Health Care Ethics
Lecture # 3
Dr. Segun Gbdegasian

 I.             Senses of Ethics 

A.    Code of Conduct

1.     Individual 

2.     Group 

B.     Branch of Philosophy 

1.      Systematic and Critical 

2.      Reflection on the Phenomena of Morality – 

II            Phenomena of Morality 

Morality is the social institution for regulating social life.  

The phenomena of morality consists of: 

a.      Moral Beliefs

b.      Moral Rules

c.      Moral Principles

d.      Moral Judgments

e.      Moral Issues 

III        Moral Problems 

1.      Moral Distress       I know what to do, but how can this obstacle in my way be removed?

2.      Moral Dilemma       Two or more courses of action, with plausible moral considerations on their side, are open to me.  Which should I pursue?

3.      Dilemma of Justice      Which is the fairest way to distribute these benefits among equally deserving candidates?

4.      Dilemma of Authority Who has the authority to act or take decision in this situation?

IV            Resolving Moral Problems 

1.      Seek more relevant information

2.      Aim at conceptual clarity

3.      Adopt a common framework of moral principles

4.      Use examples and counter examples

5.      Examine the arguments for and against 

V            Relativism

1.      Cultural: What is believed to be right in one culture may be believed to be wrong in another culture. 

2.      Normative: Whatever a culture believes to be right is right and whatever it believes to be wrong is wrong. 

Is all morality relative?  To culture? To individuals? 

VI            Utilitarianism 

Thesis/Principle: 

An action, practice, or policy is right only if it promotes the greatest possible balance of good consequences or the least possible balance of bad consequences compared with any alternative action, practice, or policy. 

This principle rests on a theory of value, which determines what is a good consequence. 

A.    Utilitarian Positions on a Theory of Value 

1.      Hedonistic Utilitarians: Pleasure alone is intrinsically good; pain is bad.  Therefore, the only intrinsically desirable ends are pleasure and freedom from pain.

2.      Pluralistic Utilitarians: In addition to pleasure, love, health, knowledge, - beauty and friendship are intrinsically good and desirable as ends.  Therefore, the rightness or wrongness of actions is to be determined by the totality of all intrinsic goods it produced.

3.      Preference Utilitarians: Desire-satisfaction is the intrinsic goo; therefore the maximization of an individual's utility by satisfying his/her desires and preferences must be the determinant of right and wrong.

 

4.      Act-Utilitarianism and Rule-Utilitarianism:  Should the principle of utility be applied to (judging) particular actions in particular circumstances or to (judging) moral rules?

 

a.      Rule-Utilitarianism:  Rules justify actions; the principle of utility justifies rules.

b.      Act-Utilitarianism:  The principle of utility justifies actions directly without the mediation of moral rules.

 B.     Problems with Utilitarianism 

1.      Measurement of Utility:  comparison of relative weight of values, goods, and preferences is almost possible.

2.      Conflict with Justice:  aggregate and maximizing considerations of utilitarianism may violate principles of fairness and justice. 

VII            Deontological Theories 

Thesis/Principle:  

An act or rule is morally right, not an account of the ends it promotes, but to the extent that it conforms to the demands of an overriding obligation.  The nature of an obligation is determined by appeal to an overriding principle. 

* An act is not right simply because it serves a utilitarian goal. 

A.    Types of Deontological Theories  

1.      Act Deontology -- No reliance on rules to grasp what must be done in a particular situation: conscience, faith, intuition are good candidates.

2.      Rule Deontology -- Acts are right to the extent that they conform to some fundamental principle or rule: The golden rule, the categorical imperative are good candidates. 

B.     Kant's Deontological Theory 

An act is morally right and praiseworthy only if it is what duty requires and it is done for the sake of (or from the motive of) duty.  

n      Moral rules are ultimately validated by pure reason and apply universally to all rational beings.

n      A person is autonomous when he/she acts in accordance with rules valid for all rational beings. 

C.    Kant's Moral Law  

The supreme principle of morality: The categorical imperative. 

Two formulations: 

1.      So act that through the maxim of your action, you can will a universal law for all rational agents.

2.      So act that through the maxim of your action, you treat humanity in yourself as well as in others never as mere means but always as an end. 

