PHI-240 Chap. 10: Health Care Ethics

Bioethics

application of ethical judgment to topics involving life and living things; includes health care ethics (medical ethics)

What topics does bioethics cover?

issues in healthcare & medicine, thinking about birthing & dying, ethical questions about engineering of living things, nonliving animals (animal experimentation in biomedical research), environmental ethics

Medical Ethics

aka health care ethics; ethical issues that arise in thinking about human health;

Healthcare

the very broad concern for human health; includes public health measures, preventative care, and therapeutic care; care is a central idea in health care; important part of care is the relationship btwn the caregiver and cared-for, as it is unique to each case

How are relationships between the caregiver and cared-for unique?

caregiver must understand changing needs, interests, and experiences of cared-for; cared-for recognizes complexity of relationship and social & psychological issues that arise from it (gratitude, resentment, dependence, mutuality); no one way to have a care relationship

Casuistry

Root of word is “case”; case study-based approach to thinking about things; practice of focusing on details of particular ethical cases; approach to moral reasoning that uses practical reasoning to resolve case problems; cases are good for us to learn, discuss, and consider; common in business/business ethics

How is casuistry applied in ethics?

begins with the details of the case; case is then considered in relationship with other similar cases; paradigms are examined & analogies are employed; basic principles & larger ideas are appealed to; goal is to come up with reasonable conclusion about the specific case

What are some issues with casuistry?

cases themselves are not the only starting points for ethical decision making; (1) overemphasis on case studies can lead to us being stuck in the immediacy of details; casuistry is sometimes viewed as basically sophistry (process of quibbling over minor details); (2) approach focused entirely on details of specific cases doesn’t tell us how to solve dilemmas or what to do when intuitions conflict; (3) overemphasis on case studies leaves our intuitions intact without critically questioning them; can cause us to reach decisions based on prejudice, ignorance, or misformed judgement; (4) focusing too much on details can keep us from looking for larger patterns; can prevent us from thinking critically about larger principles

How should health care ethics be approached?

too narrow to focus entirely on concrete needs of the cared for and specific details of individual cases; should wonder about general themes & principles that should be understood & applied; can them apply basic normative theories to topics

Application of Normative Theories to Health Care Topics

may begin w/distinction btwn consequentialist (ex. utilitarianism) & non-consequentialist (rights, autonomy, respect) approaches to ehtics; application of utilitarianism can help us decide who should be cared for and how much, which helps distribute medical resources); non-consequentialist approach imposes limits on what we may do in pursuit of good outcomes; may lead to saying that health care thics should be guided & limited by the need to respect wishes & best interests of the cared-for; leads to consent being important idea in health care ethics

Rights in Health Care Ethics

some say health care is a fundamental right; claim society is obligated to provide that right; WHO states taht health is a fundamental human right; has a broad definition of health, describing it as “a state of complete physical, mental, and social well-being and not merely the absence of disease/infirmity”; broadness of definition creates questions?

Defining Health

WHO defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease/infirmity”; this definition is bland, uncontroversial, but overal broad and unattainable; “health” is a normative concpet thate creates complex philsophical, social, and ethical questions; can cover several different issues (obesity reduction to anti-poverty policies);

Defining Physical Health

hard to decide what counts as healthy/sick; connects to what is seen as a disability/disease; spectrum of disabilities; some diseases/disabilities are seen as “normal” (myopia); health cannot be reduced to objective measurements, requires qualitative evaluation & context-dependent interpretation

Health in Different Cultures

physiological occurances are subject to social, cultural, and moral interpretation & judgement; diverse cultures approach diseases differently; ex. some cultures view epilepsy as a spiritual disorder caused by witchcraft or demonic possession, homosexuality was once seen as a mental disorder; science, culture, and religion intertwine in thinking about disease & health; why cultural competence is an important feature of medical care

Health as a Normative Concept

“health” is a normative concpet thate creates complex philsophical, social, and ethical questions; can cover several different issues (obesity reduction to anti-poverty policies); idea of “well-being” includes normative assumptions about good & valuable life; determination about what is a healthy body will include a variety of judgements and values that go beyond a simple, objective definition

Johnathan Metzl

psychiatrist; wrote book Against Health; describes health as a “term replete w/value judgments, hierarchies, and blind assumptions that speak as much about power & privilege as they do about well-being. Health is a desired state, but also a prescribed state and an ideological position”;

Obesity & Judgements about Health

Kathleen LeBesco discusses “fat panic” associated w/so-called “obesity epidemic”; obesity is linked to health problems; obession w/lean bodies and fear of fatness may be more about aesthetics, marketing, and other values than health; determination about what is a healthy body will include a variety of judgements and values that go beyond a simple, objective definition

