HTH 423 (Ethics) - EXAM 1

Ethical theories and principles are helpful in addressing ethical issues in two key ways:

(1) they explain why the issue at hand is an ethical issue (2) they justify why one course of action ought to be preferred over another

why is health ethics important for the work of WHO?

- One of WHO's six core functions is to develop "ethical and evidence-based policy options - While principles of human rights must guide the analysis of these issues, those principles often do not point to a single, objectively correct answer

Nozick vs Rawls

- Rawls: liberal tradition that the government should step in to help people disadvantaged in life's lottery - Nozick: conservative tradition that if you want something you should obtain it yourself

ideal rights

- a statement of a right that is meant to be motivational, a goal to seek - serve to guide organizations, communities, and nations to provide higher standards

4 key points of double effect

- act must be good, or at least morally neutral, independent of its consequences - the agent intends only the good effects, not the bad - the bad effect must not happen because of the good effect - the good effect must outweigh the bad effect

process rights

- also legal rights - many laws relate to ensuring that due process is followed

substance rights

- can be legal rights or not - the right to do a particular thing (healthcare, housing, minimum wage, welfare, food stamps, safe streets, a clean environment, etc)

importance of ethics theories to health care professionals

- clinicians and healthcare administrators can use practical wisdom to advance interests of specific patients, the aggregate, the community, and healthcare organizations - helps in decision making - policy makers can enhance their evaluation of the behaviors or motivations of various stakeholders by determining the stakeholders' ethical system

categorical imperative

A concept developed by the philosopher Immanuel Kant as an ethical guideline for behavior. - In deciding whether an action is right or wrong, a person should evaluate the action in terms of what would happen if everybody else in the same situation acted the same way. - criterion for determining what ethics principles meet the test of reason

Utilitarianism

A set of theories centred on the principle of utility which is often taken to require that any action should maximize benefits for the greatest number of people

solidarity

A social relation in which a group, community, or nation stands together

procedural justice

Discussion of the values and processes necessary to bring about a just outcome

8 KQs

Fairness Outcome Responsibility Character Liberty Empathy Authority Rights

accountability for reasonableness

Framework that requires that the rationale or reasons underlying health-care-limiting decisions be made publicly available

negative rights

- you have the right to be left alone and to do anything not strictly forbidden by the law - Bill of Rights is all negative rights - they are clear and enshrine liberty

elitism theory

a good person who exemplifies virtue or integrity has likelihood of being better than other people, which causes them to set a standard that many people may fall below; creates a hierarchy

distributive justice

a set of principles that provide "moral guidance for political processes and structures that affect the distribution of economic benefits and burdens within societies

specific competence

ability to do some things but not others

preexisting conditions

ailments or diseases that the patient has before health insurance coverage begins

the goal of consequentialism theory is

the greatest good for the greatest number; intent doesn't matter only outcomes

what is health ethics?

the interdisciplinary field of study and practice that seeks to understand the values undergird-ing decisions and actions in health care, health research and health policy, and to provide guidance for action when these values conflict

nonmaleficence

to do no harm

substituted judgment

trying to figure out the person's wishes when they were competent and making the best call from that

consequentialism theory is also known as

utilitarianism

______ are central to ethical judgments

values

Character - question

what actions will help me become my ideal self? am I allowing my own personal beliefs to get in the way of how I interact with people/making the right decision?

Outcomes - question

what are the short and long term outcomes of possible actions?

Authority - question

what do legitimate authorities (experts, law, my god(s)) expect of me?

Responsibilities - question

what duties and obligations apply?

ethical relativism

what is ethical in one situation may not be ethical in another and that is accepted by most philosophers

Liberty - question

what principles of liberty and personal autonomy apply?

