Healthcare Ethics Final Exam

Jonas' Descending Order Principle

-A way of justly selecting subjects -Choose the most educated and highly motivated members of society first (people who are least vulnerable to exploitation), then proceed to descend to less educated and less well-off people

Helsinki Declaration (1964)

-Added the idea that the interests of the research subject should be given greater weight than those of society -Also discouraged use of placebos: subject should get either the best known treatment or the experimental treatment -Acknowledged the the Nuremberg meaning of voluntary consent was too restrictive: may need children to participate in experiments in order to develop effective treatments for children; possibility of using prisoners

Tom L. Beauchamp and James F. Childress

-Agree that sometimes, active euthanasia is morally permissible, but do not agree with Rachels' conclusion that active euthanasia should always be permitted -Make a distinction between acts and practices: even though we can imagine situations in which one could morally defend an act of active euthanasia, to formally permit the practice of it would introduce the potential to destroy/weaken the trust that patients have with their physicians in the healthcare system

Liberty Principle

-All parties would insist on a very strong priority being given to basic civil and political liberties -Endorsed to ensure that once the veil is lifted, each person's fundamental liberties and freedoms would be protected, no matter who they turned out to be

Difference Principle

-All parties would prefer a distribution of basic goods that would tolerate inequalities only when those inequalities raise the level of the least well-off persons -Endorsed in case they are among the least well-off

Principle of Double Effect

-Deals with an action that has two effects, one good and one bad, and tries to describe the conditions under which such an act would be permitted -In the context of debates about euthanasia: specifies conditions under which indirect active euthanasia would be justified and distinguishes direct active from indirect active and passive

The Manner in Which Death is Brought About

-Direct Active: physician-assisted suicide; some pharmacological agent is given with the intention of death -Indirect Active: patient dies not as an intention, but because of the pharmacological agent that was used -Passive: letting die; either the removal of a particular treatment of withholding of it; patient dies because of an underlying disease condition

Michael Brannigan

-Distinction between ordinary and extraordinary care has gone away from the original understanding to being conceptualized solely in terms of the treatment/technological understanding -Need to approach our understanding of the meaning of ordinary/extraordinary from the perspective of the patient's experience and preferences -Cannot evaluate the treatment apart from the patient: in very particular cases, it may be okay to withhold something like nutrition/hydration

Principlism

-Emerges out of the Belmont Report -States that its principles for healthcare are universal; synthesizes insights/commitments across many moral traditions -4 principles: autonomy (respect for persons), beneficence, nonmaleficence, justice

Michael Sandel

-Enhancement makes parents unable to accept and embrace imperfections in their children -Part of parenthood is accepting and loving their child for who they are; have a sense of humility in being a parent -Distinguishes between enhancement and restoring/maintaining health: the latter is a 'bounded good' while the former tempts parents to "overreach" -Primary dangers in pursuing enhancement: threatens our humility, excessive responsibility, and undermines solidarity

Rawls' Criticism of Utilitarianism

-Focus on the general welfare leads to the neglect of the basic needs of particular persons -A society cannot be called just if it tolerates the neglect of some for the benefit of many

Julian Savulescu

-Genetic selection is a way of being a responsible parent -There are traits that would be good to genetically enhance, no matter what (EX: memory, empathy)

To Each According to His or Her Choice

-More or less a market approach to distribution of healthcare -Argue that we have the right to select what we think is important, and we should be free to pursue what we think we need; if we need it badly enough, we will secure it

Belmont Report

-Goal was to articulate principles that should govern researchers in the area of human experimentation and norms that follow -Correct weakness of Nuremberg and Helsinki: long list of can-do's and can't-do's in an effort to be exhaustive of everything ; however, there are too many possible circumstances -Gives rise to theory of Principlism -3 principles: respect for persons, beneficence, and justice -Norms that follow: informed consent, assessment of risks and benefits, and assessment of who bears the burdens and who reaps the benefits

James Rachels

-In principle, there is NOT a moral difference between active and passive euthanasia -Sometimes letting die leads to more suffering than killing -Distinction between letting die and killing leads to decisions between life and death being made on irrelevant grounds -Killing, in itself, is not always morally worse than letting die (bathtub example) -Challenges the idea that the intention to kill is only present in active euthanasia

Ordinary Treatment

-Morally obligatory -"All medicines, treatments, and operations, which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or other inconvenience" -Benefit does NOT mean cure

Assessing Risk-Benefit Ratio

-Need to assess the risks and benefits to patients and risks and benefits to society as a whole -If risk to one is very high, this may lead to toleration of a higher risk to the other

Similar Treatment for Similar Cases

-Needs will differ, so the allocation of healthcare should differ -Gutmann's argument -If we are going to provide a treatment for a particular condition, we should provide it for everyone with this condition -Not that we should treat every type of condition, just that if we treat one condition, we should treat similar ones