Complexity of Health and Public Health

public health is focused on finding a balance that promotes the best/optimal health for most people; complexity of health complicates this; COVID-19 pandemic caused debate about what public health response was needed; main goal was to prevent deaths, which led to shutdowns; critics of shutdowns claimed they had health risks of economic collapse, loss of learning, and mental disorders caused by loneliness; created questions about what health issues should be focused on, and which people should be cared about

Hippocratic Oath

associated w/Greek physician Hippocrates; ancient doctors swore this oath in the name of Apollo, Asclepius, and other healing gods, promising to practice medicine ethically; promised not to cause abortion, cause euthanasia, have sexual relations w/pts, and to keep info confidential; associated w/idea of avoiding harm; serves as reminder that knowledge possessed by other health care professionals can be dangerous, as they can cure or cause disease

Primum non nocere

means “first, do no harm”; connected w/Hippocratic Oath and practice of ancient medicine; serves as reminder that knowledge possessed by other health care professionals can be dangerous, as they can cure or cause disease

Caduceus

ancient symbol of the medicinal arts; represents double-sided nature of medicine; staff w/two serpents intertwined about it; sometimes has wings, or only one snake; snakes are venomous, and can be dangerous, but are tamed and turned to good use in the caduceus; symbolic idea is that the physician’s knowledge must be turned in the right direction

Why do oaths, codes, and legal regulations exist in healthcare?

to make sure that health care professionals use their knowledge for good

Connection btwn Medicine & Philosophy

there has always been a significant connection; Socrates often made arguments employing medical analogies; suggested we need a “physician of the soul” who can help us figure out the difference btwn good & evil; philosophical inquiry into good & evil, virtue & knowledge has implications for what counts as health and for how we understand & construct codes of ethics for health care

The Belmont Report

produced in 1970s by National Commission for the Protection of Human Subjects of Biomedical & Behavioral Research; created in response to the Tuskegee Syphilis Experiment; highlights 3 values: respect for persons, beneficence, and justice; respect for persons focuses on issues such as consent; basic idea that the autonomy of persons should be respected; ppl w/diminished autonomy should get special protection; beneficence means working toward the well-bing of ppl & protecting ppl from harm; justice is the fair & equal distirubtions of harms & benefits; includes awareness of post injustices

Helsinki Declaration

Adopted by World Medical Association in 1960s and updated in 2013; attempt to respond to atrocities of Nazi doctors during WWII; built on the Nuremburg Code

Nuremburg Code

developed from Nazi war crimes tribunals after WW2; emphasizes importance of informed consent for participation in biomedical experiments; basic principle is idea of voluntary, uncoerced, and informed consent; principle says that persons are autonomous, and that autonomy should be respected & protected even if it inhibits benefical research; implies that some cannot freely consent (ex. prisoners, disabled ppl)

How do Nazi doctors serve as an example of the bioethics failing?

Nazi doctors (ex. Josef Mengele) did mass sterilizations & variety of unethical experimentation; did procedures w/out anesthesia; some doctors did mass murder in death camps against vulnerable populations (disabled ppl); was described as euthanasia and connected to eugenics; Nazi doctors show double-sided nature of medicine and need for ethical & legal regulation ohealth care

Tuskegee Syphilis Experiment

390 poor, illiterate Black men w/syphilis were followed btwn 1932 & 1972 to examine progress, fatality, and spread of disease; researchers didn’t give men penicillin for disease after it became available; public was outraged bc men had been exploited

Bioethics & Vulnerable Groups

significant issue in bioethics is that it’s possible to exploit vulnerable ppl (prisoners, minorities, children, disabled ppl, elderly); exploitation is worse bc health care is about caring for vulnerable; Helsinki Declaration discusses this

Regulation of Biomedical Research

extensive training for researchers; Universities that do research have Institutional Review Board (IRB) that supervises & approves research protocols involving humans; research involving animals reports to Institutional Animal Care & Use Committee

Tom Beauchamp & James Childress

created list of bioethical principles; included non-maleficence in list; suggest 4 main values: autonomy, beneficence, non-maleficence, and justice

What are the basic principles of Health Care Ethics?

autonomy, beneficence, non-maleficence, distributive justice, human rights, health maximization, care for the vulnerable

Autonomy (Health Care Ethics)

concern to protect ppl’s right to choose & freedom from coercion; connected w/practice of obtaining voluntary, informed consent & w/virtue of honesty in healthcare; focuses our attention on the importance of self-rule, self-control, self-regulation, and self-determination; bioethical principle of autonomy emerged to safeguard against exploitation & abuse; standardized through informed consent (central part of health care ethics); some think autonomy is overrated bc doctor knows what’s best; leads to idea of paternalism