Rights - question

what rights (innate, social, legal) apply?

what is harm as negligence?

when a person has not exercised the due diligence expected of someone in his or her role and level of responsibility

Autonomy means what?

you rule yourself

natural rights

- we should respect attributes that humans have by nature (life, liberty, and pursuit of happiness) - moral right to healthcare

Rawls version of deontology

- defined characteristics of a just society; "justice as fairness" - principle #1: liberty; people should have equal rights to basic liberties (bill of rights) - principle #2: justification of inequalities (difference principle); social and economic inequalities are appropriate if they are arranged such that the inequalities help out the least fortunate persons in society

deontology theory

- duty based ethics - ability to choose good makes us human - free will makes ethics possible/necessary - actions judged by intention and not outcome - categorical imperative and golden rule (due unto others as you would have them do unto you) - difficult in modern society

Nozick's version of deontology

- emphasized autonomy and right of individual - we should influence people to take steps to improve their own situations - no principle of distributive justice; everyone has equal opportunity

key ethical issues in health research

- ethical issues regarding groups (economically disadvantaged, topic selection, new drug/device patents, whether research surveillance is necessary) - ethical issues regarding individuals - managing ethical dilemmas

research ethics committees

- evaluate research protocols with the aim of safeguarding participants' rights and well-being - reduce risks of the research - make sure risks are reasonable in relation to anticipated benefits - make sure the researchers have made adequate plans for obtaining participants' informed consent

Consolidated Omnibus Budget Reconciliation Act (COBRA)

- forerunner to HIPAA - mandates that businesses with more than 20 employees must provide employees who leave that business extended health insurance for up to 18 months

examples of need based on misfortune

- genetic defects - reduced abilities in physical or mental capacity - motivation - special talents - children/elderly

harm as a violation of autonomy

- giving a patient treatment even though they don't want it - not fully educating a patient/dissuading a patient due to cost or a lack of insurance - making best decision if person is incompetent

key ethical issues in public health

- harm prevention, public good, and individual liberty - treatment and prevention - health promotion and equity - public health surveillance

clinical ethics committees

- multidisciplinary - may include ethicists, health care professionals, patient advocates, and religious representatives - provide guidance to clinicians, patients, and families in clinical dilemmas - may also contribute to the development of institutional policies and procedures

3 types of ethics committees

- national ethics committees (NECs) - research ethics committees (RECs) - clinical ethics committees

national ethics committees

- official bodies to advise their executive and legislative branches, and often the general public, about ethics of health and health care. - meet to facilitate international dialogue and foster consensus on ethical issues of global concern

relationship between health ethics and law

- often complementary; define how people are supposed to act - some laws could be considered unethical - ethics is concerned with a broader set of relationships and behaviors than most forms of legal regulation - concrete punishment for breaking a law but social/individual grief for being unethical

examples of material reasons to discriminate

- one's level of contribution or results and effort - circumstances characterized as misfortune - mental/physical disabilities; unequal natural endowments - special talents or abilities - opportunities a person might have or lose - past discrimination against a group that is perceived as having negative effects in the present - structural social problems perceived as restricting opportunity or motivation

egoism theory

- people either should seek to advance solely their self-interests or this is actually what people do - the benefit, pleasure, or greatest good is from the self alone - not very important in health care ethics which is all about the patient not the provider

major criticisms of consequentialism

- portion of the minority is always left out - some say that this theory says that the ends justify the means (no matter how you get there it's fine as long as the end result is good)

key ethical issues in clinical care

- proper communication of info with patient - clinician's opinion/treatment recommendation vs patient's needs - when should patient be able to make own decisions?

key ethical issues in health organizations and systems

- resource allocation across health services and programs - corporate partnerships and philanthropic fundraising - workplace ethics - equitable access - individual vs population health - public accountability

key ethical issues in global health

- specification of actions that wealthier countries should take to help poor countries - cultural relativity - should everyone be treated the same regardless of their culture? - standards of care - should they be equal for everyone regardless of location or if in a control group in a trial

authority-based ethics theory

- usually based on religion, elders, traditions, culture, or ideology - many authority based theories conflict so there is no way to sort them out other than by an appeal to reason - arguments may also arise relating to the religion itself and the truth behind it - can help in patient understanding, treatment, and creation of healthcare policy

two important conditions must be met for autonomy:

1. are patients competent to make decisions for themselves? 2. are patients free of coercion in making decisions?

