Week 2 319

WEEK 2 – INTRODUCTION TO APPLIED HEALTH ETHICS

  • Course Details:

    • HSCI 319W D100 – Fall 2025 Applied Health Ethics

    • Date: Sept 5th, 2024

    • Instructor: Jean-Christophe Bélisle-Pipon, PhD, Assistant Professor in Health Ethics, Faculty of Health Sciences, Simon Fraser University

CORE FOUNDATION OF ETHICS

  • Key Question: What should be the core foundation of ethics?

    • Focus on moral grounding.

WHY DO WE NEED MORAL THEORIES?

  • Definition of a Moral Theory:

    • A discourse constituted by a structured set of normative, coherent, and justifiable assertions.

    • Explains why an action is right or wrong or why a person’s character is good or bad.

    • Provides grounds for establishing what is deemed right or wrong, including reasons why.

    • Importance:

      • Using and assessing moral theories is a common aspect of moral life.

EXPLORING MORAL FOUNDATIONS

  • 1. Virtues:

    • Definition: Inner qualities and moral character guiding behavior toward goodness.

    • Examples: Courage, Honesty, Wisdom.

    • Philosophical Background: Aristotelian Virtue Ethics.

  • 2. Duty:

    • Definition: Responsibilities and obligations owed to oneself and society.

    • Examples: Keeping promises, Respecting others.

    • Philosophical Background: Kantian Deontology.

  • 3. Utility:

    • Definition: Principle of maximizing overall happiness and welfare.

    • Examples: Cost-benefit analysis, Effective altruism.

    • Philosophical Background: Utilitarianism (Bentham, Mill).

  • 4. Rights:

    • Definition: Fundamental privileges and entitlements bestowed upon individuals.

    • Examples: Protecting liberties, Freedom of speech.

    • Philosophical Background: Rights Theories.

  • 5. Natural Law:

    • Definition: Moral standards governing behavior derived from human nature and the world.

    • Examples: Moral deification, Moral reading, Positive and negative liberty.

    • Philosophical Background: Classical Natural Law Theory (Thomas Aquinas) or Interpretivism (Ronald Dworkin).

  • 6. Principles:

    • Definition: Basic truths and standards guiding moral reasoning.

    • Examples: Justice, Fairness.

    • Philosophical Background: Principlism (Beauchamp and Childress) or Contractarianism (Rawls).

  • 7. Capacities:

    • Definition: Inherent abilities enabling ethical behavior.

    • Examples: Empathy, Critical thinking.

    • Philosophical Background: Modern Virtue Ethics (MacIntyre) or Capabilism (Amartya Sen, Martha Nussbaum).

THE BIG THREE PHILOSOPHERS

  • 1. Aristotle (384-322 BC):

    • Philosophy of Virtue Ethics.

    • Key Concept: Rightness of actions based on whether they accord with relevant virtues.

  • 2. Immanuel Kant (1724-1804):

    • Philosophy of Deontologism.

    • Key Concept: Rightness of actions determined by intrinsic nature and duty.

  • 3. John Stuart Mill (1806-1873):

    • Philosophy of Consequentialism.

    • Key Concept: Rightness of actions depends on their consequences or results.

CONSEQUENTIALISM

  • Definition: Morality depends solely on outcomes.

  • Basic Idea: The rightness or wrongness of an action is determined only by its consequences.

  • Central Claim: Good outcomes justify the action.

  • Contrast with Non-consequentialism:

    • Duties, intentions, or rules matter independent from outcomes.

  • Guiding Question: What will produce the best results overall?

KEY FEATURES OF CONSEQUENTIALISM

  • Consequences determine morality: Outcomes are the sole moral criterion.

  • Impartiality: Every person’s well-being counts equally, no individual's happiness is prioritized.

  • Aggregation: Sum harms and benefits across all affected individuals.

  • Flexibility: No act is inherently right or wrong; context and outcomes dictate morality.

  • Forward-looking: Projects moral reasoning into the future evaluating likely outcomes.

HEALTH CONTEXTS WHERE CONSEQUENCES DRIVE ETHICS

  • Resource Allocation: Determining access to limited resources (e.g., ICU beds, ventilators).