Autonomy in Ethics

central idea in Kantian ethics, as Kant emphasized importance of rational, free will; suggestred human capacity for rational autonomy was source of human dignity & worth; argued rational beings were “ends-in-themselves” and not merely means for instrumental purposes; autonomy also seen in natural rights & human rights tradition, as it is a fundamental right to liberty; utlitiarian thinkers (John Stuart Mill) saw liberty as important

Violations of Autonomy in Healthcare

doctors have violated autonomy of pts and research subjects; Henrietta Lacks had tissue samples taken from her w/out consent for cancer research; bioethical principle of autonomy emerged to safeguard against exploitation & abuse;

What are some issues with informed consent?

some lack the education, information, or psychological capacity to rationally decide; pts often do not understand pros & cons of treatment; pain and anxiety can inhibit decision making; creates questions about how “autonomous” consent really is; seen in end-of-life situations w/ppl w/cognitive impairments; solution is advance directives & living wills

Advance Directives

health care directive that stipulates in advance what sort of care & pt wants/doesn’t want in case of incapacity & inability to consent to care; important part of modern medicine & end-of life situations and conversations about euthanasia; organ donation card another type of advance directive; advance directives only useful when pt has document on file & has discussed wishes w/loved ones; hard to predict what one would want in advance even when written document exists

Critical Ethical Analysis of Ethics

some challenge idea of autonomy and reality of informed consent; some worry that there is subtle coercion in our decision making processes

Paternalism

literally means to act like a “father”; implies “father knows best”; idea that those w/relevant knowledge & expertise are better positioned to make decisions; paternalism involves idea that expert/authority is taking action in our best interest;

Criticisms of Paternalism

defenders of autonomy do not like idea of paternalism, as it can inhibit liberty; autonomy serves as institutional safeguard against abuse of patients; critics of pandemic restrictions rejected paternalism of public health authorities; some believe individuals have a better sense of themselves & values

Beneficence (Health Care Ethics)

means doing good in Latin; “bene” means good, “ficus” means doing/producing; concern to provide beneficial care to individuals that is in the best interest of the person cared for; could become paternalistic if beneficence occurs w/out consent; idea that health care is primarily focused on pt well-being or benefit; can mean that other concerns are irrelevant; implies non-maleficence

Beneficence & Paternalism

beneficence can be used to support paternalism; paternalists believe beneficial care should be provided when informed consent is lacking; basic focus is not paternalism but well-being of pt

Therapeutic Interventions

return ppl to normal function; ex. reconstructive breast surgery after mastectomy

Enhancement

treatment aiming beyond normal function; ex. breast augmentation; some enhancements can be expensive, painful, and risky; principle of autonomy says it is acceptable, but may not be beneficial; some say it is beneficial bc it makes pt happy; concern is that some who seek cosmetic surgery have body dysmorphic disorder (BDD), where they focus obsessively on flaws in appearance

Non-Maleficence (Health Care Ethics)

concern to avoid causing harm; do no harm; imposes a limit on harmful & risky procedures; prohibits malicious cruelty; creates grey area w/beneficial treatments that may cause harm; must use cost-benefit analysis; connected to due care; tells us what to avoid, not what to do

Opioid Crisis

80,000 ppl died in 2021 from opioids; some pts take advantage of doctors to get opioid prescriptions; opioids have increased risk of addiction & overdose death; some say health care workers should focus on risk of addiction when prescribing to avoid harm; some worry that by preventing harm, some may under-prescribe helpful medications; solution is to balance non-maleficence w/beneficence

Precautionary Principle

risk averse strategy of erring onside of caution when imposing possible harm; avoidign action that has any risk of causing harm

Negligence

harm resulting from neglecting to do something; connected to due care; problems occur when health care professionals are careless

Harm

philosophically complicated; not all painful things are harmful; definition depends on circumstance & intent

Distributive Justice (Health Care Ethics)

concern to distribute the benefits of health care across populations; may include addressing inequalities in health & access to health care; various theories & frameworks for creating just distributions; can focus on need, equality, randomness, time spend waiting, money; creates questions about procedural justice (fair procedure for allocating resources)

Justice

justice tells us to treat similar cases in similar ways (equality); linked to fairness & impartiality; basic idea is that it is wrong to treat ppl differently w/out reason; creates question about when ppl should receive special treatment; idea is linked to “non-discrimination in health care”; linked to health equity

Health Equity

aka equitable health care; concern for fairness & equal opportunity in healthcare; basic idea is that there should be equitable distributions of health & health care in society for all w/out regard for race, gender, etc; CDC defines health equity as when everyone has opportunity to attain full health potential; many inequalities in healthcare, seen in disease rates