Rawls' Criticism of Libertarianism

-Nozick fails to account for the fact that the current status quo effectively privileges "morally arbitrary" social realities and personal characteristics -Social realties and personal characteristics are not things we "earn" or "deserve", but are arbitrarily distributed -Since one does not have a moral claim to something obtained through luck or chance, Nozick's argument that we have an absolute moral claim to all that we possess is unfounded

Extraordinary Treatment

-Optional -"All medicines, treatments, and operations, which cannot be obtained or used without excessive expense, pain, or other inconvenience, or which, if used, would offer a reasonable hope of benefit"

Factors that Led to Increased Discussion About End-of-Life Ethics

-People are living longer than ever before -Developments in medical technology -Changes in the doctor-patient relationship -Important legal decisions that were accompanied by a fair amount of media coverage

Amy Gutmann

-Principle of equal access: doesn't require that society provide any particular treatment, it only requires that if one person has the opportunity to receive care for a given disorder, all persons with that disorder ought to have the effective opportunity to be treated as well -Equal access permits certain kinds of discrimination, but NOT that based upon those characteristics of people that can reasonably be assumed they did not freely choose -Rejects the charge that a single payer system (mechanism to ensure equality of access) is overly paternalistic: no diminishment of individual freedom, no one would be forced to use the system, it would be fully democratic legislation

Beneficence

-Promoting the wellbeing of persons and refraining from doing harm -Includes subjects and society as a whole -Did acknowledge that sometimes, you cannot always protect subjects and society simultaneously

Nuremberg Code (1947)

-Replaced paternalistic model of consent with a more human-centered approach -Set out a number of guidelines that must be followed -First item: the voluntary consent of human subjects is essential -Exclusion of using populations that aren't able to give voluntary consent: children, prisoners, patients in mental institutions

Informed Consent

-Requires comprehension: person must be mentally competent, information must be presented in a way that is intelligible -Adequate information must be provided -Must be voluntary consent: no coercion; no undue influence

Respect for Persons

-Respecting the autonomy of people -Give weight to the subject's opinion and choices; listen to their view and respect their choices -NO use of coercion -Protect those with limited autonomy: the sick, the mentally disabled, those with limited liberty (prisoners), children

Best Interest

-Standard that is invoked when neither a living will nor a proxy directive is available, and the collection of evidence does not reveal what the patient wants -Reasonable patient standard: what would any reasonable patient want done in this particular situation?

Egalitarianism and John Rawls

-Starting point: "each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override. For this reason, justice denies that the loss of freedom for some is made right by a greater good shared by others. It does not allow that the sacrifices imposed on a few are outweighed by the larger sum of advantages enjoyed by many" -Focuses on the best way to justly arrange society so that we meet the basic needs of all persons in society and morally arbitrary characteristics do not disproportionately impact our life chances

Libertarianism

-Starting point: "individuals have rights, and there are things that no person or group may do to them (without violating their rights)" -Principle of justice: "if something is justly acquired, then it can be justly held" -Corollaries to the principle of justice: if someone acquires something in accordance with the principles of justice it can be justly held; a person who acquires something from someone else so long as it is in accord with the principle of justice is entitled to it; no one is entitled to anything except by repeated application of 1 and 2 -Any public policy that takes compensation or fails to provide compensation is theft; the government has no claims on anything made through our income -Greatly opposed to a universal, free system of healthcare

Utilitarianism

-Starting point: actions should be judged good or bad, depending upon the consequences they have vis-a-vis the greatest number of people affected by such actions -Principle of justice: distribution of social goods should be done in such a way as to produce the greatest good for the greatest number of people -As long as the majority is satisfied, then the distribution is just

Norman Daniels

-The UK has a closed healthcare system (with respect to revenue and expenditures) whereas the U.S. has an open system -A closed system enables providers to legitimately claim that saying no to a costly procedure for one patient allows them to treat many other patients -In an open system, money flows out of the system to provide benefits that are not health-related (EX: cost savings may lead to higher dividend payments to share holders) -So, when a U.S. doctor says no, patients cannot be sure that this "no" isn't said for non-health reasons

Original Position

-The space occupied by those standing behind the veil of ignorance -While we can't know any of the particular features of ourselves or others, we do know this: everyone wants to act in their own self-interest so that, once the veil is lifted, they will be insured of benefiting form the principles of justice that are developed

Veil of Ignorance

-The veil obscures from our view any knowledge of particular features about ourselves: race, gender, innate intelligence, socioeconomic status, whether we have some chronic disease, etc. -No one knows where in society they will end up once the veil is lifted

Advance Directives

-Treatment directive (living will): tries to specify in advance of being in an incompetent state what sort of treatments the patient would want and wouldn't want in the case of being incompetent -Proxy directive (double power of attorney): a person who has been appointed to speak for the incompetent patient and decide about treatment

