $10 a visit. The same premise applies for expensive and sophisticated medical technologies (Unit Three).

Our discussion of informed consent in Unit Five helped me create my own rubric for human experiment that I will adapt and apply in evaluating research I encounter or participate in during the course of my career:

In addition, this author would be for therapeutic studies if and only if the following applies:

1. Subjects must volunteer

2. Freedom to withdraw

3. Unnecessary risks are eliminated and prior animal experiments have been conducted

4. Benefits to subjects / society must outweigh the risks and harms

5. Only qualified individuals and researchers

CONDITIONS for an experiment to proceed

1. Experiment is justified because science has progressed to that point

2. Prior non-human experiments have been conducted

3. Chance of benefit for the subject

4. Subject is informed of diagnosis, prognosis, and alternatives

5. Subject consents

6. No better alternative is available

7. Continuation of the experiment is not assumed

8. Side effects or damage to the subjects caused by the experiment is responsibility of researchers

INFORMED CONSENT

a. Competent individuals

b. Informed

c. Voluntary

Our Unit Five made me question my own personal values in the case of a different kind of absence of consent, sexual assault, in ways I had never anticipated considering before:

I used to think that rape was at best the most rational reasoning for an abortion until I met a friend who told me that her 12-year-old daughter, whom I complemented and thought of as so loving and adorable, was the product of an assault and rape she sustained when she was younger. She went on to explain to me that as hard as it was for her to overcome and endure the rape, that the unborn life in her had no fault of such act and that she never regrets having her.

In the same assignment, the terms we were discussing revealed an absurd result from commonplace justifications for abortion, which demonstrates how finding absurd results from a sound ethical process is the means ethics uses to demonstrate flaws in real-world assertions:

Then there are other situations where I believe that an abortion is not warranted. In those cases I subscribe to natural law and Kantian ethics. Natural law is associated with the instinctive desire of persons to have offspring and their willingness to invest immense energy in children's upbringing and well-being -- even to the point of personal sacrifice, and even to sacrifice of life. Kantian deontology would be against abortion based on the premise that as a universal law every woman would have to get an abortion and in that case the human race would eventually cease to exist. I believe that if one supports abortion as a personal decision then it is fair to ask if one would support the idea of their own non-existence had they been aborted, as a moral, ethical, fair, and just decision as well?

This absurd result of someone considering their own non-existence through abortion moral, fair and just is a classic example of the method ethics uses to demonstrate either a flawed proposition in the empirical world around us, or a flawed reasoning model. If the model holds, in this case relying on the fundamental deontic requirement of universalizeability, then the real-world argument fails. Given this assignment to do over again, I would have probed for exceptions to the generalizeability constraint and developed this model farther to make sure this constraint was truly universal. The way it is phrased here, however, holds if we insert or imply an "if" before "Kantian deontology would be...;" also this discussion was only halfway through the course. My perspective now is the result of more refined information since this assertion but the consideration demonstrates how "Analytical Skill Building" from section I above is a process rather than an outcome just like the practice of applying formal bioethics to real-world problems.

In the same way, I have new perspectives considering my own work as recently as Unit Five, for example. Whereas before I argued that