  • Public Health Programs: Decisions around vaccinations, quarantines, and intervention programs.

  • Emergency Triage: Prioritizing individuals with the highest survival probabilities during disasters.

  • Everyday Clinical Care: Evaluating risks/benefits of treatment options and managing side effects versus expected improvements.

COVID-19 DILEMMA EXAMPLE

  • Scenario: A hospital has one ventilator available. Two patients need it:

    • Patient A: 80 years old, multiple chronic illnesses.

    • Patient B: 25 years old, healthy.

  • Options for Decision-making:

    • Option 1: Allocate ventilator to Patient A (older).

    • Option 2: Allocate ventilator to Patient B (younger).

    • Option 3: Random selection (toss a coin).

WHY CONSEQUENTIALISM APPEALS IN HEALTH ETHICS

  • Clear Decision Rule: Choose the option with the best overall outcome.

  • Practical in Emergencies: Functional for triage and disaster planning.

  • Population Focus: Aligns closely with public health and policy goals to maximize health.

  • Adaptability: Principles can apply across various contexts while maintaining consistency.

LIMITATIONS OF CONSEQUENTIALISM

  • Ends Justify Means: Can allow for harmful acts (e.g., sacrificing one to save many).

  • Neglect of Rights: May ignore duties such as truth-telling or consent for perceived greater good.

  • Measurement Problem: Difficulty in comparing diverse outcomes (e.g., pain versus dignity).

  • Distribution Issue: Maximizing total good may overlook equity while benefitting some at the expense of others.

UTILITARIANISM: A CONSEQUENTIALIST FRAMEWORK

  • Definition: Most influential form of consequentialism focused on utility, happiness, or well-being as the outcome measure.

  • Key Features:

    • Morality equals producing the greatest happiness for the greatest number.

    • Happiness or utility is defined as pleasure, well-being, or preference satisfaction.

    • Neutral stance across individuals: No one's happiness is privileged.

    • Aim maximization involves balancing benefits and harms.

THE PRINCIPLE OF UTILITY

  • Greatest Happiness Principle:

    • “The right action is one that produces the greatest overall balance of pleasure over pain.” (Bentham)

  • Central Features:

    • Maximization: Seek the option with the best net results for happiness.

    • Aggregation: Sum total happiness from all affected individuals.

    • Equality: Everyone’s happiness counts equally in the decision-making process.

  • Health Application: Cost-effectiveness analysis in healthcare, such as evaluating QALYs (quality-adjusted life years).

ACT UTILITARIANISM

  • Definition: Evaluate each act by whether it maximizes happiness.

  • Characteristics:

    • No rigid rules; evaluation based on specific circumstances.

    • Flexibility allows for justifying actions that may typically be considered harmful if it yields a greater overall benefit.

  • Example in Health Care: Breaking confidentiality if it can save a life.

RULE UTILITARIANISM

  • Definition: An action is deemed right if it adheres to a rule that, if generally followed, would maximize happiness.

  • Focus: Concentrates on rules/practices instead of individual actions.

  • Rationale: Rules provide long-term stability, trust, and predictability in society compared with isolated actions.

  • Contrast with Act Utilitarianism:

    • Act: Does this specific action maximize happiness?

    • Rule: Would a general policy allowing this action maximize happiness?

APPLICATIONS OF RULE UTILITARIANISM (1)

  • Confidentiality: Protect confidentiality except in well-defined cases (e.g., imminent harm).

    • Rationale: Preserves long-term trust in the health system encouraging patient honesty.

  • Informed Consent: Always obtain informed consent before any medical intervention.

    • Rationale: Transparency promotes autonomy and cooperation yielding better outcomes.

APPLICATIONS OF RULE UTILITARIANISM (2)

  • Resource Allocation Protocols: Adhere to established triage frameworks during emergencies.

    • Rationale: Avoids chaos and discrimination, ensuring fair care.

  • Public Health Mandates: Implement vaccination programs based on evidence demonstrating they maximize community protection.

    • Rationale: Clear rules enhance compliance and collective benefits.