Substituted Judgment

-Used when there is no living will or proxy directive -Judge tries to make a decision about what the patient wold want; solicits testimonies and statements form friends and family to gain a better understanding of what the patient wants

The Role of the Patient in the Decision

-Voluntary: when the patient gives their consent to stopping/withholding treatment or lethal injection; patient is in a condition to give consent -Non-Voluntary: patient is not in a position to give consent

Subject Selection

-Who should participate in research? -Jonas' Descending Order Principle

3 Legal Standards for Incompetent Patients

1. Advance directives 2. Substituted judgement 3. Best interest

3 Important Claims from the Cruzan Case

1. Competent patients have the right to refuse even lifesaving treatment 2. Artificial feeding is a form of medical treatment (different from food and water), and therefore may be refused 3. With respect to incompetent patients: each state has the right to require clear and convincing evidence of the patient's wishes (prior to the patient becoming incompetent) to decline medical treatment and each state may interpret for itself what constitutes clear and convincing evidence

Norms of the Belmont Report

1. Informed consent 2. Assessing Risk-Benefit Ratio 3. Subject Selection

2 Principles of Justice Endorsed in Original Position

1. Liberty principle 2. Difference principle

Issues in Reproductive Technology that Raise Moral Questions

1. Low success rate 2. High costs 3. Risks to mother and child 4. Abortion to reduce multiple pregnancies/fertilized embryos housed at clinics 5. Bringing in a third person (donor and/or surrogate) 6. Age of parents 7. Issues of distributive justice 8. Human experimentation on non-consenting subjects? 9. Morality of genetic engineering 10. Should human reproduction be governed by market norms?

3 Principles of the Belmont Report

1. Respect for persons 2. Beneficence 3. Justice

Two Main Rights in Legal Decisions About Euthanasia

1. Right to privacy 2. Right to liberty/autonomy

2 Suppositions of the Principle of Double Effect

1. That there is a morally significant difference between intending and permitting evil (moral difference between direct active and indirect active) 2. That one cannot defend morally the idea that evil means can be used to achieve a good end: the ends do not justify the means

Four Conditions to Allow an Action with Good and Bad Effects

1. The action from which evil results is good or indifferent in itself; it is not morally evil 2. The intention of the one committing the act is upright; i.e., the evil effect is sincerely not intended 3. The evil effect must be equally immediate causally with the good effect (i.e., the good and bad effect need to occur simultaneously or as a part of a single act), for otherwise it (the evil done) would be a means to the good effect and would be intended 4. There must be a proportionately grave reason for allowing the evil to occur

2 Factors Used to Classify Types of Euthanasia

1. The manner in which the death is brought about 2. The role of the patient in the decision

2 Heuristic Devices Used to Think Neutrally About a Just Society

1. The veil of ignorance 2. The original position

To Each According to His or Her Merit

1. To each according to his or her efforts: distribution is based on what efforts people have put into getting what is needed to provide for themselves (system now) 2. To each according to his or her achievement: distribution is based on who takes care of their health

Four Distributional Principles for Just Distribution of Healthcare

1. To each according to his or her merit 2. To each according to his or her choice 3. To each according to his or her essential/basic needs 4. Similar treatment for similar cases

Three Theories of Justice

1. Utilitarian 2. Libertarian 3. Egalitarian

Accepting Love

Affirms the being of the child

To Each According to His or Her Basic Needs

Distribution is based on whether an individual needs it or not

Pure Transforming Love

Hyperparenting; parents think that they have to have full control of the child

Henry Greely

If enhancement drugs and technologies are developed and used properly and responsibly, there is no reason why we shouldn't use them

Pure Accepting Love

No limits or restrictions; whatever the child wants to do, the child is permitted to do; no sense of boundaries

Voluntary Direct Active Euthanasia

Patient is in a position to give consent; manner of death is pharmacological with the intention of causing death

Voluntary Indirect Active Euthanasia

Patient is in a position to give consent; manner of death is pharmacological without the intention of causing death

Voluntary Passive Euthanasia

Patient is in a position to give consent; manner of death is withdrawal or withholding of treatment

Non-Voluntary Direct Active Euthanasia

Patient is not in a position to give consent; manner of death is pharmacological with the intention of causing death

Non-Voluntary Indirect Active Euthanasia

Patient is not in a position to give consent; manner of death is pharmacological without the intention of causing death

Non-Voluntary Passive Euthanasia

Patient is not in a position to give consent; manner of death is withdrawal or withholding of treatment

Transforming Love

Seeks the well-being of the child

Right to Liberty/Autonomy

Understood as the liberty to decide for oneself what medical treatment to receive

Right to Privacy

Understood as the right to control what is or isn't done to one's own body

Justice

Who receives the benefits and who bears the burdens of research