D.    Kant's Account of Duties 

PERFECT DUTIES

(No legitimate exceptions) 

To Self	To Others
e.g. Do not treat self as means (suicide prohibited)	Do not treat others as means (breaking promise prohibited) (lying is wrong)

 IMPERFECT DUTIES

(exceptions allowed) 

To Self	To Others
Promote good (Develop self and talents)	Promote good (promote well-being of others)

 * Application: Ought a physician lie to her patient to benefit her?

 VIII      Ross' Deontological Theory 

A.     Prima Facie vs. Actual Duty 

n      A prima facie duty is a duty that is always to be performed unless it conflicts with an equal or stronger duty.

n      An actual duty is the prima facie duty that has a stronger weight in case of conflict.

n      We know our duties in particular situations just on the basis of our moral beliefs and conventions. 

B. Ross' List of Duties 

1.      Fidelity

2.      Reparation

3.      Gratitude

4.      Beneficence

5.      Non-Maleficence

6.      Justice

7.      Self-Improvement 

* Conflict of duties can only be resolved by considered judgment. 

C. Applications: 

Is it right for a physician to lie to her patient? 

1.      Duty of Fidelity - do not lie.

2.      Duty of Beneficence - act in the best medical interest of patient.

Is it right to disclose medical record held in confidence if the patient has infectious disease? 

3.      Duty of Fidelity - keep medical records confidential.

4.      Duty of Beneficence - keep innocent spouse and public informed.

 IX  Major Moral Principles 

1.      The Principle of Non-Malificence

-          "Above all, do not harm."

-          "Do not cause needless harm to others." 

2.      The Principles of Beneficence

-          "Act in ways that promote the well-being of others"

-          "Prevent evil or harm."

-          "Remove evil or harm."

-          "Promote good." 

3.      The Principle of Utility

-          Act in such a way as to promote the greatest good and the least evil. 

4.      The Principle of Justice 

-          Formal:

       Treat similar cases in similar ways.

Substantive:

-          Equality:

       Distribute all benefits and burdens equally.

Need:

      Distribute goods and services based on need.

-          Contribution:

-         Distribute goods & services according to the contribution of each person.

-          Effort:

-         Distribute social good based on the effort made by each person. 

5.      The Principle of Autonomy

-          An individual's action ought to be the result of his or her own choices.

-          Persons ought to be self-determining.  External force or coercion is a violation of autonomy 

A.      Autonomy Requires: 

-          Liberty of Action (versus coercion)

-          Freedom of Choice (versus zero option)

-          Effective (rational) deliberation

-          Ability to:

1.      Formulate appropriate goals

2.      Establish priorities

3.      Determine best means to goals

4.      Effectively realize goals

5.      Make appropriate changes in goals and means

6.      Have access to all pertinent information

X.  Paternalism 

Interference with an individual's autonomy on account of his/her own interest either to: 

a.      Keep him/her from harming him/herself (paternalism), or

b.      Benefit him/her (extreme paternalism.)

c.      Prevent a person with diminished autonomy from doing an irrevocable harm to him/herself.

d.      Temporarily constrain a person from actions that are presumed to be irrational and harmful until it can be determined that he or she is acting autonomously.

Ethical Questions 

1.      Is there a right to die?

2.      Is abortion as morally problematic as infanticide?

3.      Does everyone have a right to adequate health care?

4.      Is the use of human beings as experimental subjects morally justifiable?

5.      Should genetic considerations be a factor in allowing people to have children? 

WHAT IS TO BE DONE? 

            An eighty-year-old woman has a family history of Alzheimer's disease.  She had lost her brother and sister to the disease in very painful ways that she would not like to experience.  She therefore decided, and recorded it in writing, that in case she had any life-threatening condition she would prefer not to be treated.  A nurse was caring her for at home.  One day her Doctor paid a visit and discovered that she had a high temperature.  He brought her to the hospital for examination, and it was confirmed that she had severe pneumonia.  If she was not treated, she had only 36 hours to live.  The doctors were worried because of her recorded wish.  On the other hand, they were not sure if this was a sign that she could be developing the disease that she feared.  What should they do?