3 reasons for engaging stakeholders

1. to improve the quality of decisions by examining ethical issues from diverse perspectives and bringing relevant experience and expertise, both lay and professional, to the table 2. to provide input on values, to inform policy decisions and guide the application of available evidence 3. to provide a mechanism for improving public accountability for these decisions

beneficence

Principle requiring that governments, health care providers, and researchers do good for, provide benefit to, or make a positive contribution to the welfare of populations, patients and study participants

virtue ethics theory

The Greek philosopher Aristotle's theory that we must cultivate character traits that will best bring us the best life and eudaimonia

proportionality

The balancing of the positive features and benefits of a particular intervention, policy, or research study against its negative features and effects, when deciding whether or not to implement it

bioethics

The field of enquiry that examines ethical issues arising from the "creation and maintenance of the health of living things"

natural law theory

all things subject to Divine providence are rules and measured by the eternal law - can be seen as a version of deontology which is simply any view that defines the right thing to do as dependent on something other than consequences

beneficence requires a decision to engage in beneficent acts or to be ________

altruistic

autonomy

an individual's right to make their own decisions and to be their own person

egalitarianism

belief in equality

eudaimonia

human flourishing brought about by a perfection of character nurtured by engaging in virtuous acts over a life of experience

health ethics and _______ go hand in hand

human rights

classical utilitarianism vs rule utilitarianism

classical: each act considered on its own; can make it very hard to make a quick decision rule: based on rules/policies and acts more as a guideline for decision making

autonomy and liberty are very important to the _______ theory

consequentialism

making ethical decisions requires ________ ________ and rational ______ _________

considered judgments; moral reasoning

reflective equilibrium model provides a process for:

considering and reconsidering decisions

the principle of double effect

distinguishing between good and evil

what do you need to determine the answers to the following issues? - physicians deciding how much time to spend with patients - nurses deciding how quickly to respond to patients - which employees deserve a pay raise? - Texas department of health public hearing re: HIV/AIDS funding cut

distributive justice

non-maleficence

duty to do no harm

what is an example of a distributive justice principle?

egalitarianism

What human beings have a right to as a matter of _______ is not necessarily the same as what they have a right to as a matter of _______.

ethics; law

________ remains a foundation for law, and often provides a justificatory basis for legal ________

ethics; norms

the original position

hypothetical or mind experiment by Rawls to explain why rational people would protect everyone's self interests - if we were in the original position, we could all be equal and treated the same in society, and therefore it would be in our best interest to make sure everyone was given an equal share of benefits and burdens

veil of ignorance

forgetting everything about you and your situation to make a clear, moral decision - useful when you have a patient who cannot make a decision for themselves

examples of need based on past discrimination

groups who have been discriminated/treated poorly in the past which have led to downfalls in their lives today whether it be SES, education, housing, transportation, etc.

example of a positive right

health care

beneficence is a fundamental principle of _______

health care practice

Fairness - question

how can I act equitably and balance all interests?

Empathy - question

how would I respond if I cared deeply about those involved?

best interest or reasonable person decision

if patient is incompetent, professional must make the decision that a reasonable person would choose in his/her best interest

procedural injustice most frequently occurs when

in employee situations (who is going to get fired if economic reasons arise)

competence and autonomy are part of _______

informed consent

legal and positive rights

legal rights: someone has legal obligation to fulfill your right, whatever it happens to be positive right: example of a legal right because it is a specific social good

the right to privacy is a ______ right but not a ______ right

legal; positive

ethical theories and principles are used to explain _______ reasoning

moral

- we have the freedom to pursue our lives as we see fit - we have the right to not have smokers in our workplace - privacy protections under HIPAA - sexual harassment protections These are all examples of which type of rights?

negative

malfeasance

neglect of fiscal responsibility and actions that conflict with policy or the law

portability

no lapse of healthcare coverage occurs when a person changes from one job to another, even when insurance carriers change

public good

nonexcludable (no one can be excluded from consumption, irrespective of individual contributions to provision) and nonrival (consumption by some does not reduce the benefits of consumption accrued by others)

intermittent competence

patient is able to make decision one hour and the next hour is incompetent

procedural justice vs distributive justice

procedural: were the procedures put in place fair and were they followed as they should be?; aka due process distributive: balancing benefits and burdens; resource allocation issues in health care are always present

getting treated in the ER regardless of whether you are able to pay or not is an example of what kind of right?

substance

Ethical decision-making frameworks provide ________ and _______ approaches to the analysis of ethical _______ and _______

systematic and practical; issues and questions

what is harm in the clinical setting?

that which worsens the condition of the patient

preference utilitarianism

the good is the fulfillment of preferences and the bad is frustrating preferences; good at individual level but has less value as a policy statement for everyone