Anita Silvers

said “health is good for justice, and justice is good for health”; ppl willl be healthier when society treates everyone fiarly; society w/healthier ppl will be more just; also said that a just society will have broad access to health care that will keep at-risk ppl alive; asks us to consider whether there will be more unhealthy people in a just society

Rationing Health Care

occures when there are not enough resources, and decisions must be made about distributing resources; occurs w/organ donation bc not enough organs for everyone natter if distributive justice; difficult when there are complex differences in ppl needing resources; criteria can include need, first in line, chance, or market forces; some question if one’s social value/usefulness increases their qualification for resources; if not, shoudl not use market forces to ration; relates to “life-year maximization”; social/cultural differences, as well as unequal funding complicates things

Fair Innings

related to “life-year maximization”; certain number of years (innings) that are expected in order to have a “fair share” of life’s goods & experiences; those who haven’t gotten their fair share of years (young ppl) should be treated 1st, while the older ppl should go to the back of the line; how do you assess how many years is fair? John Harris argues that drawing a line at a # of years would be agist; similar argument for disabilities

Human Rights (Health Care Ethics)

concern to respect & support human rights in health care; associated w/claim that ppl have a right (or are entitled to) health care; justice means that people should be given what they deserve; rights may be based on what is deserved; do sick ppl have the right to care? How will this right be administered? relates to disparities in health care; some want universal health care, while others want private health care & insurance

Affordable Care Act

expanded insurace coverage; required that individuals obtain insruance; addressed coverage denials for those w/preexisting conditions; let to debates & efforts to verturn

Healthcare for All

movement supported by Bernie Sanders; claims that healthcare is a human right; wants to bolster ACA by expanding Medicare and creating Medicare for all; would create single health care system that pays for everything; some think it is socialism, expensive, and inefficient

Kai Nielsen

argues that quality health care should be free and openly available to all; socialism promotes democracy, equality, and autonomy better than free market capitalism

What are some criticisms of universal health care?

some claim that universal health care is inefficient; say that individuals have the right to choose their health care provider and not pay into insurance system; John David Lewis argues that univeral health care will infringe on doctor’s rights; said that rights should be understood negatively (as projects against violations of liberty); to claim that others have the right to health care creates a positive dut to help

Norman Daniels

provides middle ground btwn Lewis’s free market libertarianism and Nielsen’s egalitarian socialism; has a liberal approach buidling on John Rawl’s work; combines liberty & equality; argues that health is a primary good that should be distributed fairly; basic institutions of society should help equalize the natural lottery

Health Maximization (Health Care Ethics)

utilitarian concern to promote the greatest health for the greatest number of ppl; focused on public health policies; could support parternalistic violations of autonomy to support public health; could violate liberty to maximize health of population; questions on what counts as maximizing health; requires care for the vulnerable to prevent eugenics; public health should be focused on the most vulnerable

Measuring Public Health

mortality rates can tell us something about public health; public health is more than minimizing deaths; quality adjusted life-years (QALY) or disability adjusted life-years (DALY) are also used as measurments; can have cultural/social biases

Eugenics

practice of creating good genes/improving genetic stock of humanity; widely discredity by bioethicists bc it resulted in atoricites; led to forced sterilizations of vulnerable populations in the name of public health; atrocities can be prevented by emphasizing autonomy and respect for the dignity & worth of humans

Care for the Vulnerable (Health Care Ethics)

focus on the special needs of most vulnerable; conncected w/the “ethics of care” and care for those who are dependent, disabled, lacking autonomy, or otherwise vulnerable

Prima Facie Duties

duties “on the face of it” or at first appearance; means that each is valuable but may conflict in some cases; ex. pandemic restrictions; leads to open-ended result in ethics

Rushworth Kidder

pointed out diff btwn dilemma & temptation in Good People Make Tough Choiuces; dilemma is right vs right situation, while temptation is right vs wrong situation

Dilemma

occurs when two good things conflict with each other; right vs right situtation

Temptation

we know right answer, but are tempted by wrong answer; right vs wrong situation

Code of Ethics

guides decisions of ethics committees; found in a variety of professions; those who violate codes may face sanctions, as well as criminal & civil liability; very important in health care bc issues are life and death; punishments can be severe

Wendy Rogers

argues that bioethical principles of autonomy, beneficence, and non-maleficence can be appealed to to protect vulnerable ppl in clincial settings; argues race, gender, economic status, and ability are included in vulnerablility

John Rawl’s Difference Principle

allows for social inequalities as long as the help the least advantaged members of society; Nussbaum argues that the system cannot account for ppl w/disabilities