Ethics

How would you describe a good moral judgement?

Prescriptive and justified through reasoning

Which ethical theories are act-based?

Consequentialism, deontology and the 4 principles

Which ethical theories are character-based?

Virtue ethics

What are ethical dilemmas?

Situations where values conflict, moral obligations conflict, and a choice needs to be made between 2 equal, and usually undesirable, alternatives

What is medical ethics?

An applied branch of ethics or moral philosophy

How does medical ethics explore ethics?

It explores it in relation to medical practice, and is particularly focused on medical practitioners

What are the two main ethics questions?

What should I do and why should I do it?
What kind of person should I be?

What do the two ethics questions become in medical ethics?

What should I do as a practitioner?
What kind of practitioner should I be?

Where does virtue ethics originate?

In Ancient Greek philosophy, Socrates/Plato eg

What kind of person should I be (virtue ethics)?

A virtuous person

What does virtue ethics focus on?

The excellence of character, it is concerned with the agent, not only the agent's choices/actions

When is an agent of excellent character (virtuous)?

If they have the right motive, intention, emotion and desires (the right inner moral life)

What is a virtue?

The mean between two opposing vices

What is courage a mean of?

Mean between recklessness and cowardice

What is generosity a mean of?

Mean between wastefulness and meanness

What are the challenges to virtue ethics?

Not action guiding \= some say it is unable to provide action-guidance, but perhaps we can create rules based on virtues
Conflict problem \= two virtues may point different directions

Describe the non-action guiding problem of virtue ethics:

Some say virtue ethics is unable to provide action-guidance, but perhaps we can create rules based on virtues

Describe the conflict problem of virtue ethics:

Two virtues may point in different directions

What should I do (consequentialism)?

Do what produces the best consequence(s)

What is the best known theory of consequentialism?

Utilitarianism

Describe classical utilitarianism:

Right action produces the greatest happiness for the greatest number

Describe act utilitarianism:

Consider the consequences of each specific act

Describe rule utilitarianism:

Formulate rules that seek to produce the best consequences

What are the challenges to consequentialism?

Prediction problem \= difficult to predict all the consequences of every different possible action
Incomparability problem \= can be difficult to compare consequences of two different kinds
Demandingness problem \= people might find it unreasonably difficult to be impartial and maximise the greater good for the greatest number
Aggregation problem \= calculating general utility doesn't take into account the separateness of persons

Describe the prediction problem of consequentialism:

Difficult to predict all the consequences of every possible action

Describe the incomparability problem of consequentialism:

Can be difficult to compare consequences of two different kinds

Describe the demandingness problem of consequentialism:

People might find it unreasonably difficult to be impartial and maximise the greater good for the greatest number

Describe the aggregation problem of consequentialism:

Calculating general utility doesn't take into account the separateness of persons

What should I do (deontology)?

That which is your duty to do

What is deontology concerned with?

Whether an action is right or wrong in itself

What is deontology not so concerned with?

Consequences

Describe deontology in terms of not being concerned with consequences:

Some acts are wrong in themselves, independent of the consequences
Doing your duty is intrinsically good, rather than good because of the consequences produced by following the rule

What is Kant's categorical imperative?

A moral duty holds in all circumstances, and that moral duties are rationally determined

What are two important formulations of Kant's categorical imperative?

Act only in such a way that, as a rational person, you would want that rule to be universal
Act in such a way that you treat people as ends-in-themselves and never merely as a means to your end

What are the challenges to deontology?

Conflict problem \= unclear what to do when two rules point in opposite directions
Not action guiding \= maybe only offers a principle of non-contradiction (logic), rather than substantial ethical guidance
Misrepresents ethics \= overlooks ethically important considerations (e.g. doesn't account for people's character)

Describe the conflict problem of deontology:

Unclear what to do when two rules point in opposite directions

Describe the non action guiding problem of deontology:

Maybe only offers a principle of non-contradiction, rather than substantial ethical guidance

Describe the misrepresentation of ethics problem of deontology:

Overlooks ethically important considerations

What should I do (4 principles)?

That which balances the four principles

What are the 4 principles based on?

Different ethical theories

What do the 4 principles seek?

Seek to capture the general values underlying medical practice

What are the 4 principles said to reflect?

A common morality

How should the 4 principles act?

As a guide, not precise instructions

What are the 4 principles?

Autonomy
Beneficence
Non-maleficence
Justice

Describe the 'autonomy' principle:

Respect for people's decisions about their lives, based on their values
Avoid paternalism
Requires information/mental capacity

Describe the 'beneficence' principle:

Promotes the patient's welfare (best interests)

Describe the 'non-maleficence' principle:

Do not intentionally cause harm
Prevent harm where possible

Describe the 'justice' principle:

Treat people fairly and without discrimination

What are the challenges to the 4 principles?

Imperialist \= western principles, not clear that these are 'common' or the right principles
Inapplicable \= some principles may not apply in some situations (e.g. autonomy in infants)
Conflict problem \= principles can point in different directions
Inadequate \= only a simplistic check-list and not really a theory; more ethical reflection is needed to ensure the principles can guide action

Describe the imperialist problem to the 4 principles:

Western principles
Not clear that these are 'common' or the right principles

Describe the inapplicable problem to the 4 principles:

Some principles may not apply in some situations

Describe the conflict problem to the 4 principles:

Principles can point in different directions

Describe the inadequate problem to the 4 principles:

Only a simplistic check-list and not really a theory
More ethical reflection is needed to ensure the principles can guide action

What does the ethical theory of 'patients' narrative and perspectives' focus on?

The patient's story

How does the ethical theory of 'patients' narrative and perspectives' help us make sense of human (moral) life?