CONFIDENTIALITY REVISITED

  • Scenario: A nurse learns a teenager uses opioids secretly and pleads for confidentiality to avoid disclosing to parents.

  • Options Under Rule Utilitarianism:

    • Option 1: Keep confidentiality (prioritize long-term trust).

    • Option 2: Break confidentiality (risk of preventing death).

    • Option 3: Follow established rules (disclose only if specific imminent harm is certain).

ACT VS RULE UTILITARIANISM




  • Comparison Table:


    Feature

    Act Utilitarianism

    Rule Utilitarianism



    Focus

    Each individual act

    General rules/practices



    Decision basis

    Immediate consequences

    Longer-term outcomes of following rules



    Flexibility

    Highly flexible, no fixed rules

    More stable, promotes predictability



    Risk

    Can justify harmful acts if benefits exceed harm

    Can entrench harmful rules if not updated



    Health example

    Break confidentiality to save a life

    Keep confidentiality as a rule to maintain trust









    UTILITARIANISM AND PUBLIC HEALTH DECISIONS

    • Utilitarian logic is prevalent in public health focusing on maximizing overall well-being across populations.

    • Examples of applications:

      • Vaccination programs justified by disease and death reduction.

      • Quarantine measures may restrict freedoms but protect the larger community.

      • Harm reduction strategies like needle exchanges that mitigate risk, save lives, and reduce infections.

      • Cost-effectiveness analysis in policy making, assessing outcomes (e.g., money spent per quality-adjusted life year gained).

    UTILITARIAN REASONING IN CLINICAL CONTEXTS

    • Key Tensions: Balancing collective benefits versus individual patient duties.

    • Examples:

      • Confidentiality vs. safety: Breaking confidentiality to prevent serious harm.

      • Truth-telling vs. hope: Maintaining patient morale versus disclosing difficult prognosis.

      • Resource allocation: Prioritizing ICU beds and organs for those who may save the most lives or years.

      • Everyday decisions: Opting for treatments with best benefit-risk profiles and withholding costly options with marginal benefit when supporting more individuals is possible.

    KEY CRITIQUES OF UTILITARIANISM

    • Ends Justify Means: Justifies potentially unjust acts (e.g., sacrificing one to spare five).

    • Neglect of Basic Moral Considerations: Ignores duties such as truth-telling and consent if breaking them promotes the greater good.

    • Demandingness: Requires constant pursuit of maximum good, limiting personal freedom.

    • Measurement Problem: Difficulty arises in how to quantify happiness or compare various forms of harm.

    • Distribution Problem: Maximizing total happiness can obscure inequalities, benefitting some while disenfranchising others.

    NON-CONSEQUENTIALISM

    • Definition: Morality does not depend solely on outcomes; some actions are intrinsically right or wrong.

    • Core Idea: Certain actions hold moral weight irrespective of consequences.

      • Duty-Based Ethics (Deontology): Morality grounded in obligations, principles, and duties.

    • Contrast with Consequentialism:

      • Consequentialism posits do whatever yields the best outcomes.

      • Non-consequentialism posits some actions must never be undertaken even for beneficial ends.

    KEY FEATURES OF DUTY-BASED ETHICS

    • Intrinsic Rightness or Wrongness: Certain actions are inherently morally required or forbidden.

    • Duties and Obligations: Moral principles include truth-telling, promise-keeping, respect for entities.

    • Rules and Principles: Provides clear ethical guidelines (e.g., “Do not kill,” “Always respect autonomy”).

    • Universalism: Moral duties apply universally, not just when convenient.

    • Respect for Persons: Everyone possesses intrinsic worth independent of their utility to others' happiness.

    IMMANUEL KANT

    • Biography:

      • German philosopher (Prussian, 1724-1804).

      • Influential texts: The Critique of Pure Reason, The Critique of Practical Reason, The Critique of Judgment.

      • Philosophical Contribution: Famous for morality theories emphasizing duty.

      • Quote: "Have courage to use your own understanding! – this is the motto of enlightenment."

    DEONTOLOGY

    • Definition: Derived from the Greek word "deon" meaning duty, and logos (“study of”)