By focusing on communication, perspectives and relationships

What can the ethical theory of 'patients' narrative and perspectives' be linked with?

Casuistry (a case-based approach) - seeks to resolve ethical dilemmas by comparing each new situation with others and with paradigm cases

What kind of approach is casuistry?

A case-based approach

What is casuistry?

An case-based approach that seeks to resolve ethical dilemmas by comparing each new situation with others and with paradigm cases

What are the challenges to 'patients' narrative and perspectives'?

'Wrong story/ethics' \= what if the story is missing relevant features because it is only one person's story, why should the story guide us, what if the person has the wrong values
Conflict problem \= might be different versions of the story

Why do we need to be concerned with distributive justice?

Because demand for health resources is outstripping supply

How is demand for healthcare increasing?

Aging population with more chronic illnesses
Medicalisation (increasing remit of healthcare)
Increased consumer demand
Technological advances are making more possible

How is supply of healthcare not keeping up with demand?

Staff shortages / low recruitment in some areas
Inadequate funding to meet demand
Clinical Commissioning Groups (CCGs) choosing to cut/reduce some services

What is necessary as demand for healthcare is outstripping supply?

Prioritisation and rationing

What ethical questions arise within prioritisation and rationing of healthcare services?

Who/what to treat first, and why? (prioritisation)
What, if anything, to cut/limit, and why? (rationing)

How are distributive justice decisions made?

Nationally \= public health campaigns targeting specific issues; certain treatments approved
Locally \= strategic focusing of services (e.g. limiting IVF funding)
Individually \= which treatment options to offer; referral decisions
WIthin the NHS \= allocation decisions concerning how to spend resources; responsibilities both to individual tax payers and the wider community

Who makes distributive justice decisions nationally?

National Institute for Health and Care Excellence (NICE)
Department of Health and Social Care (DH)
Public Health England (PHE)

Who makes distributive justice decisions locally?

Clinical Commissioning Groups (CCGs)
NHS Trusts
Practices

Who makes distributive justice decisions individually?

Clinicians

What does NICE stand for?

National Institute for Health and Care Excellence

What does PHE stand for?

Public Health England

What does CCG stand for?

Clinical Commissioning Groups

What does DH stand for?

Department of Health and Social Care

What is a 'want'?

A good that someone wishes to have but is not essential to life

What is a 'need'?

Something that is essential to life

What is a possible solution (not distributive justice) to deciding what needs to prioritised/rationed?

Distinguishing between 'want' vs 'need'

What are limitations of 'distinguishing between want vs need' as a way of deciding what needs to be prioritised/rationed?

It is hard to define 'essential'
Problem with indeterminacy (at which point does want become pathologised into a need) and medicalisation (what kind of needs must the health service provide for)

Describe distributive justice:

Distribution of goods in accordance with the principle of justice

Describe the consequentialist approach to distributive justice:

Distribution of resource is 'just' if it is maximally effective (brings about the best overall health outcome, for the most people, for the least cost)
Distribution on the basis of effectiveness (priority for services for which there is evidence of effectiveness)

What does NICE do in terms of the consequentialist approach to distributive justice?

It collects evidence on cost-effectiveness and advises what should be provided
Effects are measured in terms of gain in life-years or quality adjusted life years (QALYs)

What is a QALY?

Quality adjusted life year (one year spent in perfect health)

What is the equation for a QALY?

1 life year * 1 utility value

Describe the 'Equality and Egalitarianism' approach to distributive justice:

All persons are equal in their fundamental worth and therefore entitled to be treated equally
Decisions are made according to the principle of equality
It is unjust to give one person access/opportunity but not another person

Why is the 'Equality and Egalitarianism' approach to distributive justice challenging?

Because there wouldn't be sufficient funding to treat every patient the same as some are more sick than others

Describe the Aristolean approach to distributive justice:

'Persons in equal circumstances should be treated equally; persons in unequal circumstances should be treated unequally'

In the Aristolean approach to distributive justice, what do we still need to know to allow people to be treated differently in terms of access to healthcare?

The relevant criteria which can influence/be influenced, such as health behaviour and lifestyle

What is non-relevant criteria in terms of the Aristolean approach to distributive justice?

Criteria that cannot be influenced or changed (e.g. race, sex, mental/physical disability)

What are possible relevant criteria in terms of the Aristolean approach to distributive justice?

To each person an equal share; to each person according to individual need, acquisition in a free market, individual effort, societal contribution, merit or desert

What are some criteria that the Equality Act 2010 prohibits from being used to discriminate between persons?

Age
Disability
Gender reassignment
Marriage and civil partnership
Pregnancy and maternity
Race
Religion and belief
Sex
Sexual orientation

What do allocation decisions often include?

Balancing individual vs community interests
Balancing harms and benefits
Making decisions about both prioritisation and rationing
Dealing with and accepting opportunity cost
Denying goods to some

What is the primary concern of a health professional in distributive justice?

Treating the patient in front of you

What are deontological reasons based on?

Duty-based

What are consequentialist reasons based on?

Effect-based

What are the deontological reasons for maintaining confidence?

Keeping a promise
Respecting autonomy

What are the consequentialist reasons for maintaining confidence?

People will trust healthcare professionals/researchers
Patients will disclose their medical history
Healthcare/research will flourish

What is the nature of law and medical law?

Law \= guiding actions based on rules
Medical law \= rules governing the healthcare professional-patient relationship

What does public law concern?

State and individual

What does private law concern?

Individual and individual(s)

What is criminal law a part of?

Public law

What is civil law a part of?

Private law

What are the main sources of law?

Acts of Parliament (Acts, statutes, legislations)
Common law (cases, rulings, precedents)
European Union law (trade focus, Luxembourg court)
European Convention of Human Rights law (human rights focus, Strasbourg court)